Encyclopedia of Health Services Research

Editorial Board
Editor
Ross M. Mullner
University of Illinois at Chicago
Associate Editors
Tricia J. Johnson Robert F. Rich
Rush University Medical Center University of Illinois at Urbana-Champaign
Editorial Board
Lu Ann Aday Gregory S. Finlayson
University of Texas School of Public Health University of Manitoba
Jeffrey A. Alexander Jack Hadley

University of Michigan School of Public Health The Urban Institute
Ronald M. Andersen Michael A. Morrisey

University of California, Los Angeles University of Alabama-Birmingham
Kyusuk Chung Steven M. Shortell
Governors State University University of California, Berkeley
Kendon J. Conrad Katherine Swartz
University of Illinois at Chicago Harvard University
John G. Demakis
University of North Carolina at Charlotte
Copyright © 2009 by SAGE Publications, Inc.
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Library of Congress Cataloging-in-Publication Data
Encyclopedia of health services research/edited by Ross M. Mullner.

p. cm.
Includes bibliographical references and index.
ISBN 978-1-4129-5179-1 (cloth: alk. paper)
1. Public health—Research—Encyclopedias. 2. Medical care—Research—Encyclopedias.
I. Mullner, Ross M.
[DNLM: 1. Health Services Research—Encyclopedias—English. W 13 E554 2009]
RA440.85.E63 2009
362.103—dc22 2008052885
This book is printed on acid-free paper.
09 10 11 12 13 10 9 8 7 6 5 4 3 2 1
Publisher: Rolf A. Janke

Acquisitions Editor: Jim Brace-Thompson
Editorial Assistant: Michele Thompson
Developmental Editor: Carole Maurer
Reference Systems Manager: Leticia M. Gutierrez
Reference Systems Coordinator: Laura Notton
Production Editor: Kate Schroeder
Copy Editor: QuADS Prepress (P) Ltd.
Typesetter: C&M Digitals (P) Ltd.
Proofreader: Kevin Gleason, Anne Rogers
Indexer: Mary Fran Prottsman
Cover Designer: Glenn Vogel
Marketing Manager: Amberlyn McKay
Contents
1009
G 429 S 1059
H 453 T 1111
I 623 U 1133
J 663 V 1173
K 669 W 1181
L 679
Annotated Bibliography 1197

Appendix: Web Resources 1255
Index 1323
List of Entries
AARP Anderson, Odin W.

Abt Associates Antitrust Law
Academic Medical Centers Arrow, Kenneth J.
AcademyHealth Association for the Accreditation of Human
Access, Models of Research Protection Programs (AAHRPP)
Access to Healthcare Association of American Medical Colleges
Accreditation (AAMC)
Activities of Daily Living (ADL) Association of University Programs in Health
Acute and Chronic Diseases Administration (AUPHA)
Aday, Lu Ann
Administrative Costs Benchmarking
Adverse Drug Events Berwick, Donald M.
Adverse Selection Bioterrorism
Agency for Healthcare Research and Quality Blue Cross and Blue Shield
(AHRQ) Brook, Robert H.
Aiken, Linda H. Brookings Institution
Allied Health Professionals
Altman, Drew E. Canadian Association for Health Services and
Ambulatory Care Policy Research (CAHSPR)
American Academy of Family Physicians (AAFP) Canadian Health Services Research Foundation
American Academy of Pediatrics (AAP) (CHSRF)
American Association of Colleges of Nursing Canadian Institute of Health Services and Policy
(AACN) Research (IHSPR)
American Association of Preferred Provider Cancer Care
Organizations (AAPPO) Capitation
American College of Healthcare Executives Carve-Outs
(ACHE) Case Management
American Enterprise Institute for Public Policy Case-Mix Adjustment
Research (AEI) Cato Institute
American Health Care Association (AHCA) Causal Analysis
American Health Planning Association (AHPA) Center for Studying Health System Change
American Hospital Association (AHA) Centers for Disease Control and Prevention
American Medical Association (AMA) (CDC)
American Nurses Association (ANA) Centers for Medicare and Medicaid Services
American Osteopathic Association (AOA) (CMS)
American Public Health Association (APHA) Certificate of Need (CON)
American Society of Health Economists (ASHE) Charity Care
America’s Health Insurance Plans (AHIP) Chassin, Mark R.
Andersen, Ronald M. Child Care
vii
viii List of Entries
Chiropractors Diagnosis Related Groups (DRGs)

Chronic-Care Model Diagnostic and Statistical Manual of Mental
Chronic Diseases. See Acute and Chronic Disorders (DSM)
Diseases Direct-to-Consumer Advertising (DTCA)
Clancy, Carolyn M. Disability
Clinical Decision Support Disease
Clinical Practice Guidelines Disease Management
Cochrane, Archibald L. Diversity in Healthcare Management
Codman, Ernest Amory Donabedian, Avedis
Cohen, Wilbur J. Drummond, Michael
Cohort Studies
Coinsurance, Copays, and Deductibles Economic Barriers to Healthcare
Committee on the Costs of Medical Care Economic Recessions
(CCMC) Economic Spillover
Commonwealth Fund Economies of Scale
Community-Based Participatory Research E-Health
(CBPR) Eisenberg, John M.
Community Health Electronic Clinical Records
Community Health Centers (CHCs) Ellwood, Paul M.
Community Mental Health Centers (CMHCs) Emergency and Disaster Preparedness
Comparing Health Systems Emergency Medical Services (EMS)
Compensation Differentials Emergency Medical Treatment and Active Labor
Competition in Healthcare Act (EMTALA)
Complementary and Alternative Medicine Emerging Diseases
Computers Employee Health Benefits
Congressional Budget Office (CBO) Employee Retirement Income Security Act (ERISA)
Consumer-Directed Health Plans (CDHPs) Enthoven, Alain C.
Continuity of Health Service Operations During Epidemiology
Pandemics E-Prescribing
Continuum of Care Equity, Efficiency, and Effectiveness in
Cost-Benefit and Cost-Effectiveness Analyses Healthcare
Cost Containment Strategies Ethics
Cost of Healthcare Ethnic and Racial Barriers to Healthcare
Cost Shifting Evans, Robert G.
Credentialing Evidence-Based Medicine (EBM)
Critical Access Hospitals (CAHs) Eye Care Services
Cross-Sectional Studies
Crowd-Out Farr, William
Cultural Competency Feder, Judith
Culyer, Anthony J. Federally Qualified Health Centers (FQHCs)
Current Procedural Terminology (CPT) Fee-for-Service
Flat-of-the-Curve Medicine
Data Privacy Flexible Spending Accounts (FSAs)
Data Security Flexner, Abraham
Data Sources in Conducting Health Services Focused Factories
Research Forces Changing Healthcare
Davis, Karen For-Profit Versus Not-for-Profit Healthcare
Davis, Michael M. Fraud and Abuse
Dentists and Dental Care Free Clinics
Diabetes Fuchs, Victor R.
List of Entries ix
Gates Foundation Health Services Research in Sub-Saharan Africa

General Health Questionnaire Health Services Research in the People’s Republic
General Practice of China
Genetics Health Services Research in the United Kingdom
Geographic Barriers to Healthcare Health Services Research Journals
Geographic Information Systems (GIS) Health Surveys
Geographic Variations in Healthcare Health Systems Agencies (HSAs)
Ginsburg, Paul B. Health Workforce
Ginzberg, Eli Healthy People 2010
Grossman, Michael Home Health Care
Hospice
Health Hospital Closures
Healthcare Cost and Utilization Project (HCUP) Hospital Emergency Departments
Healthcare Effectiveness Data and Information Hospitalists
Set (HEDIS) Hospitals
Healthcare Financial Management
Healthcare Financial Management Association Iatrogenic Disease
(HFMA) Indian Health Service (IHS)
Healthcare Informatics Research Infectious Diseases
Healthcare Markets Inflation in Healthcare
Healthcare Organization Theory Informed Consent
Healthcare Reform Inner-City Healthcare
Healthcare Web Sites Institute for Healthcare Improvement (IHI)
Health Communication Institute of Medicine (IOM)
Health Disparities Intensive-Care Units
Health Economics Intermediate-Care Facilities (ICFs)
Health Indicators, Leading International Classification for Patient Safety
Health Informatics (ICPS)
Health Insurance International Classification of Diseases (ICD)
Health Insurance Coverage International Health Economics Association
Health Insurance Portability and Accountability (iHEA)
Act of 1996 (HIPAA) International Health Systems
Health Literacy
Health Maintenance Organizations (HMOs) Joint Commission
Health Planning
Health Professional Shortage Areas (HPSAs) Kaiser Family Foundation
Health Report Cards Kane, Robert L.
Health Resources and Services Administration Katz, Sidney
(HRSA) Kellogg Foundation
Health Savings Accounts (HSAs) Kimball, Justin Ford
Health Services Research, Definition
Health Services Research, Origins Leapfrog Group
Health Services Research at the Veterans Health Lee, Philip R.
Administration (VHA) Lewin Group
Health Services Research in Australia Licensing
Health Services Research in Canada Life Expectancy
Health Services Research in Dentistry and Oral Lomas, Jonathan
Health Long-Term Care
Health Services Research in Eastern Europe Long-Term Care Costs in the United States
Health Services Research in Germany Luft, Harold S.
x List of Entries
Malpractice National Health Policy Forum (NHPF)

Managed Care National Health Service Corps (NHSC)
Market Failure National Information Center on Health Services
Marmor, Theodore R. Research and Health Care Technology
Mathematica Policy Research (MPR) (NICHSR)
Maynard, Alan National Institutes of Health (NIH)
McNerney, Walter J. National Medical Association (NMA)
Measurement in Health Services Research National Patient Safety Goals (NPSG)
Mechanic, David National Practitioner Data Bank (NPDB)
Medicaid National Quality Forum (NQF)
Medical Errors Naylor, C. David
Medical Group Practice Newhouse, Joseph P.
Medicalization Nightingale, Florence
Medical Sociology Nonprofit Healthcare Organizations
Medical Travel Nurse Practitioners (NPs)
Medicare Nurses
Medicare Part D Prescription Drug Benefit Nursing Home Quality
Medicare Payment Advisory Commission Nursing Homes
(MedPAC)
Mental Health Obesity
Mental Health Epidemiology O’Leary, Dennis S.
Meta-Analysis ORYX Performance Measurement System
Midwest Business Group on Health Outcomes-Based Accreditation
Milbank Memorial Fund Outcomes Movement
Minimum Data Set (MDS) for Nursing Home Outpatient Care. See Ambulatory Care
Resident Assessment
Moral Hazard Pacific Business Group on Health (PBGH)
Morbidity Pain
Mortality Pan American Health Organization (PAHO)
Mortality, Major Causes in the United States Patient-Centered Care
Multihospital Healthcare Systems Patient Dumping
Patient-Reported Outcomes (PRO)
National Alliance for the Mentally Ill (NAMI) Patient Safety
National Association of Health Data Patient Transfers
Organizations (NAHDO) Pauly, Mark V.
National Association of State Medicaid Directors Pay-for-Performance
(NASMD) Payment Mechanisms
National Business Group on Health (NBGH) Pew Charitable Trusts
National Center for Assisted Living (NCAL) Pharmaceutical Industry
National Center for Health Statistics (NCHS) Pharmacoeconomics
National Citizens’ Coalition for Nursing Home Pharmacy
Reform (NCCNHR) Physician Assistants
National Coalition on Health Care (NCHC) Physicians
National Commission for Quality Long-Term Physicians, Osteopathic
Care (NCQLTC) Physician Workforce Issues
National Committee for Quality Assurance (NCQA) Preferred Provider Organizations (PPOs)
National Guideline Clearinghouse (NGC) Prescription and Generic Drug Use
National Healthcare Disparities Report (NHDR) Preventive Care
National Healthcare Quality Report (NHQR) Primary Care
National Health Insurance Primary-Care Case Management (PCCM)
List of Entries xi
Primary-Care Physicians Single-Payer System

Project HOPE Skilled-Nursing Facilities
Prospective Payment Starfield, Barbara
Provider-Based Research Networks (PBRNs) Starr, Paul
Public Health State-Based Health Insurance Initiatives
Public Health Policy Advocacy State Children’s Health Insurance Program
Public Policy (SCHIP)
Stevens, Rosemary A.
Quality-Adjusted Life Years (QALYs) Structure-Process-Outcome Quality Measures
Quality Enhancement Research Initiative Substance Abuse and Mental Health Services
(QUERI) of the Veterans Health Administration (SAMHSA)
Administration (VHA) Supplier-Induced Demand
Quality Improvement Organizations (QIOs)
Quality Indicators Tarlov, Alvin R.
Quality Management Tax Subsidy of Employer-Sponsored Health
Quality of Healthcare Insurance
Quality of Life, Health-Related (HRQOL) Technology Assessment
Quality of Well-Being Scale (QWB) Telemedicine
Terrorism. See Bioterrorism
RAND Corporation Thompson, John Devereaux
RAND Health Insurance Experiment Timeliness of Healthcare
Randomized Controlled Trials (RCTs) Tobacco Use
Rationing Healthcare Transportation
Regulation TRICARE, Military Health System
Reinhardt, Uwe E.
Relman, Arnold S. Uncompensated Healthcare
Resource-Based Relative Value Scale (RBRVS) Uninsured Individuals
Rice, Dorothy P. United Kingdom’s National Health Service (NHS)
Risk United Kingdom’s National Institute for Health
Robert Wood Johnson Foundation (RWJF) and Clinical Excellence (NICE)
Roemer, Milton I. University HealthSystem Consortium (UHC)
Roos, Leslie L. Urban Institute
Roos, Noralou P. U.S. Department of Veterans Affairs (VA)
Rorem, C. Rufus U.S. Food and Drug Administration (FDA)
Rosenbaum, Sara U.S. Government Accountability
RTI International Office (GAO)
Rural Health U.S. National Health Expenditures
Sackett, David L. Volume-Outcome Relationship

Safety Net Vulnerable Populations
Satisfaction Surveys
Scott, W. Richard Ware, John E.
Selective Contracting Wennberg, John E.
Severity Adjustment White, Kerr L.
Shapiro, Sam Wilensky, Gail R.
Sheps, Cecil G. Williams, Alan H.
Shortell, Stephen M. Women’s Health Issues
Short-Form Health Surveys (SF-36, -12, -8) World Health Organization (WHO)
Reader’s Guide
Access to Care Associations

Access, Models of AARP
Access to Healthcare AcademyHealth
Critical Access Hospitals (CAHs) American Academy of Family Physicians (AAFP)
Cultural Competency American Academy of Pediatrics (AAP)
Direct-to-Consumer Advertising (DTCA) American Association of Colleges of Nursing
E-Health (AACN)
E-Prescribing American Association of Preferred Provider
Ethnic and Racial Barriers to Healthcare Organizations (AAPPO)
Geographic Barriers to Healthcare American College of Healthcare Executives
Healthcare Web Sites (ACHE)
Health Communication American Health Care Association (AHCA)
Health Literacy American Health Planning Association (AHPA)
Health Professional Shortage American Hospital Association (AHA)
Areas (HPSAs) American Medical Association (AMA)
Hospital Closures American Nurses Association (ANA)
Inner-City Healthcare American Osteopathic Association (AOA)
Medical Travel American Public Health Association (APHA)
National Health Service Corps (NHSC) American Society of Health Economics (ASHE)
Patient Dumping America’s Health Insurance Plans (AHIP)
Patient Transfers Association of American Medical Colleges
Rural Health (AAMC)
Safety Net Association of University Programs in Health
Telemedicine Administration (AUPHA)
Transportation Healthcare Financial Management Association
(HFMA)
Accreditation, Associations, Foundations, and
Institute for Healthcare Improvement (IHI)
Research Organizations
International Health Economics Association
Accreditation (iHEA)
National Alliance for the Mentally Ill (NAMI)
Association for the Accreditation of Human National Association of Health Data
Research Protection Programs (AAHRPP) Organizations (NAHDO)
Joint Commission National Association of State Medicaid Directors
National Committee for Quality Assurance (NASMD)
(NCQA) National Center for Assisted Living (NCAL)
xiii
xiv Reader’s Guide
National Citizens’ Coalition for Nursing Home Brook, Robert H.

Reform (NCCNHR) Chassin, Mark R.
National Coalition on Health Care (NCHC) Clancy, Carolyn M.
National Commission for Quality Long-Term Culyer, Anthony J.
Care (NCQLTC) Davis, Karen
National Health Policy Forum (NHPF) Drummond, Michael
National Medical Association (NMA) Ellwood, Paul M.
National Quality Forum (NQF) Enthoven, Alain C.
University HealthSystem Consortium (UHC) Evans, Robert G.
Feder, Judith
Business Coalitions Fuchs, Victor R.
Leapfrog Group Ginsburg, Paul B.
Midwest Business Group on Health Grossman, Michael
National Business Group on Health (NBGH) Kane, Robert L.
Pacific Business Group on Health (PBGH) Katz, Sidney
Lee, Philip R.
Foundations Lomas, Jonathan
Luft, Harold S.
Commonwealth Fund Marmor, Theodore R.
Gates Foundation Maynard, Alan
Kaiser Family Foundation Mechanic, David
Kellogg Foundation Naylor, C. David
Milbank Memorial Fund Newhouse, Joseph P.
Pew Charitable Trusts O’Leary, Dennis S.
Robert Wood Johnson Foundation (RWJF) Pauly, Mark V.
Reinhardt, Uwe E.
Research Organizations Relman, Arnold S.
Abt Associates Rice, Dorothy P.
American Enterprise Institute for Public Policy Roos, Leslie L.
Research (AEI) Roos, Noralou P.
Brookings Institution Rosenbaum, Sara
Cato Institute Sackett, David L.
Center for Studying Health System Change Scott, W. Richard
Institute of Medicine (IOM) Shortell, Stephen M.
Lewin Group Starfield, Barbara
Mathematica Policy Research (MPR) Starr, Paul
Project HOPE Stevens, Rosemary A.
RAND Corporation Tarlov, Alvin R.
RTI International Ware, John E.
Urban Institute Wennberg, John E.
White, Kerr L.
Biographies of Current and Past Leaders Wilensky, Gail R.
Current Leaders
Past Leaders
Aday, LuAnn
Aiken, Linda H. Anderson, Odin W.
Altman, Drew E. Cochrane, Archibald L.
Andersen, Ronald M. Codman, Ernest Amory
Arrow, Kenneth J. Cohen, Wilbur J.
Berwick, Donald M. Davis, Michael M.
Reader’s Guide xv
Donabedian, Avedis Disease, Disability, Health,

Eisenberg, John M. and Health Behavior
Farr, William
Activities of Daily Living (ADL)
Flexner, Abraham
Acute and Chronic Diseases
Ginzberg, Eli
Adverse Drug Events
Kimball, Justin Ford
Chronic-Care Model
McNerney, Walter J.
Diabetes
Nightingale, Florence
Disability
Roemer, Milton I.
Disease
Rorem, C. Rufus
Emerging Diseases
Shapiro, Sam
Genetics
Sheps, Cecil G.
Health
Thompson, John Devereaux
Health Indicators, Leading
Williams, Alan H.
Iatrogenic Disease
Cost of Care, Economics, Finance, Infectious Diseases
and Payment Mechanisms International Classification of Diseases (ICD)
Administrative Costs Life Expectancy
Capitation Medicalization
Charity Care Medical Sociology
Committee on the Costs of Medical Mental Health
Care (CCMC) Morbidity
Compensation Differentials Mortality
Cost-Benefit and Cost-Effectiveness Analyses Mortality, Major Causes in the United States
Cost Containment Strategies Obesity
Cost of Healthcare Pain
Cost Shifting Prescription and Generic Drug Use
Current Procedural Terminology (CPT) Tobacco Use
Diagnosis Related Groups (DRGs) Government and International
Economic Barriers to Healthcare Healthcare Organizations
Economic Recessions
U.S. Government Organizations
Economic Spillover
Economies of Scale Agency for Healthcare Research and Quality
Fee-for-Service (AHRQ)
Flat-of-the-Curve Medicine Centers for Disease Control and Prevention (CDC)
Healthcare Financial Management Centers for Medicare and Medicaid Services (CMS)
Healthcare Markets Congressional Budget Office (CBO)
Health Economics Health Resources and Services Administration
Inflation in Healthcare (HRSA)
Long-Term Care Costs in the United States Indian Health Service (IHS)
Market Failure Medicare Payment Advisory Commission
Pay-for-Performance (MedPAC)
Payment Mechanisms National Center for Health Statistics (NCHS)
Pharmacoeconomics National Guideline Clearinghouse (NGC)
Prospective Payment National Information Center on Health Services
Resource-Based Relative Value Scale Research and Health Care Technology
(RBRVS) (NICHSR)
Supplier-Induced Demand National Institutes of Health (NIH)
Uncompensated Healthcare Substance Abuse and Mental Health Services
U.S. National Health Expenditures Administration (SAMHSA)
xvi Reader’s Guide
TRICARE, Military Health System Case Management

U.S. Department of Veterans Affairs (VA) Chiropractors
U.S. Food and Drug Administration (FDA) Community Health Centers (CHCs)
U.S. Government Accountability Office (GAO) Community Mental Health
Centers (CMHCs)
International Organizations Complementary and Alternative Medicine
Canadian Association for Health Services and Dentists and Dental Care
Policy Research (CAHSPR) Disease Management
Canadian Health Services Research Foundation Diversity in Healthcare Management
(CHSRF) Emergency Medical Services (EMS)
Canadian Institute of Health Services and Policy Eye Care Services
Research (IHSPR) Federally Qualified Health Centers (FQHC)
Pan American Health Organization (PAHO) Free Clinics
United Kingdom’s National Health Service General Practice
(NHS) Health Maintenance Organizations (HMOs)
United Kingdom’s National Institute for Health Health Systems Agencies (HSAs)
and Clinical Excellence (NICE) Health Workforce
World Health Organization (WHO) Healthcare Organization Theory
Home Health Care
Health Insurance
Hospice
Adverse Selection Hospital Emergency Departments
Blue Cross and Blue Shield Hospitalists
Carve-Outs Hospitals
Coinsurance, Copays, and Deductibles Intensive-Care Units
Consumer-Directed Health Plans (CDHPs) Intermediate-Care Facilities (ICFs)
Crowd-Out Long-Term Care
Employee Health Benefits Managed Care
Flexible Spending Accounts (FSAs) Medical Group Practice
Health Insurance Multihospital Healthcare Systems
Health Insurance Coverage Nonprofit Healthcare Organizations
Health Savings Accounts (HSAs) Nurse Practitioners (NPs)
Medicaid Nurses
Medicare Nursing Homes
Medicare Part D Prescription Drug Benefit Pharmaceutical Industry
Moral Hazard Pharmacy
RAND Health Insurance Experiment Physician Assistants
Selective Contracting Physicians
Single-Payer System Physicians, Osteopathic
State-Based Health Insurance Initiatives Physician Workforce Issues
State Children’s Health Insurance Program Preferred Provider Organizations (PPOs)
(SCHIP) Primary Care
Tax Subsidy of Employer-Sponsored Health Primary-Care Case Management (PCCM)
Insurance Primary-Care Physicians
Health Professionals and Skilled-Nursing Facilities
Healthcare Organizations Health Services Research
Academic Medical Centers Data Sources in Conducting Health Services
Allied Health Professionals Research
Ambulatory Care Health Services Research, Definition
Reader’s Guide xvii
Health Services Research, Origins Healthcare Effectiveness Data and Information

Health Services Research at the Veterans Health Set (HEDIS)
Administration (VHA) Healthcare Informatics Research
Health Services Research in Australia Health Informatics
Health Services Research in Canada Health Surveys
Health Services Research in Dentistry and Oral Measurement in Health Services Research
Health Meta-Analysis
Health Services Research in Eastern Europe Minimum Data Set (MDS) for Nursing Home
Health Services Research in Germany Resident Assessment
Health Services Research in Sub-Saharan Africa National Practitioner Data Bank (NPDB)
Health Services Research in the People’s Republic ORYX Performance Measurement System
of China Provider-Based Research Networks (PBRNs)
Health Services Research in the United Kingdom Quality of Well-Being Scale (QWB)
Health Services Research Journals Randomized Controlled Trials (RCTs)
Satisfaction Surveys
Laws, Regulations, and Ethics
Severity Adjustment
Antitrust Law Short-Form Health Surveys (SF-36, -12, -8)
Certificate of Need (CON)
Outcomes of Care
Emergency Medical Treatment and Active Labor
Act (EMTALA) Health Report Cards
Employee Retirement Income Security Act Outcomes-Based Accreditation
(ERISA) Outcomes Movement
Ethics Patient-Reported Outcomes (PRO)
Fraud and Abuse Volume-Outcome Relationship
Health Insurance Portability and Accountability
Policy Issues, Healthcare Reform, and
Act of 1996 (HIPAA)
International Comparisons
Informed Consent
Licensing Comparing Health Systems
Regulation Competition in Healthcare
Equity, Efficiency, and Effectiveness in
Measurement, Data Sources
Healthcare
and Coding, and Research Methods
Focused Factories
Case-Mix Adjustment Forces Changing Healthcare
Causal Analysis For-Profit Versus Not-for-Profit Healthcare
Clinical Decision Support Healthcare Reform
Cohort Studies Health Disparities
Community-Based Participatory Research International Health Systems
(CBPR) National Healthcare Disparities Report (NHDR)
Computers National Health Insurance
Cross-Sectional Studies Public Policy
Data Privacy Rationing Healthcare
Data Security Technology Assessment
Diagnostic and Statistical Manual of Mental
Public Health
Disorders (DSM)
Electronic Clinical Records Bioterrorism
Evidence-Based Medicine (EBM) Community Health
General Health Questionnaire Continuity of Health Service Operations During
Geographic Information Systems (GIS) Pandemics
Healthcare Cost and Utilization Project (HCUP) Emergency and Disaster Preparedness
xviii Reader’s Guide
Epidemiology Nursing Home Quality

Health Planning Patient-Centered Care
Healthy People 2010 Patient Safety
Mental Health Epidemiology Quality-Adjusted Life Years (QALYs)
Preventive Care Quality Enhancement Research Initiative
Public Health (QUERI) of the Veterans Health
Public Health Policy Advocacy Administration (VHA)
Risk Quality Improvement Organizations (QIOs)
Quality Indicators
Quality and Safety of Care
Quality Management
Accreditation Quality of Healthcare
Benchmarking Quality of Life, Health-Related (HRQOL)
Clinical Practice Guidelines Structure-Process-Outcome Quality Measures
Continuum of Care Timeliness of Healthcare
Credentialing
Special and Vulnerable Groups
Geographic Variations in Healthcare
International Classification for Patient Safety (ICPS) Cancer Care
Malpractice Child Care
Medical Errors Uninsured Individuals
National Healthcare Quality Report (NHQR) Vulnerable Populations
National Patient Safety Goals (NPSG) Women’s Health Issues
About the Editors
Editor-in-Chief Who in America, and Who’s Who in the World. He

earned his bachelor’s degree from Chicago State
Ross M. Mullner is a health services researcher and University, and two master’s degrees and a doctoral
a public health professional. For over 30 years, he degree from the University of Illinois.
has worked as an academic, healthcare administra-
tor, and consultant. He is an associate professor of
health policy and administration at the School of Associate Editors
Public Health of the University of Illinois at Chicago.
He also holds appointments in the University of Tricia J. Johnson is a health economist and an
Illinois’s School of Pharmacy, Department academic. She is the director of the Center for
of Pharmacy Administration, and the College of Health Management and Policy Research and an
Medicine, Department of Psychiatry. Before joining assistant professor in the Department of Health
the faculty of the University of Illinois, he was Systems Management at Rush University. She is
Director of Research at the American Hospital also an economist for Rush Medical Group at
Association’s Healthcare Research and Educational Rush University Medical Center in Chicago. She
Trust (HRET) and Associate Director of the Hospital is a 2008–2009 Fulbright Scholar to Austria at
Data Center. He has authored seven books and the Vienna University of Economics and Business
more than 90 articles in the areas of healthcare data, Administration, working with its Department of
hospital financial management, and health insur- Economics, Institute for Social Policy and
ance coverage. His work has appeared in journals Research, and Institute for Health Care Mana
such as New England Journal of Medicine, Health gement and Health Economics. Her research
Services Research, Medical Care, and Social Science interests focus on economic issues related to
and Medicine. He is the associate editor of Journal healthcare providers and consumers, including
of Medical Systems and has served on the editorial the globalization of the healthcare industry and
boards of Health Services Research, Inquiry, and understanding the economic factors affecting con-
Quality Management in Health Care. To keep sumers’ healthcare decisions. She has an interest
abreast of the healthcare literature, he has written in understanding the drivers of healthcare utiliza-
45 book reviews for Library Journal, Choice, and tion and expenditures, where her work has focused
Inquiry. He has served on a number of national on the hospital environment, patient safety, and
boards and has been a consultant to a number of occupational injuries. In addition, she does work
government and healthcare organizations, including related to the cost-effectiveness of healthcare and
the national Institute of Medicine (IOM), U.S. community-based interventions. She is currently
Government Accountability Office (GAO), Health the principal investigator on a project to examine
Resources and Services Administration (HRSA), how anticipated access to Medicare influences
Joint Commission, and Cancer Treatment Centers people’s decisions about healthcare use prior to
of America. He recently served as special assistant to age 65, and how these decisions influence long-
the director of the Illinois Department of Healthcare term health outcomes. She is also a coinvestigator
and Family Services. He has received a number of on projects funded by the Cardinal Health
honors for his work, including being elected to Foundation, Alfred P. Sloan Foundation, National
Who’s Who in Medicine and Healthcare, Who’s Institute on Aging, and National Institute of
xix
xx About the Editors
Nursing Research. She has received grant funding Germany, and he was also appointed a Permanent
from the World Bank and the Albanian Ministry Fellow in the European Center for Comparative
of Health as well as the U.S. Department of Government and Public Policy. Before joining
Commerce for professional training programs in the faculty of the University of Illinois, he
hospital and financial management. She earned served on the faculties of the Heinz School of
her bachelor’s degree from Coe College, a master’s Urban and Public Affairs at Carnegie-Mellon
degree from the University of Iowa, and a doc- University, the Woodrow Wilson School of
toral degree from Arizona State University. Public and International Affairs at Princeton
Robert F. Rich is a political scientist and public University, the University of Michigan Institute
policy analyst. He is the director of the Institute for Social Research, and the University of
of Government and Public Affairs (IGPA) and Chicago. He is the author of seven books and
professor of law, political science, medical more than 50 articles in the areas of health law
humanities and social sciences, community and policy, federalism, information policy, and
health, and health policy and administration at science and technology policy. His most recent
the University of Illinois. In 2004, he was a vis- book, Consumer Choice: Social Welfare and
iting scholar at the Max Planck Institute for Health Policy, was published in 2005. He
Foreign and International Social Law in Munich, earned his bachelor’s degree from Oberlin
Germany. In 2003, he was the Mercator College and his master’s degree and doctorate
Professor at the Humboldt University in Berlin, from the University of Chicago.
Contributors
Lu Ann Aday David J. Ballard Peter Broderick

University of Texas School Baylor Health Care System Abt Associates Inc.
of Public Health
Kieva A. Bankins Anne L. Buchanan
Gary L. Albrecht University of Maryland Saint Xavier University
University of Illinois
Renardis Banks Peter P. Budetti
at Chicago
Rush Medical Center University of Oklahoma
Lynn Allchin Health Sciences Center
Richard E. Barrett
University of Connecticut
University of Illinois Grace Budrys
Ruth Ann Althaus at Chicago De Paul University
Ohio University Elizabeth A. Calhoun
Cathy Batscha
Ketsya Manuella Amboise University of Illinois at Chicago University of Illinois
University of Illinois at Chicago
Bernard H. Baum
at Chicago Richard T. Campbell
Association, American at Chicago University of Illinois
Osteopathic at Chicago
American Osteopathic Anne R. Bavier
Michael F. Cannon
Association Saint Xavier University
Cato Institute
Halle R. Amick Ralph Bell William R. Carpenter
University of North Carolina Governors State University University of North Carolina
at Chapel Hill School of Public Health
William S. Bike
Ronald M. Andersen University of Illinois Jean Gayton Carroll
University of California, at Chicago Independent Scholar
Los Angeles
Nick Black Alwyn Cassil
Matthew M Anderson University of London Center for Studying Health
Rush University System Change
Imre Boncz
Steven Andes Gerard M. Castro
University of Pécs
Independent Scholar Joint Commission
Marcia Angell Carol A. Boyer
Dennis Cesarotti
Harvard University Rutgers University
Northern Illinois University
Richard J. Arnould Tanguy Brachet Stacey Chamberlain
University of Illinois Children’s Hospital University of Illinois
at Urbana-Champaign of Philadelphia at Chicago
xxi
xxii Contributors
Kayla Chase Julie S. Darnell Caswell A. Evans

University of Illinois University of Illinois University of Illinois
at Chicago at Chicago at Chicago
Lisa Chimento Pritha Dasgupta Rupert M. Evans

Lewin Group Rush University Medical Governors State University
Center
Kyusuk Chung Connie J Evashwick
Governors State University Guy David St. Louis University
University of Pennsylvania
Carolyn M. Clancy Judith Feder
Agency for Healthcare John M. Davis Georgetown University
Research and Quality University of Illinois
at Chicago Joe Feinglass
J. Robert Clapp Northwestern University
Rush University Gordon H. DeFriese
University of North Carolina Jennifer Feld
Medical Center
John G. Demakis at Chicago
Richard L. Clarke
University of North Carolina
Healthcare Financial
at Charlotte Robert I. Field
Management Association
University of the Sciences
Della Derscheid in Philadelphia
Kimberly R. Clawson
Mayo Medical Center
Rush University Medical
Blair C. Filler
Center Michael Dieter University of California,
University of Illinois Los Angeles
Kendon J. Conrad
at Chicago
Capri Mara Fillmore
at Chicago Benedict S. Dillon Medical College of Wisconsin
Karon Cook
at Chicago Gregory S. Finlayson
University of Washington,
University of Manitoba
Seattle Valerie A. Dobiesz
Richard S. Cooper University of Illinois Heather Forst
Loyola Medical School at Chicago Rush University
Llewellyn J. Cornelius Xinjian Du Daniel M. Fox

University of Maryland University of Illinois Milbank Memorial Fund
at Chicago
Stephanie Y. Crawford Sally A. Freels
University of Illinois Anna M. S. Duloy University of Illinois
at Chicago University of Illinois at Chicago
at Chicago
Sergio Cristancho Richard Freeman
University of Illinois College J. Andrew Dykens University of Edinburgh
of Medicine at Rockford University of Illinois
at Chicago Kristen Friscia
Kevin Croke University of Illinois
University of Illinois Chris T. Erb at Chicago
at Chicago University of Illinois
at Urbana-Champaign Kaori Fujishiro
Ellen K. Cromley National Institute for
Institute for Community Paul J. Erickson Occupational Safety
Research Independent Scholar and Health
Contributors xxiii
Sumul Gandhi James C. Hagen William C. Hsiao

University of Illinois Saint Xavier University Harvard University
at Chicago
Jane P. Hall Lynn Huls
David N. Gans University of Technology Westbriar Consulting, LLC
Medical Group Management Bethany Hardy
Association Li-Ching Hung
National Academy of Sciences Mississippi State University
Marcela Garces Allen Harrison
University of Illinois College Lee H. Igel
Sinai Health System
of Medicine at Rockford New York University
Kristin Hartsaw
Iris Garcia-Caban DuPage County Health L. Michele Issel
Massachusetts Medicaid Office Department University of Illinois
at Chicago
Andrew N. Garman Memoona Hasnain
Rush University University of Illinois Susan Jacobson
Thomas E. Getzen at Chicago
Temple University Penny L. Havlicek
Governors State University Jayani Jayawardhana
Mary F. Giffin Medical University
U.S. Government Catherine Hawes of South Carolina
Accountability Office Texas A&M University
Health Science Center Mark M. Jewell
Blair D. Gifford EPI-Q, Inc.
University of Colorado Lorens A. Helmchen
at Denver University of Illinois Ana P. Johnson
at Chicago Queens University
Darin P. Gonzalez
University of Illinois Klaus-Dirk Henke Tricia J. Johnson
at Chicago Technical University of Berlin Rush University
Medical Center
Robert C. Good Laurie A. Hensley
Rush University Mount Sinai Hospital Michael C. Jones
Elaine C. Hickey Illinois Department Healthcare
Tiosha T. Goss and Family Services
University of Illinois U.S. Department of
at Chicago Veterans Affairs Robert Kaestner
Molly Higham University of Illinois
Benn J. Greenspan at Chicago
Rush University
at Chicago James Hill Stuart Kantor
Pearson, Inc. Urban Institute
Samuel N. Grief
University of Illinois Peter Hilsenrath Angela M. Kargus
at Chicago University of the Pacific American Chiropractic
Robert S. Hopkins, III Association
Sunanda Gupta
University of Illinois Baylor Health Care System Anjali Kartha
at Chicago Diane M. Howard Rush University
Richard A. Guthmann Rush University Achilles Katamba
University of Illinois Alyssa Howell Case Western Reserve University
at Chicago Rush University School of Medicine
xxiv Contributors
Michele A. Kelley Scott M. Leikin Harold S. Luft

University of Illinois Highland Park Hospital University of California,
at Chicago San Francisco
Patrick Lenihan
Erin Hayes Kelly University of Illinois Jared Lane K. Maeda
Shriners Hospitals for at Chicago University of Illinois
Children of Chicago at Chicago
Stefan Leucht
Tae Hyun Kim Klinik und Poliklinik für Grace Male
Governors State University Psychiatrie und Aurora St. Luke’s Medical
Psychotherapie, Technische Center
William C. Kling Universität München
University of Illinois Ronald W. Manderscheid
at Chicago Samuel Levey Constella Group
University of Iowa
Elisa Stamm Kogan Willard G. Manning
University of Illinois Judith Levy
University of Chicago
at Chicago Karl Matuszewski
Gene J. Koprowski University HealthSystem
Cancer Treatment Centers Chunbo Li
Tongji University Hospital Consortium
of America
Richard C. Lindrooth Jeffrey S. McCullough
Richard Koss University of Minnesota
Joint Commission Medical University of
South Carolina
Robin B. McFee
Niranjana Kowlessar Long Island Regional
Christopher G. Lis
University of Illinois Poison & Drug Information
Cancer Treatment Centers
at Chicago Center
of America
Joseph D. Kubal Niccie L. McKay
Ilya Litvak
Independent Scholar University of Florida
Case Western Reserve
Frederick J. Kviz University
David Mechanic
University of Illinois Wei Liu Rutgers University
at Chicago Edward Mensah
Kathryn Langley University of Illinois
University of Illinois Jerod Loeb at Chicago
at Chicago Joint Commission
Ellen Meyer
John N. Lavis Kathleen N. Lohr American Public Health
McMaster University RTI International Association
Keon-Hyung Lee Helen Look Patricia R. Meyers
Florida State University University of Michigan Oak Lawn Writer’s Group
Katherine Lehman Anthony T. LoSasso Lakisha C. Miller
American Health Care University of Illinois Case Western Reserve
Association at Chicago University School
of Medicine
Jerrold B. Leikin Denise Love
Evanston Northwestern National Assoc. of Health Data Arnold Milstein
Healthcare Organizations Mercer Health & Benefits
Contributors xxv
Janet B. Mitchell Daniel J. O’Brien E. Carol Polifroni

RTI International University of Illinois University of Connecticut
at Chicago
Tara Moore Heather M. Prendergast
Rush University Kevin O’Brien University of Illinois Hospital
Medical Center University of Illinois
at Chicago Laurie Quinn
Vincent Mor University of Illinois
Brown University Jillian R. O’Neill at Chicago
Ophelia T. Morey
at Chicago Edward M. Rafalski
University of Buffalo
Alexian Brothers Hospital
Michael Morgenstern Thomas W. O’Rourke Network
Rush University University of Illinois
at Ubana-Champaign Lydia M. Reed
Michael A. Morrisey Association of University
University of Alabama Mary C. Odwazny Programs in Health
at Birmingham Rush University Administration
Medical Center
Deann Muehlbauer Sang-O Rhee
University of Illinois Javette C. Orgain Governors State University
at Chicago Thomas Rice
Benjamin C. Mueller University of California,
University of Illinois College Douglas Pace
Los Angeles
of Medicine Rockford National Commission for
Quality Long-Term Care Katie Rich
Ross M. Mullner University of Connecticut
University of Illinois Erin R. Page
at Chicago University of Chicago Robert F. Rich
Barbara Nail-Chiwetalu Lawrence M. Pawola
University of New Mexico University of Illinois Thomas C. Ricketts
at Chicago University of North Carolina
Imelda Namagembe
Case Western Reserve David A. Pearson Gary D. Rifkin
University School Independent Scholar University of Illinois
of Medicine at Rockford
Lubina Perez
Jack Needleman Advocate Healthcare Barth B. Riley
University of California, Chestnut Health Systems
Los Angeles Karen E. Peters
University of Illinois Daniel K. Roberts
Duncan Neuhauser at Chicago Illinois College of Optometry
Case Western Reserve
University Laura A. Petersen Veronique Rodman
Baylor College of Medicine American Enterprise Institute
Beth Newell
University of California, Charles D. Phillips Cherise Rosen
San Francisco Texas A&M Health University of Illinois
Science Center at Chicago
Amie Lulinski Norris
University of Illinois Frank S. Phillips Sara Rosenbaum
at Chicago Rush University George Washington University
xxvi Contributors
Kristin Rosengren Heather Sherman Susan M. Swider

Academy Health Joint Commission Rush University
Medical Center
Emily Rosenthal Alicia Shillington
University of Illinois EPI-Q, Inc. Raymond J. Swisher
at Chicago Centers for Medicare and
Elizabeth A. Skinner Medicaid Services
Jason Rothstein Johns Hopkins University
University of Illinois Elizabeth Tarlov
at Chicago Jonathan Small Hines VA Hospital
Institute for Healthcare
Louis Rowitz Improvement Raymond Tatalovich
University of Illinois Loyola University Chicago
at Chicago Cary Stacy Smith
Rima Tawk
Mississippi State University
Zepure Boyadjian Samawi University of Illinois
University of Connecticut Kat Song at Chicago
Linda F. Samson Leapfrog Group Bamidele Olusegun Tayo
Governors State University Loyola University
Todd Stankewicz
Medical Center
Susan M. Sanders Centers for Medicare and
Saint Xavier University Medicaid Services Sharon Telleen
Judith V. Sayad Barbara Starfield at Chicago
University of Illinois Johns Hopkins University
at Chicago Sarah Thomas
Gina Steiner American Academy
John Schrom American Academy of Family Physicians
University of Illinois of Pediatrics
at Chicago Gregory Vachon
Donald M. Steinwachs Northwestern Memorial
John Henning Schumann Hospital
Johns Hopkins University
University of Chicago
Annette L. Valenta
Sarah-Anne Henning Greer W. P. Stevenson
Schumann University of Illinois
at Chicago
University of Chicago at Chicago
Vikrant Vats
W. Richard Scott Nicole E. Stoller University of Illinois
Stanford University University of Illinois at Chicago
at Chicago
Andreea Seicean Kenneth L. Vaux
Case Western Reserve Heather Stuart Garrett-Evangelical
University Queen’s University Theological Seminary
Sinziana Seicean Ann L. Viernes
Amy L. Sulkin
Case Western Reserve Rush University
University Medical Center
Medical Center
Catherine Selden Rosemary Walker
U.S. National Library Katherine Swartz University of Illinois
of Medicine Harvard University at Chicago
Richard H. Sewell Daniel Swartzman Lisa C. Wallis
University of Illinois University of Illinois Northeastern Illinois
at Chicago at Chicago University
Contributors xxvii
Surrey M. Walton Saul J. Weiner Brad Wright

University of Illinois University of Illinois University of North Carolina
at Chicago at Chicago
Michelle Choi Wu
Thomas T. H. Wan Cherie Weinewuth University of Illinois
University of Central Florida University of Illinois College of Nursing
at Chicago
Virginia Wang Xiaoyan Ying
Bruce A. Weiss Walgreens Health
University of North Carolina
Independent Scholar Services
at Chapel Hill
William D. White
Teresa M. Waters Luis L. Zegers-Febres
Cornell University
University of Tennessee Acumanage, Inc.
Curtis R. Winkle
Frances M. Weaver University of Illinois
Veterans Affairs at Chicago
Bryan J. Weiner Gregory S. Wolfe
University of North Carolina University of Illinois
School of Public Health at Chicago
Introduction
The Field the study of the accessibility, costs, quality, and out-
comes of healthcare. Access to healthcare includes
There is a critical paradox at the very heart of everything that facilitates or impedes the use of
modern healthcare. Today, as never before, health- healthcare services. Cost of healthcare includes the
care has the ability to save lives and enhance the payments by insurers and individuals for healthcare
duration and quality of life. Advances in health- services as well as the cost of lost wages and the
care such as open-heart surgery, organ transplants, societal cost of decreased productivity. Quality of
and test-tube babies stand at the forefront of healthcare encompasses elements of the structure,
human endeavor. At the same time, however, process, and outcomes of healthcare. Outcomes of
healthcare has become so enormously costly that healthcare include death, disease, disability, discom-
it can easily bankrupt governments and impover- fort, and dissatisfaction with care. The overall aim
ish families and individuals. of health services research is to improve the equity,
America is facing a growing healthcare crisis. It efficiency, and effectiveness of healthcare, mainly by
spends more money on healthcare, in terms of influencing and developing public policies.
both total amount and per capita spending, than
any other nation on earth. Yet America has a rela-
tively high infant mortality rate and a low life Rationale for This Encyclopedia
expectancy compared with other industrialized This encyclopedia is needed and timely for three
nations such as Canada, the United Kingdom, and major reasons. First, the field of health services
Japan. Many of America’s hospitals and nursing research has grown enormously over the past two
facilities provide poor-quality healthcare. Medical decades, with an ever-widening range of topics
errors and unsafe conditions are common, result- being studied. Second, the organization, financing,
ing in thousands of patient deaths annually. and delivery of healthcare have become increas-
Millions of Americans are unable to access health- ingly complex. Third, because health services
care, especially those without health insurance and research is highly multidisciplinary, including
those who are underinsured. For many Americans, areas such as health administration, health eco-
routine and preventive care is unaffordable. And nomics, medicine, medical sociology, political sci-
many who do receive healthcare are unable to pay ence, public policy, and public health, there is no
for it; healthcare expenses are the leading cause of single extant reference source that captures the
bankruptcy in America. Although politicians, busi- diversity and complexity of the field. The
ness leaders, health practitioners, and the general Encyclopedia of Health Services Research was
public all agree that America’s current healthcare designed to fill this void. This encyclopedia is the
system needs to be reformed, there is no consensus first in the field, and it is one of the largest single
on how to accomplish it. works ever published on health services research.
Health services research addresses these and The encyclopedia is designed to be an introduc-
other crucial issues. Specifically, the multidisci- tion to the various topics of health services research
plinary field of health services research focuses on for an audience including undergraduate students,
xxix
xxx Introduction
graduate students, and lay audiences seeking non- journals included Health Affairs, Health Services
technical descriptions of the field and its practices. Research, Inquiry, Journal of Health Services
It is also useful for healthcare practitioners wishing Research and Policy, Medical Care, and New
to stay abreast of the changes and updates in the England Journal of Medicine. The draft list was
field and doctorate-level academics seeking a por- then reviewed by the entire advisory board, which
tal into a new specialty area. made a series of additions and subtractions.
Third, the editors and the advisory board iden-
tified and invited contributors. The editors also
Content and Organization
searched the literature to find individuals who
To help the reader navigate the encyclopedia, a published on certain topics and invited them to
detailed Reader’s Guide comprising 16 sections is submit entries. The invited authors ranged from
provided. Additionally, there is a list of the entries promising young doctoral students to the most
presented in alphabetical order. The individual well-known luminaries in the field.
entries range in length from approximately 500 Fourth, all the contributors were given basic
words for the biographies of current and past lead- guidelines and instructions regarding the writing
ers, to 1,000 words for associations, foundations, of their entries. In particular, they were encouraged
and research organizations, to 3,000 words for to be as thorough as possible in describing the
major concepts and topics such as health insur- entire topic area and to write in clear, nontechni-
ance, risk, and quality of healthcare. Each entry is cal, accessible language.
designed to provide the reader with a basic descrip- Fifth, the editor and associate editors then
tion and understanding of the topic. Following reviewed all the entries and asked the authors for
each entry is a Further Readings and a Web Sites revisions as necessary.
section that can take the reader to the next level. Sixth, the editors finalized the volumes and
Although the field of health services is large, the compiled the bibliography and appendix.
encyclopedia attempts to be as comprehensive as
possible without being overly redundant. To
accomplish this, all entries include several associ- Acknowledgments
ated topics and cross-references. In a small number This encyclopedia is a testament to the efforts of a
of cases, a topic that was covered in the context of large number of dedicated and talented people.
a larger topic did not receive its own entry; in First, I would like to thank the advisory board for
those cases, the smaller topic is listed with a cross- their time, effort, and encouragement, particularly
reference to the entry in which it is discussed. Lu Ann Aday and Michael Morrisey. I am indebted
to the many first-rate scholars and professionals
How the Encyclopedia Was Created who authored the entries. And, of course, I would
like to thank the publishing team at Sage, particu-
The encyclopedia was developed in six steps. larly Jim Brace-Thompson, Carole Maurer, and
First, leading health services researchers in the Laura Notton.
United States were invited to serve on the encyclo- I also appreciate the advice, counsel, and friend-
pedia’s advisory board. All the advisory board ship of my current and former colleagues at the
members are prestigious academicians, healthcare University of Illinois School of Public Health: Gary
managers, and researchers who have published in Albrecht, Kendon Conrad, Gregory Finlayson,
the field of health services research. Two of the Sally Freels, Benn Greenspan, Louis Rowitz, and
board members, Steven Shortell and Katherine Richard Sewell. Special thanks also go to Kathryn
Swartz, were former long-time editors of Health Langley and Jared Lane K. Maeda for their edito-
Services Research and Inquiry, respectively. rial assistance.
Second, the encyclopedia’s editors developed a On a personal level, I want to thank my wife,
draft list of topic headwords. To make sure the list Linda, for her unyielding support, and my two
was as comprehensive as possible, six journals that sons, Erik and Jason.
publish the majority of health services research
articles were reviewed for the past 10 years. The Ross M. Mullner
A
Before founding the AARP, Andrus established
AARP the National Retired Teachers Association
(NRTA) in 1947. Andrus’s initial goal was to
The AARP (formerly the American Association of promote her philosophy of productive aging and
Retired Persons) is the nation’s largest association to respond to the needs of retired teachers. After
representing individuals 50 years of age or older. successfully working with Davis to develop insur-
With more than 39 million members, the AARP is ance policies for them, Andrus developed other
an influential advocate at the federal, state, and benefits and programs, including an early dis-
local levels on public policy issues concerning count mail-order pharmacy service. With the
aging and the elderly, and it is also instrumental in growing success of the NRTA’s programs, thou-
shaping public opinion. The AARP conducts pol- sands of other retirees who were not teachers
icy research, publishes various reports and several wanted to obtain them. So in 1958, Andrus and
widely circulated popular magazines, and sells Davis established a new organization open to all
various products and services, including life and retired individuals—the American Association of
health insurance, prescription drugs, and travel Retired Persons (AARP). In 1999, the association
services. changed its name to AARP.
Membership
History
Membership in the AARP is open to any person
Ethel Percy Andrus (1884–1967), a retired
aged 50 or older. Members need not be U.S. citi-
California high school principal, and Leonard
zens or residents. Most members live in the United
Davis (1925–2001), a New York insurance execu-
States, although about 40,000 members live out-
tive, founded the AARP in 1958. Andrus taught
side the country. Although most AARP members
in California for many years, becoming that
are retired, more than 40% of its members work
state’s first female high school principal. After
part- or full-time, which is why the association
retiring, she became concerned with the poverty
shortened its name from the American Association
her fellow retired teachers experienced who were
of Retired Persons to simply AARP. The median
living on meager pensions. Davis, with Andrus’s
age of members is 65 years; slightly more than
encouragement and help, pioneered insurance
half of the members are women.
programs for retirees. He would eventually form
the Colonial Penn Group of insurance companies,
Vision, Mission, and Organizational Structure
and he went on to found the Leonard Davis
Institute of Health Economics of the University of The AARP is a nonprofit, nonpartisan organiza-
Pennsylvania. tion. Its vision is for a society in which everyone
1
2 AARP
ages with dignity and purpose, and it helps people affecting older Americans, taking public positions,
fulfill their goals and dreams. Its mission is dedi- and expressing its views to state and national law-
cated to enhancing the quality of life for all as they makers and regulatory agencies. The association
age and to leading positive social change and also undertakes selective litigation in age discrimi-
delivering value to members through information, nation, pension, healthcare, economic security,
advocacy, and service. and consumer cases.
The AARP is organized into a central headquar- To define its advocacy endeavors, the AARP
ters, state offices located in all 50 states, the reviews existing data, conducts its own research,
District of Columbia, Puerto Rico, and the Virgin and surveys its members to gather information on
Islands, and more than 2,500 local chapters their concerns and views. The association’s board
throughout the nation. Its national headquarter is of directors is given the task of discussing and bal-
located in Washington, D.C., to allow its staff and ancing various perspectives. The board hears from
volunteer leaders access to the federal government. experts, elected officials, business and industry
The national headquarters coordinates the activi- representatives, and a special advisory council con-
ties of the field operations and state offices and sisting of 25 volunteers. The council makes recom-
supports the initiatives of the local chapters, which mendations to the board, which then approves
are separately incorporated groups that provide federal, state, and local policies. The AARP’s top
members with opportunities to volunteer in their advocacy priorities currently include issues such as
own communities. State chapters identify areas of health, financial security, independence and long-
legislative concern locally and support volunteers term care, and consumer protection. The associa-
and staff as they work toward accomplishing the tion’s lobbying efforts helped the passage of
goals and objectives of the association and its Medicare Part D, the Medicare drug benefit, in
members. 2003. It was also instrumental in stopping changes
The association has two affiliates: the AARP to Social Security in 2005.
Foundation and AARP Services, Inc. The
AARP Foundation’s focus is to lead positive social
Criticism
change to help people aged 50 and older, espe-
cially the most vulnerable, by delivering informa- Over the years, the AARP has been sharply criti-
tion, education, and direct service to communities cized. Some have criticized the AARP’s lobbying
and families. Specific AARP Foundation pro- efforts, which they believe, in many instances, are
grams include various training programs, free tax geared primarily to advancing the association’s
preparation and counseling for seniors, and hom- business interests. Others have criticized AARP
eowner interests. AARP Services, Inc., is a wholly because it derives so much of its revenue from
owned subsidiary of the AARP. It manages a advertising, and selling insurance and other prod-
range of products and services made available to ucts, accusing the association of acting like a for-
the association’s members, provides marketing profit company. This allegation was taken so
services to the association and its member service seriously that in 1995, Republican Senator Alan
providers, and manages the association’s Web K. Simpson of Wyoming, then Chairman of the
site. Some of the programs that AARP Services, Finance Committee’s Subcommittee on Social
Inc., manages are Medicare supplement, long- Security and Family Policy, held hearings investi-
term healthcare, insurance (automobile, life, and gating the AARP’s nonprofit tax-exempt status.
homeowners), and member discounts and savings The investigation, however, did not reveal suffi-
on prescription drugs, eye health services, and cient evidence to warrant revoking its nonprofit
eyewear products. status. The association has also been criticized as
using scare tactics to frighten its older members to
influence their opinions. Last, the AARP has been
Advocacy Activities
criticized for assuming it can represent the views
The AARP is the largest advocacy group in of all its very large and diverse membership. Some
America for those 50 years of age and older. Its of its members were disappointed that it
advocacy activities include monitoring issues supported the passage of the Medicare Part D
Abt Associates 3
drug benefit, which they viewed as being poorly development, clinical trials and registries, and
designed, confusing, and complicated. business research. The company’s staff of more
than 1,000 is located in offices in Cambridge,
Ross M. Mullner and Cherie Weinewuth Lexington, and Hadley, Massachusetts; and offices
in Bethesda, Maryland; Chicago, Illinois; Durham,
See also Access to Healthcare; Health Insurance; Long- North Carolina; New York, New York; and more
Term Care; Medicaid; Medicare Part D Prescription than 35 project offices around the world.
Drug Benefit; Nursing Homes; Public Policy; The company has more than 30 years of experi-
Vulnerable Populations ence evaluating the effectiveness and impacts of
health programs and policy. Its comprehensive
process and outcomes evaluation and expert policy
Further Readings analysis help improve quality of medical care and
patient safety, expand access to care, lower costs,
Campbell, Andrea Louise. How Policies Make Citizens:
Senior Political Activism and the American Welfare
and empower consumer choice.
State. Princeton, NJ: Princeton University Press, 2003.
Public and private healthcare initiatives face
Hudson, Robert B. The New Politics of Old Age Policy. significant challenges to achieve desired outcomes
Baltimore: Johns Hopkins University Press, 2005. while managing shifting demands and ever-increasing
Morris, Charles R. The AARP: America’s Most Powerful costs. In addition, policymakers continue to explore
Lobby and the Clash of Generations. New York: new strategies to ensure that people receive appro-
Times Books, 1996. priate healthcare.
Osterlund, Hob. “The Nurses of AARP: For the First To assist clients as they address these issues, Abt
Time, Three Nurses Lead AARP—as President-Elect, Associates employs a variety of methodologies. It
Board Chairperson, and Board Member,” American performs complex quantitative evaluations, includ-
Journal of Nursing 106(8): 86–87, August 2006. ing analysis of large data sets and statistical and
“A Salute to William D. Novelli and AARP,” Caring econometric modeling. The company’s qualitative
25(11): 56–58, November 2006. evaluation capabilities include conducting focus
Van Atta, Dale. Trust Betrayed: Inside the AARP. groups, developing case studies, and reviewing the
Washington, DC: Regency, 1998. professional and scientific literature. It specializes
in surveying hard-to-reach and vulnerable popula-
tions, including people with chronic medical con-
Web Sites ditions, individuals with disabilities, HIV-positive
populations, families of children with special
AARP: http://www.aarp.org
healthcare needs, Medicare beneficiaries, and
Administration on Aging (AOA): http://www.aoa.gov
Medicaid recipients. Abt Associates’ capabilities
American Society on Aging (ASA):
include cost-effectiveness analysis, technology
http://www.asaging.org
assessment, performance measurement, drug/
National Council on Aging (NCOA):
http://www.ncoa.org
medical claims analytic file construction and analy-
National Institute on Aging (NIA):
sis, epidemiological studies, consumer satisfaction
http://www.nia.nih.gov evaluations, literature reviews and meta-analysis,
United Seniors Association (USA): and clinical trial design and analysis.
http://www.unitedseniors.org Abt Associates also has expertise and experience
in a wide range of domains, including community-
based health, maternal and child health, disability
and rehabilitation, post-acute care, mental health,
Abt Associates health disparities, health outcomes and patient
safety, healthcare finance, managed care, and
Founded in 1965 by Clark Abt, Abt Associates addiction prevention, treatment, and recovery.
applies scientific research, technical assistance, and Over the years, Abt Associates has analyzed
consulting expertise to a wide range of issues in numerous health policy issues, examining the
social, economic, and health policy, international impact of federal and state regulatory policy on
4 Abt Associates
provider behavior and quality of care. The Evaluating Drug Utilization and
company’s health economists and clinicians have Coverage and the New Medicare Benefit
developed and refined prospective payment and
Abt Associates worked with CMS to assess the
case-mix reimbursement systems for a variety of
impact of prescription drug coverage on Medicare
provider settings, analyzed the potential impact of
expenditures, to address design issues for the
new payment policies on healthcare outcomes and
evaluation of prescription drug programs, and to
expenditures, and evaluated the effect of regula-
analyze the determinants of per capita drug spend-
tory change on provider behavior.
ing for Medicare beneficiaries. In addition, the
Abt Associates works closely with clients to
company surveyed Medicare beneficiaries to assess
develop evaluation and analysis strategies that
their understanding of the new Medicare drug
provide the information they need to make
plan. Abt Associates is also working with CMS to
informed choices. Its skilled, multidisciplinary staff
design a more accurate methodology for estimat-
includes health services researchers, clinicians,
ing the costs of prescription drugs to pharmacies
data analysts, policy analysts, health economists,
and physicians. Researchers at Abt Associates have
statisticians, and survey research methodologists
also analyzed Medicaid drug expenditures, pro-
who combine technical knowledge and integrated
vided strategic consulting to state Medicaid pro-
perspectives derived from years of experience.
grams, and designed state-level drug insurance
Primary clients include federal and state healthcare
programs for senior citizens.
and public health agencies, national provider asso-
ciations, and foundations.
Evaluating the National Healthy Start Program
The federal Healthy Start program provides
Examples of Health comprehensive, community-based, perinatal health
Services Research Projects services to women, infants, and families in com-
Gathering Data on Home Health munities with high infant mortality rates. The
to Design a New Payment System program’s goal is to reduce disparities in birth out-
comes by increasing access to and utilization of
Under the Home Health Case-Mix Development
health services. Abt Associates is working with the
Project for the U.S. Department of Health and
Maternal and Child Health Bureau of the U.S.
Human Services’ Centers for Medicare and
Health Resources and Services Administration
Medicaid Services (CMS), Abt Associates collected
(HRSA) to conduct the national evaluation of
a wide range of data from a representative sample
Phase III of Healthy State. The company is con-
of home health agencies. It used this information
ducting an implementation analysis to assess the
to develop a model of home health resource use
success of 96 Healthy Start sites. This 2-year evalu-
and to design a system of case-mix adjustment for
ation will result in a detailed look at the effective-
use in Medicare’s per-episode prospective payment
ness of these sites and will help guide the program
system.
as it moves ahead.
Determining Appropriate Quality Indicators

Minimum Nurse Staffing Levels
Abt Associates and its partners are involved
Abt Associates and its partners assisted CMS with quality indicators (QIs) development, valida-
with a mandated report to the U.S. Congress on the tion, risk adjustment and analysis, and reporting
“appropriateness” of establishing minimum care- for CMS and the Agency for Healthcare Research
giver nursing staffing ratios for Medicare- and and Quality (AHRQ) as well as for states across
Medicaid-certified nursing homes. The first objec- various providers, including nursing homes, home
tive of the study was to determine whether mini- health care, hospitals, and health plans. The com-
mum nurse staffing ratios were appropriate. The pany has developed QIs for nursing homes, vali-
study then examined the potential cost and budget- dated the indicators through direct-care observation
ary implications of minimum ratio requirements. across a large, multistate sample, and worked with
Academic Medical Centers 5
states and CMS in public reporting. The culmina- Further Readings

tion of these efforts was the selection of the quality Franco, Lynne, Sara Bennett, and Ruth Kanfer. “Health
measures that are currently publicly reported Sector Reform and Public Worker Motivation: A
for all Medicare- and Medicaid-certified nursing Conceptual Framework,” Social Science and Medicine
homes. The company is developing new home 54(8): 1255–66, 2003.
health care measures in anticipation of federal pay- Lee, W. C., Y. E. Chavez, T. Baker, et al. “Economic
for-performance initiatives and assessing how con- Burden of Health Failures: A Summary of Recent
sumers, clinicians, and discharge planners will use Literature,” Heart and Lung: The Journal of
nursing home and home health care QIs to select Acute and Critical Care 33(6): 362–71,
post-acute providers. The company has worked November–December 2004.
with state organizations and is working with CMS Liu, Xingzhu, and Anne Mills. “The Influence of Bonus
to assess the best way to display hospital and Payments to Doctors on Hospital Revenue: Results of
health plan QIs to support consumer choice. It also a Quasi-Experimental Study,” Applied Health
supported the development of hospital nursing- Economics and Health Policy 2(2): 91–98, 2003.
sensitive measures and helped design the pilot ini- Minden, S. L., D. Frankel, L. Hadden, et al. “Access to
tiative for public reporting. Health Care for People with Multiple Sclerosis,”
Multiple Sclerosis 13(4): 547–58, May 2007.
Reddy, Prabashi. “Cost Comparisons of Pharmacological
Multiple Sclerosis Longitudinal Study Strategies in Open-Heart Surgery,”
Pharmacoeconomics 21(4): 249–62, 2003.
Abt Associates is conducting a 4-year epidemio-
Schneider, Pia. “Why Should the Poor Insure? Theories
logical longitudinal study of 2,000 adults with
of Decision-Making in the Context of Health
multiple sclerosis (MS) for the National Multiple
Insurance,” Health Policy and Planning 19(6):
Sclerosis Society. Also, the company is conducting
349–57, November 2004.
studies examining access to MS therapies and spe- Travis, Phyllida, Sara Bennett, Andy Haines, et al.
cialists, the characteristics of quality MS mental “Overcoming Health-Systems Constraints to Achieve
health services, and the psychosocial impacts of the Millennium Development Goals,” Lancet 364:
the disease. 900–906, September 4, 2004.
Wrobel, M. V., J. Doshi, B. C. Stuart, et al.
Analyzing the Economic “Predictability of Prescription Drug Expenditures for
Impact of Healthcare Regulations Medicare Beneficiaries,” Health Care Financing
Review 25(2): 37–46, Winter 2003.
Abt Associates assisted the U.S. Department of
Health and Human Services in analyzing the eco-
nomic impact of regulations that impose economic Web Sites
burden beyond their benefit. The company con-
ducted a series of town hall meetings across the Abt Associates, Inc.: http://www.abtassociates.com
country to receive public comment about quantify-
ing regulatory burden. It conducted a major review
of the literature to evaluate prior research and evi-
dence quantifying regulatory burden. And it con- Academic Medical Centers
ducted a series of expert interviews with providers
to gather detailed evidence on the economic bur- An academic medical center (AMC) is an organiza-
den of regulation in nursing homes, hospitals, tion whose mission encompasses emphases on
physician offices, and other healthcare providers. clinical care, research, and education. Typically, it
includes the following elements: an accredited
Peter Broderick medical school, one or more affiliated hospitals in
See also Epidemiology; Health Economics; Home Health which a majority of the medical staff are physician-
Care; Medicare Part D Prescription Drug Benefit; faculty members, hospital admissions that are pri-
Nurses; Public Policy; Quality Indicators; Vulnerable marily made by physician-faculty members, and an
Populations affiliated faculty practice plan that is tax-exempt
6 Academic Medical Centers
under federal law or is part of an exempt organiza- and evidence-based discipline present in this set-
tion under an umbrella designation. ting, promising clinical developments occur. An
example is the discovery of the prostate-specific
antigen (PSA), which led to a test that helps detect
Background prostate cancer in men of age 50 and older. AMCs
The modern structure of the AMC has its roots in also often curtail the introduction of techniques
the highly critical Flexner Report of 1910, which that are unsafe or lack efficacy. One such example
criticized medical education for its lack of an is the Jarvik artificial heart, which was banned
evidence-based approach and paved the way for when practitioners found that most of the recipi-
the modern, more allopathic approach. There was ents could not live more than half a year.
also a concomitant migration from the “commer-
cial” medical school of the time to formalized Prestige
programs of medical education. Subsequently, the
medical education model was characterized by an The output of AMCs significantly contributes
academic venue, staffed by scientifically rooted to the United States’ international presence and
faculty practicing in an associated teaching hospi- prestige. Healthcare is often a source of national
tal. The ensuing leap in the caliber of medical pride and economic benefit; thus, advances in sci-
education has seen highly complex organizational ence and medicine represent a significant portion
models and intricate connectivity through the of a nation’s economic and political agenda.
multifaceted mission that characterizes today’s
academic medical centers.
Physician Scientists
AMCs are essential to the development of the
Distinguishing Features United States’ base of young scientists. Federally
AMCs are differentiated from public health sys- funded programs such as the National Science
tems, community hospitals, and safety net health- Foundation’s Science, Technology, Engineering
care complexes in large measure due to distinct and Mathematics (STEM) program leverage AMCs
characteristics that came about with the advent to encourage the study of science, making these
of the AMC model of the 20th century. Additional centers important settings for training physician
distinguishing features, combined with the mul- scientists.
tifaceted mission of the AMC organization, go
well beyond the purely academic elements that
Preparedness
serve to differentiate AMC. These include the
following. Along with federal and local government agen-
cies, AMCs play an integral role in the United
States’ preparedness infrastructure for national
Technology emergency and terrorism response. Routinely seen
AMCs are on front lines of emerging technol- as the tertiary- and quaternary-care centers for the
ogy. They are the environment in which new clini- country in the event of any number of national
cal treatment methods and scientific advances are health scenarios (e.g., terrorism attacks, epidemics,
typically developed. The nature of translational bioscientific responses), AMCs play key roles in
research efforts and the setting in which tertiary drill scenarios. Without the involvement of AMCs,
and quaternary care is delivered embolden provid- the nation’s response armamentarium would be
ers to make critical advancements in care; as such, substantially less robust.
AMCs are the setting where these advances can
most efficiently occur. These advances take many
Challenges
forms, including new device development and test-
ing, as well as diagnostic and treatment protocols AMCs currently face a number of critical challenges,
and surgical techniques. With the scientific rigor including environmental factors associated with
Academic Medical Centers 7
healthcare economics, technology advances, Additional significant forces are on the horizon,
changes in the makeup of healthcare professions, although they are not unique to AMCs. For exam-
regulations, and, increasingly, political forces. ple, the availability of healthcare personnel is
Internal structural weaknesses can also arise expected to be significantly affected by the aging
from internal conflicts associated with the multi- workforce and declining enrollment in training
faceted missions typical of AMCs, further chal- programs, particularly nursing. In terms of train-
lenging their viability. There are also influencers ing programs, there has been a trend toward more
that revolve around future revenues and niche highly qualified and more costly caregivers (e.g.,
competition. master of science in nursing, doctorate of phar-
AMCs operate on a costly platform, in part due macy, doctorate of physical therapy) who are
to their aggressive development and adoption of increasingly unwilling to perform traditional tasks
emerging technology as well as investigational and associated with previous generations of healthcare
clinical protocols. The inherent inefficiencies of professionals. Healthcare professionals, who have
training clinical practitioners or scientific investi- in recent years earned high incomes, are an increas-
gators places further cost pressures on such cen- ingly attractive target for union organizers. If the
ters. There is broad recognition that the models efforts of these organizers are successful, unioniza-
under which AMCs operate will face substantial tion within AMCs personnel may increase in the
challenges in the years ahead, but a consensus is coming years. Medical travel, once considered a
lacking as to the direction AMCs should take in fairly isolated market force as far as its impact on
the future. the healthcare market is concerned, has also begun
On the immediate horizon are corresponding to draw more attention. International private-pay
environmental and internal issues that threaten the patients have been an important source of income
viability of AMCs and will drive the industry for AMCs; as international healthcare markets
response. Funding sources needed to support direct begin to mature, they are increasingly attracting
operating costs, as well as AMCs’ associated over- international as well as U.S. consumers of medical
head and infrastructure, are being constrained. services to travel abroad in search of less costly
Managed-healthcare penetration, along with fed- care in a more service-oriented environment.
eral and state-level clinical program revenues (e.g., Potential failure of “safety net” hospitals, particu-
Medicare and Medicaid), have diminished clinical larly in urban areas, could overload AMCs because
income streams available to these centers. Increasing they are a natural alternative to the typical alterna-
debt for medical school graduates is forcing a tive large urban provider of public acute and ter-
closer examination of tuition levels. And the per- tiary care.
centage of funded National Institutes of Health
(NIH) grant applications is declining along with
other sources of research funding. Philanthropy, Future Implications
another source of revenues on which AMCs are Despite the distinguishing characteristics of AMCs
highly dependent, can be volatile due to a depen- and their critical position in our national health-
dence on economic conditions affecting the very care infrastructure, these organizations are subject
wealthy. to numerous current and emerging political and
In the realm of economic challenges, another economic forces and will need to adapt in order to
high-profile issue is the threatened removal of the continue as essential contributors to our nation’s
not-for-profit tax status of AMCs. Regardless of health system. AMCs will be pressed to take a
whether the motive for this threat is to “punish” proactive approach to counter the negative forces
not-for-profit hospitals for not providing commu- they face entering the 21st century. Their ongoing
nity-based charitable care to a level consistent with success will require leadership and continued
the tax benefit received, or to serve as a source of national recognition for the major role these
property tax revenues for local government, a important institutions play in the support infra-
change in tax laws creating a substantial tax bur- structure of our society.
den on AMCs could severely affect the mission and
sustainability of these institutions. J. Robert Clapp and Andrew N. Garman
8 AcademyHealth
See also Access to Healthcare; Association of American practitioners. AcademyHealth represents nearly
Medical Colleges (AAMC); Flexner, Abraham; 4,000 individual members and 125 affiliated orga-
Hospitals; Inner-City Healthcare; Physicians; nizations in the United States and abroad.
University HealthSystem Consortium (UHC) AcademyHealth seeks to improve health and
healthcare by generating new knowledge and
moving knowledge into action.
Further Readings
Ashwali, Shally, Jil Beardmore, Jocalyn Clark, et al. The
Future of Academic Medicine: Five Scenarios to 2025. Mission
New York: Milbank Memorial Fund, 2005. To achieve its mission, AcademyHealth collabo-
Beck, Andrew H. “The Flexner Report and the rates with the health services research community
Standardization of American Medical Education,” and other key stakeholders to support the devel-
Journal of the American Medical Association 291(17):
opment of health services research by expanding
2139–40, May 5, 2004.
and improving the scientific basis of the field by
Cooke, Molly, David M. Irby, William Sullivan, et al.
increasing the capabilities and skills of researchers
“American Medical Education 100 Years After the
and promoting the development of the necessary
Flexner Report,” New England Journal of Medicine
355(13): 1339–44, September 28, 2006.
financial, human, infrastructure, and data sources.
Koenig, Lane, Allen Dobson, Silver Ho, et al.
It also seeks to facilitate the use of the best avail-
“Estimating the Mission-Related Costs of Teaching able research and information by translating
Hospitals,” Health Affairs 22(6): 112–22, research findings and the lessons of experience
November–December 2003. into useful information for clinical, management,
Moses, Hamilton, Samuel O. Their, and David H. M. and policy decisions, and enhancing communica-
Matheson. “Why Have Academic Medical Centers tion and interaction between health services
Survived?” Journal of the American Medical researchers and health policymakers. In addition,
Association 293(12): 1495–1500, March 23, AcademyHealth assists health policy and practice
2005. leaders in addressing major health challenges by
Newhouse, Joseph P. “Accounting for Teaching providing high-quality policy and technical assis-
Hospitals’ Higher Costs and What to Do About tance by offering educational programs that
Them,” Health Affairs 22(6): 126–29, advance the use of policy analysis and research
November–December 2003. and identifying areas where additional research
and information are needed.
AcademyHealth’s work concentrates its efforts
Web Sites and expertise on a variety of issues that are essen-
Association of Academic Medical Colleges (AAMC): tial to health policy making and practice. These
http://www.aamc.org include healthcare financing, organization, and
Health Resources and Services Administration (HRSA): delivery; the problems of the uninsured; the qual-
http://www.hrsa.gov ity and costs of care; public health systems and
National Science Foundation (NSF): http://www.nsf.gov issues; health information technology; and long-
University HealthSystem Consortium (UHC): term care.
http://www.uhc.edu
Background
AcademyHealth was established in June 2000 fol-
AcademyHealth lowing a merger between the Alpha Center and the
Association for Health Services Research (AHSR).
AcademyHealth (formerly the Academy for Health The Alpha Center was founded in 1976 as a
Services Research and Health Policy) is a nonfederally funded, regional health-planning center.
profit, nonpartisan resource for health services It evolved into a nonprofit, nonpartisan health
research and policy and the professional home for policy center dedicated to improving access to
health services researchers, policy analysts, and affordable, quality healthcare. The Alpha Center
AcademyHealth 9
provided expert technical assistance, objective AcademyHealth consists of 21 members who

analysis and research, and comprehensive educa- serve 4-year terms, with 5 members elected each
tion and facilitation services. year. Two candidate slates are developed, one for
The AHSR was formed in 1981 and was a election by the board and one for election by the
nonprofit professional society for individuals membership. The board elects two directors each
and organizations committed to health services year. The membership elects three. In June, the
research. Its mission was to educate consumers nominating committee submits the slate of board-
and policymakers about the importance of health elected candidates to the full board for its approval
services research, disseminate information gener- and election. The board also ratifies the slate of
ated by health services researchers, secure funding member-elected candidates. This slate is presented
for the field, and provide networking and profes- to the membership for election in September. The
sional development opportunities. board meets twice annually.
To better integrate the development of the field
of health services research with the use of research
to inform public- and private-sector decision mak- Membership
ers, the Alpha Center and the AHSR merged to
become the Academy for Health Services Research The membership of AcademyHealth is diverse,
and Health Policy in 2000. The integration of the including public policymakers, business decision
two organizations provided a strong foundation makers, health services researchers, policy ana-
for building a bridge between the research and user lysts, economists, sociologists, political scientists,
communities in the world of health policy and consultants, clinicians, and students. Through
practice. A year and a half after the merger, the journal subscriptions, conferences, professional
executive committee began to explore whether the development resources, and topic-specific interest
organization’s name accurately and effectively con- groups, AcademyHealth fosters networking and
veyed its mission, vision, and values. In 2003, the professional growth among its members by bring-
organization finalized its rebranding process, ing together a broad spectrum of players to share
unveiling its new identify, AcademyHealth, at its perspectives, learn from each other, and strengthen
2003 annual research meeting. working relationships.
AcademyHealth’s predecessor organizations Individual and organizational members receive
were historically at the forefront of the field of registration discounts for AcademyHealth meet-
health services research, organizing the initial pro- ings, complimentary subscriptions or reduced
fessional meeting of health services researchers in rates for more than 30 health publications, access
1983 and working with the academic, policy to online, members-only content on the Academy
making, and practitioner communities to provide Health Web site, and advocacy through the Coali
professional development and networking oppor- tion for Health Services Research (CHSR).
tunities. Building on their combined strengths, In 2004, AcademyHealth introduced interest
AcademyHealth provided a home for the growing groups, which convene members and nonmembers
multidisciplinary field and a vital resource for around focused topics for Web-based discussion
consumers of the field’s research. forums and annual or biannual meetings. Currently,
As the field of health services research has there are 15 interest groups addressing the topics
matured, AcademyHealth has devoted increased of (1) behavioral health services, (2) child health
attention to developing and supporting the finan- services, (3) disability research, (4) disparities,
cial, human, and data resources that make up its (5) gender and health, (6) health economics,
infrastructure. (7) health information technology, (8) health pol-
icy communications, (9) the health workforce,
(10) the interdisciplinary research group on nurs-
Organizational Structure
ing issues, (11) long-term care, (12) public health
AcademyHealth is led by a president and gov- systems, (13) quality, (14) research translation,
erned by a board of directors representing a and (15) state health research and policy.
broad range of experience in academia, clinical AcademyHealth Reports, the quarterly mem-
practice, and industry. The board of directors of bership newsletter, provides original articles on
10 AcademyHealth
issues affecting the field as well as regular updates developed and implemented. During this seminar,
on AcademyHealth-sponsored professional devel- Washington insiders provide an in-depth introduc-
opment and networking opportunities. Academy- tion to the key players, formal and informal
Health also publishes a monthly e-newsletter for policy-making process, and critical health policy
members, Member Update, and a quarterly news- issues. The program includes speakers, panel pre-
letter, Partners, comprising updates submitted by sentations, group discussions, site visits, and hands-
organizational affiliates. on tutorials.
AcademyHealth also develops full-day, expert-
led seminars in health services research methods.
Annual Meetings These seminars provide a forum for researchers
AcademyHealth hosts two major meetings each to enhance their academic and professional
year. The first, the National Health Policy knowledge base. It also offers courses designed
Conference, is held each February in Washington, for health policy professionals of all levels. These
D.C., and offers an in-depth look at key health courses give participants the tools they need
policy issues for the year ahead. The conference to learn how research affects policy decisions
brings together policy professionals, practitioners, and how to use existing data sources to inform
and researchers to discuss policy challenges, debate policymakers.
potential solutions, and identify the research In conjunction with the National Center for
needed to inform the policy process. Health Statistics (NCHS), AcademyHealth offers a
The second, the Annual Research Meeting, is health policy fellowship that brings two visiting
generally held each June. The meeting brings scholars in health services research–related disci-
together researchers from around the world to share plines to NCHS for a period of 13 to 24 months to
and discuss the latest health services research find- collaborate on studies of interest to policymakers
ings, learn new methods, debate policy issues, and and the health services research community using
network with colleagues. The Annual Research NCHS data systems.
Meeting is a key component of AcademyHealth’s
efforts to promote and expand the scientific basis
of the field. To ensure that the meeting presents Awards
top-notch research, AcademyHealth aims to have Each year, AcademyHealth recognizes individuals
at least 40% to 50% of the content chosen by peer who have made significant contributions to the
review. Approximately 50 meetings, large and fields of health services research and health policy.
small, are held in conjunction with the Annual The Alice S. Hersh New Investigator award recog-
Research Meeting. In addition, AcademyHealth nizes an outstanding early-career professional.
offers timely events and briefings to convene key The Article-of-the-Year award recognizes the best
stakeholders from the public and private sector scientific work that the field of health services
around critical health issues. research and health policy have produced and
published in the previous calendar year. The
Dissertation award honors an outstanding scien-
Seminars, Training, and Fellowships
tific contribution from a doctoral dissertation
AcademyHealth offers an array of seminars featur- in health services research. The Distinguished
ing comprehensive training in health services Investigator award is presented to an individual
research methods and health policy tools and tech- who has made a significant and long-lasting con-
niques. Seminars are offered in conjunction with tribution to the field of health services research,
the Annual Research Meetings and the National and the HSR Impact award recognizes health ser-
Health Policy Conference, as well as in smaller vices research that has had a positive impact on
meetings and cyber-seminars throughout the year. health policy and/or practice. In addition, the
AcademyHealth annually offers a 3½-day pro- Student Poster award annually recognizes the best
gram, the Health Policy Orientation, for individuals student poster presented at the Annual Research
interested in learning how national health policy is Meeting.
AcademyHealth 11
Working to Build the Field These activities supplement AcademyHealth’s

ongoing work to develop and represent its mem-
AcademyHealth has undertaken a number of ini-
bership base; provide professional development
tiatives to strengthen the infrastructure for health
opportunities for researchers, practitioners, and
services research, including a 2006 environmental
policymakers; assist in translating research into
scan to survey the perceived needs and expecta-
policy solutions and advocate for the field of
tions of both producers and consumers of health
health services research; and support funding and
services research. The resulting report, Strengthen
authorization for the federal agencies that rely on
ing the Field of Health Services Research: A Needs
its research.
Assessment of Key Producers and Users, draws
conclusions regarding the infrastructure needs and
research priorities of the field and suggests imme- Programs and Initiatives
diate and long-term actions to improve the impact
of the field’s research on health and healthcare. To facilitate translation of research into action,
The survey’s findings led to a 3-year initiative to AcademyHealth provides technical assistance to
assess, build consensus, and make recommenda- policymakers, researchers, government officials,
tions on strategies to address the future infrastruc- and business leaders, and it disseminates vital infor-
ture needs of the field of health services research. mation through research syntheses, special reports
A trilogy of summits in 2007, 2008, and 2009 will and findings, newsletters, and its Web site.
address workforce needs, methods and data, and AcademyHealth also serves as a program office or
knowledge transfer, respectively. Each will com- contractor for select foundation and government
mission new research, hold a meeting of stakehold- agency programs that complement its efforts to
ers to develop recommendations, and undertake build the field and stimulate demand for this type
dissemination activities to share those recommen- of research among policymakers and practitioners.
dations with key audiences.
In 2006, AcademyHealth convened a Methods
International Exchange
Council to assist in the development of strategies
for professional development in health services Through its International Exchange program,
research methods, respond to member-reported AcademyHealth seeks to inform U.S. policy mak-
needs, and anticipate future needs of the field. The ing with research and experiences of health sys-
council is made up of leading health services tems around the world. The program brings
research methodologists who represent a wide together experts from universities, foundations,
range of disciplines and expertise. Council mem- and policy centers to provide support that is non-
bers serve a 3-year term. Subcommittees carry out partisan and confidential. Its work includes both
specific tasks. AcademyHealth-sponsored initiatives and projects
The activities of the council include the follow- commissioned from outside organizations such as
ing: reviewing feedback and requests from mem- U.S. government agencies, international organiza-
bers for new methods offerings, assessing the tions, and private organizations. This includes
field’s current and future needs, selecting topics activities such as convening expert consultations
and faculty for the methods seminars, providing and workshops; establishing international work-
guidance and peer review of methods publications, ing groups to define shared research agendas and
and providing updates to the board on Academy- managing comparative research projects; facilitat-
Health’s research methods programs. ing contact with U.S. or foreign policymakers,
Among the council’s first activities was the cre- opinion leaders, and researchers; and producing
ation of a health services research glossary, which working papers on lessons learned for the United
is currently on the Internet at the AcademyHealth States and other nations.
Web site. It provides an organized, professional An example of such efforts is AcademyHealth’s
resource to help establish a common language and Health in Foreign Policy Forum. Held initially in
methods for health services research and assist 2005, the forum presents an overview of the many
individuals in comparing study methodologies. U.S. health policy challenges that have international
12 AcademyHealth
implications. Meeting topics have included global Coalition for Health Services Research
commerce and health, disease and international
AcademyHealth’s advocacy arm—the Coalition
security, and an in-depth focus on U.S. domestic
for Health Services Research (CHSR)—advocates
and foreign policy responses to the global shortage
for the health services research community in
of health professionals.
Washington, D.C. The coalition campaigns for
enhanced funding for agencies that support health
Public Health Systems Research services research and works to ensure that federal
agencies supporting the field continue to receive
To increase the visibility of public health reauthorization from the U.S. Congress. Some
systems research among federal and state policy- issues for which the coalition has played an instru-
makers, and to incorporate the priorities of key mental role include easing restrictions placed on
stakeholders, especially practitioners, into the researchers by the federal Health Insurance Por
national research agenda, with the aim of strength- tability and Accountability Act of 1996 (HIPAA)
ening the nation’s public health infrastructure, privacy regulations and maintaining a strong and
AcademyHealth is engaged in a series of projects independent peer-review process for federal grants.
aimed at supporting researchers, funding research, The coalition involves AcademyHealth member-
and bringing stakeholders together to link research ship in the federal legislative process and works in
to policy. partnership with other organizations that support
its goals. To broaden support for health services
National Programs research and health data, the coalition provides
AcademyHealth is the national office for the organizational support for both the Friends of the
Changes in Health Care Financing and Organization AHRQ and the Friends of the Centers for Disease
(HCFO) and the State Coverage Initiatives (SCI), Control and Prevention’s NCHS. These “Friends”
two national programs of the Robert Wood groups comprise key stakeholders for health ser-
Johnson Foundation (RWJF). The HCFO program vices research and health data, including providers,
supports investigator-initiated research and policy patients, businesses, academic health centers, uni-
analysis, evaluation, and demonstration projects versities, and health insurance plans.
examining major changes in healthcare financing Kristin Rosengren
and their effects on access, cost, and quality of
care. The SCI program provides technical assis- See also Agency for Healthcare Research and Quality
tance to state policymakers’ efforts to maintain (AHRQ); Health Services Research, Definition; Health
and expand health insurance coverage. Services Research, Origins; Health Services Research
Journals; National Center for Health Statistics
(NCHS); National Institutes of Health (NIH); Public
Federal Contracts
Policy; Robert Wood Johnson Foundation (RWJF)
Under contract to the Agency for Healthcare
Research and Quality (AHRQ), AcademyHealth
develops and implements long-range strategies to Further Readings
assist healthcare purchasers, health system leaders, AcademyHealth. Historical Analysis of Ownership and
and state and local policymakers in applying Publication Rights in Government Contracts for
research-based evidence to policy and program Health Services Research. Washington, DC:
development. Additionally, AcademyHealth and AcademyHealth, 2007.
the Cecil G. Sheps Center at the University of Austin, Bonnie J., and Emily A. Bosk. Administrative
North Carolina receive funding from the National Simplification Project: Case Study—Council of
Library of Medicine (NLM) to maintain the Affordable Quality Healthcare (CAQH). Washington,
library’s Health Services Research Projects in DC: AcademyHealth, 2008.
Progress (HSRProj) database. The database pro- Coalition for Health Services Research. Federal Funding
vides access to ongoing grants and contracts in for Health Services Research. Washington, DC:
health services research. Coalition of Health Services Research, 2008.
Access, Models of 13
Folsom, Amanda, Cyanne Demchak, Sharon B. Arnold, Additionally, access to healthcare must take
et al. Rewarding Results Pay-for-Performance: into account cultural competency, language inter-
Lessons for Medicare. Washington, DC: Robert Wood preter needs, and organizational issues that affect
Johnson Foundation and AcademyHealth, 2008. the continuity of care and delivery of services.
Trinity, Margaret, Enrique Martinez-Vidal, Isabel Resources, including location of facility, conve-
Friedenzohn, et al. State of the States: Rising to the nience of care in the community, the supply of
Challenge. Washington, DC: Robert Wood Johnson providers in shortage areas, and public and private
Foundation and AcademyHealth, 2008. financing of care, must also be considered. It also
requires defining what part of access to healthcare
Web Sites is being measured; that is, medical care, dental
care, mental healthcare, or substance abuse ser-
AcademyHealth: http://www.academyhealth.org
vices. The type of provider must also be identified
Agency for Healthcare Research and Quality (AHRQ):
as care physicians, physician assistants, nurses,
http://www.ahrq.gov
psychologists, dentists, pharmacists, social work-
Changes in Health Care Financing and Organization
ers, physical therapists, or other providers.
(HCFO): http://www.hcfo.net
Coalition for Health Services Research (CHSR):
To address an issue of this magnitude, it is often
http://www.chsr.org
helpful to use a model to systematically examine the
Health Services Research Projects in Progress (HSRProj): factors that contribute to obtaining access to health-
http://www.nlm.nih.gov/hsrproj care. Models are frameworks that use a theory or set
State Coverage Initiatives (SCI): of interrelated principles to explain or predict some
http://www.statecoverage.net aspect of behavior. Models can be used as a guide
for determining why persons are or are not gaining
access to healthcare. In addition, these models may
Access, Models of help us to identify what should be examined in
order to assist individuals in gaining access to care.
This entry reviews four models that have been
Measuring access to healthcare is a central part of
widely used to evaluate access to healthcare:
health services research and is driven by the com-
(1) the Donabedian structure-process-outcome
mitment to design and evaluate the delivery of
model, (2) the Andersen Behavioral Model, (3) the
health services. However, the task of measuring
health belief model, and (4) the theory of reasoned
access to healthcare is often complicated by the
action model. This review includes an overview of
lack of agreement regarding what actually consti-
the key components regarding each model, a dis-
tutes access to care.
cussion of the relationship between the model and
The nation’s news media often report stories of
access to care, and a brief critique of each respec-
different aspects of access to healthcare to stimu-
tive model.
late interest, including reports on the alarming
growth in the numbers of underinsured or unin-
sured persons; stories of discrimination by health- Models of Access to Healthcare
care providers; reports of persons who were denied
The Donabedian Structure-Process-Outcome Model
care in hospital emergency departments; and
accounts of individuals who were sick but could Developed by Avedis Donabedian at the School
not see a provider because one was not available. of Public Health at the University of Michigan in
While all these factors are considered access to the 1970s, the Donabedian structure-process-
healthcare, measuring it requires examining the outcome model (SPO) was constructed to examine
specific interpersonal needs of the individual such the quality of healthcare. It is also used as a means
as age, gender, race, economics, culture, disability, of examining both the use of medical services and
and sexual orientation, as well as provider issues the outcomes of the delivery of services. Since its
such as their availability, reimbursement for ser- development, the SPO model has been extensively
vices, provider liability issues, and commitment to used to measure health outcomes. This model
providing indigent care. examines access to healthcare by evaluating the
14 Access, Models of
providers and the organizations that deliver the health problem (depending on the nature and the
medical care (the structure of the medical delivery severity of the problem).
system), the amount of care delivered to the patient This model has been used extensively to identify
by these providers (the process of the medical-care systemwide factors that contribute to the outcome
delivery), and the outcomes of the care (death, dis- of care. Its benefit lies in providing a framework
ease, disability, discomfort, and dissatisfaction). that can be targeted to the end results of an activ-
This model has three key components that are ity, the use of medical services, satisfaction with
essential to its framework. First, researchers exam- services, improved health, and an increase in the
ine the structure of medical delivery by determin- number of health years alive or cost reduction. As
ing the appropriateness of necessary care within its such, it has been used as a program evaluation
given provisions. Donabedian suggests that patients tool. At the same time, the limits of the model lie
receive inappropriate care in this situation, espe- in its lack of information on an individual level,
cially when providers do not have the appropriate such as patient characteristics that interact with
amounts of training and experience to treat them. the delivery of services. Thus, it may not work as
Next, the process of medical delivery is examined well as measuring an individual’s success in seek-
by evaluating the extent to which the patients ing services as it would in mapping out what hap-
receive an equitable amount of care according to pens across a program.
their medical needs, looking at the health status or
severity of illness. Finally, the outcome of the deliv-
The Andersen Behavioral Model
ery of care is considered by determining the extent
to which the care results in an improvement in the Developed by Ronald M. Andersen at the Center
patient’s functioning. for Health Administration Studies at the University
In evaluating the system of medical delivery and of Chicago in the 1960s, the Andersen Behavioral
applying the SPO model, one should examine the Model (ABM) was constructed as a measure of the
structure and process of medical delivery; however, individual and organizational factors that contribute
one should also emphasize examining the impact to the use of and satisfaction with medical services.
of these factors on the outcome of medical delivery. It has evolved since then to include measures of envi-
Donabedian suggests that, in addition, one should ronmental and provider factors that influence access
evaluate the impact of care on a group of individu- to healthcare. The ABM focuses on examining the
als by linking up the structure and process of care predisposing, enabling, and need factors that facili-
with the outcome of care. According to Donabedian, tate access to care. It suggests that equitable access to
one should first examine the impact of the system care may be obtained through the utilization of ser-
of medical delivery on the outcome of care by link- vices as opposed to predisposing and enabling fac-
ing the providers, organization of medical delivery, tors. The need for care is reflected by health status.
and process of medical delivery to the degree of The ABM has three core components to its
improvement in the patient’s social and psycho- framework, including predisposing, enabling, and
logical functioning. Next, the impact of this system need factors. In the model, predisposing factors
can be examined by linking these to the extent to represent those factors that exist prior to any epi-
which the patient is satisfied with the care received. sode of illness such as health attitude; benefits; and
Third, they should be linked to the extent to which social demographic factors such as age, gender,
the patient’s knowledge of healthcare improves, race/ethnicity, marital status, and occupation. In
following the treatment of his or her illness. Finally, this model, organizational and financing factors
they should be linked to the extent to which the serve as the enabling factors that facilitate the use
patient’s overall health improves as a result of the of medical services. Organizational factors include
care received. On the basis of this model, patients having the usual source of care, a supply of provid-
receive appropriate access to care when they are ers, and the availability and convenience of ser-
treated by competent providers who deliver services; financing factors include the availability and
vices that are comparable in type and volume with extent of health insurance coverage. In the ABM,
those of other competent providers. In turn, this need factors represent either the patient’s subjec-
results in an improvement in the outcome of the tive assessment of their need for service, such as the
Access, Models of 15
number of disability days, limitations in activities, measure equity in the use of services. The model
and perceived health status or an objective measure focuses on examining how an individual internal-
of the need for care, including a measurement of izes a problem and whether or not it has become a
the severity of a disease. problem that is big enough to warrant immediate
In the application of the ABM to examining action; it does this without considering self-imposed
access to healthcare, one is expected to use all three or systematic barriers that may also exist. This
components of the model to measure barriers to assessment usually focuses on examining the indi-
the equitable receipt of services. This approach vidual’s perceived susceptibility, severity of illness,
would involve using the predisposing factors as benefits, barriers, cues to action, and self-efficacy.
measures of determining the fairness in the delivery Specifically, the HBM measures six core compo-
of services: Thus, if there were significant differ- nents: perceived susceptibility by determining the
ences in access to care by gender, then the medical risk of an individual of contracting an illness as a
system would be seen as providing inequitable care. result of not taking an action; perceived severity by
In examining the delivery of care by these predis- assessing how a serious illness may affect him or
posing factors, one would also need to account or her; perceived benefits by measuring the degree to
control for the enabling and need factors. Under which the individual follows a recommended
this approach, equitable access is achieved when it behavior; perceived barriers by measuring the per-
is determined by the need for services and not by ception of the negative aspects of not taking action;
predisposing or enabling factors. cues to an action by focusing on the trigger events,
On the positive side, the ABM is widely used or prompts, that either heighten an awareness of
in both descriptive and analytical research as a the importance of an activity or motivate an indi-
benchmark for examining access to healthcare as it vidual to take action; and self-efficacy by examin-
is a robust model from a measurement point of ing the extent to which an individual can successfully
view. On the other hand, earlier versions of the execute a given behavior.
model have been criticized for not adequately mea- When applying the HBM, access is measured by
suring the influence of culture and cultural compe- the specific reason for care, such as a visit for
tency and the influence of the political environment immunization or health screening. The observed
on care. It does not take into account the ever- behavior is studied against the individual factors
changing world of healthcare financing and orga- that traditionally serve as obstacles to seeking care,
nizational policies, as found in managed-care and the trigger event that led to the action of seek-
organizations. Some researchers have found the ing out care is determined.
model too cumbersome with its reliance on the The HBM has been widely used as a means to
need to have data on an array of factors to mea- design and implement health educational and
sure access to care. Finally, some argue that the health behavior interventions. Its strengths lie in its
model lacks the ability to capture aspects of the ability to help map out the direction between an
patient-provider interaction process. individual’s thinking about a behavior and his or
her readiness and willingness to change. However,
while the model has been widely used to test health
The Health Belief Model
behaviors, it has been criticized as not being uni-
Developed by Godfrey Hochbaum and other formly used. Some researchers have used only parts
researchers at the U.S. Public Health Service in the of the model and not all the components together.
1950s, the health belief model (HBM) was con- Additionally, some of the components of the model
structed as a means of examining factors that led have not been validated or tested. Last, the HBM
to a onetime change in behavior such as screening has also been criticized for not accounting for
or immunization. It was later modified by M. H. either normative behaviors or cultural factors.
Becker to examine the use of medical services. The
HBM is now used both as a means to examine the
The Theory of Reasoned Action
individual’s motivation to change some aspect of
his or her lifestyle, including diet, smoking, exer- Developed by Martin Fishbein and Icek Ajzen
cise, condom use, and medication use, and to at the University of Illinois in the 1970s, the theory
16 Access, Models of
of reasoned action (TRA) is based on the notion Future Implications

that humans are able to rationally think about and
Measuring access to healthcare is a complicated
respond to behavior based on weighing the costs
process that requires the use of some organizing
and benefits of any given action. The key compo-
framework or model for examining the factors
nents of the TRA model focus on measuring the
that facilitate entry into the medical delivery sys-
subjective norms regarding a behavior, measuring
tem. Four models were presented as examples of
the attitude toward a behavior, and measuring
frameworks that are currently used to examine
how the attitudes and subjective norms can either
access to healthcare. While each of these models
lead to the intended act or actually execute some
has its own strengths and weaknesses, their col-
type of behavior.
lective utility lies in their ability to help research-
Under the TRA model, researchers measure the
ers and policymakers to use indicators for measuring
subjective norm by examining what they think is
the various components of access to healthcare.
important or what they think others want them to
This assists in achieving an important objective
do. This is influenced by their knowledge of the
in health services research—the promotion of
factors that contribute to any given norm. Attitudes
theory-driven as opposed to data-driven research.
toward a behavior are measured by the degree to
Even if researchers are wedded to a particular
which an individual agrees or disagrees with a par-
model in looking at access to care, it is important
ticular behavior. Last, researchers measure behav-
to use an organized framework to guide the
ioral intent by developing and using measures that
work. Otherwise, the efforts would just be ana-
are closely related to the actual performance of a
lyzing the data without some sensitivity to
behavior.
whether or not some of the measures are dupli-
Under the TRA, access to healthcare is consid-
cative or poor measures of a concept. In addi-
ered a function of the consumers’ understanding of
tion, by using a framework to drive the
the importance of seeking out health services and
examination, researchers can add to the knowl-
their willingness to follow up with an interest in
edge base by discovering how the framework or
obtaining care to actually get into the medical sys-
model can be modified to better measure access
tem. It assumes that knowing something is impor-
to healthcare.
tant and having a favorable attitude about it is a
necessary precursor to obtaining access to health- Llewellyn J. Cornelius and Kieva A. Bankins
care. However, access to care is really reflected by
the documentation that a person engages in obtain- See also Access to Healthcare; Andersen, Ronald M.;
ing care that helps her or him. Donabedian, Avedis; Health Insurance; Hospitals;
Like the HBM, the TRA model has been used Physicians; Structure-Process-Outcome Quality
extensively to examine a person’s willingness to Measures
engage in healthy behaviors. This model focuses
on the role of knowledge and attitudes in seek-
ing care. Thus, its strength lies in its ability to Further Readings
examine the individual’s motivation to seek care. Andersen, Ronald M., Thomas H. Rice, and Gerald F.
However, most of the applications of the model Kominski, eds. Changing the U.S. Health Care
have been related to examining behavioral inten- System: Key Issues in Health Services Policy and
tions rather than to actual behavior. As it relates Management. 3d ed. San Francisco: Jossey-Bass, 2007.
to access to healthcare, the model has been used Gold, Marsha. “Beyond Coverage and Supply:
more to determine whether or not someone Measuring Access to Healthcare in Today’s Market,”
would intend to seek medical care, rather than Health Services Research 33(3 pt. 2): 625–52, August
whether he or she actually obtained care. A 1998.
second weakness of the TRA is a lack of consid- Hendryx, Michael S., Melissa M. Ahern, Nicholas P.
eration of the organizational and structural Lovrich, et al. “Access to Health Care and
barriers, such as financing and environmental Community Social Capital,” Health Services Research
obstacles. 37(1): 85–101, February 2002.
Access to Healthcare 17
Millman, Michael, ed. Access to Health Care in America. Ensuring access to providers and facilities is
Washington, DC: National Academies Press, 1993. related both to the distribution of these services
Ricketts, Thomas C., and Laurie J. Goldsmith. “Access and the choices consumers make regarding where
in Health Services Research: The Battle of the to go for care. Without an adequate supply of
Frameworks,” Nursing Outlook 53(6): 274–80, providers and facilities for health services, patients
November–December 2005. may have to either delay seeking care or travel
Williams, Stephen J., and Paul R. Torrens, eds. long distances to obtain services. This process of
Introduction to Health Services. 6th ed. Albany, NY: finding the right match between the patient, the
Delmar, Thomson Learning, 2002.
providers, and the facilities is further complicated
by the fact that care at these settings is often pro-
vided by a mix of providers, including physicians,
Web Sites nurses, physician assistants, physical therapists,
pharmacists, social workers, and psychologists,
rather than being provided solely by a physician.
http://www.ahrq.gov
American College of Healthcare Executives (ACHE):
However, the physician has been and remains the
http://www.ache.org
central component of the delivery of healthcare
National Center for Health Statistics (NCHS): services, either in an office-based practice or in a
http://www.cdc.gov/nchs hospital-based practice.
National Conference of State Legislatures (NCSL):
http://www.ncsl.org Access to Providers
Robert Wood Johnson Foundation (RWJF):
http://www.rwjf.org As regards the distribution of providers, one of
the long-standing issues in the quest to equitably
distribute physicians across the country is deter-
mining whether a sufficient number of physicians
are being trained to meet the needs of patients.
Access to Healthcare Additionally, consideration must be given to
whether these physicians can be encouraged to
Access to healthcare can be defined as the oppor- work in historically underserved geographic areas,
tunity or right to receive care. One of the indica- such as inner-city and rural areas. In 2004, there
tors of access to healthcare focuses on the were 884,974 practicing physicians in the United
availability of medical providers and facilities for States, 81% of whom worked in metropolitan
care. A second set of indicators focuses on the areas, while 19% worked in nonmetropolitan
availability of resources to pay for care. A third areas. The overall number of practicing physicians
set of indicators focuses on the use of medical has increased during the past two decades: In
services. These indicators are interrelated to each 1980, there were 443,502 active physicians in the
other, yet they measure different aspects of access nation. The number of medical school graduates
to healthcare. This entry highlights the national grew by 12% between 1982 and 1998, but the U.S.
trends in the availability of medical providers and population increased by 24% during the same time
facilities, trends in the availability of resources to period. The increase in the supply of physicians has
pay for care, and trends in the use of healthcare not kept up with the nation’s population.
services. Several government policies have been used since
World War II to foster the equitable distribution of
physicians across the nation. These policies include
Access to Medical Providers and Facilities
the federal government offering incentives to states
One of the issues in ensuring access to care is mak- to increase the number of medical students and
ing sure that patients have access to the medical reducing immigration barriers to international med-
providers they need to see and the facilities they ical graduates, the development and use of a needs-
need to go to when they need health services. based approach by the Graduate Medical Education
18 Access to Healthcare
National Advisory Committee (GMENAC) to man- In exchange for receiving hospital construction
age the distribution of physicians, and the recruit- grants, these hospitals were required to provide
ment of medical specialists into managed-care free care for 20 years to eligible persons unable to
organizations in the 1980s to match the expansion pay for healthcare services. The act was later
in the number of these organizations. Efforts to amended to include assistance for construction
encourage physicians to practice in underserved and modernization of nursing homes, rehabilita-
areas have been recently complicated by declining tion facilities, outpatient facilities, and public and
healthcare reimbursement rates and increasing mal- nonprofit health centers. The federal government
practice insurance rates. In terms of reimbursement has used the Civil Rights Act of 1964 to force Hill-
rates, the federal government has traditionally reim- Burton hospitals not to discriminate for receiving
bursed healthcare providers at a lower rate for ser- construction grants. In 2005, there were 316 Hill-
vices provided under the Medicaid program than Burton-obligated facilities in the nation.
that received from private health insurance compa- While the Hill-Burton Act led to an increase in
nies. As a result, providers who practice in poor the number of healthcare facilities, government
communities run the risk of receiving less payment regulation, decreasing reimbursement, increased
per patient than those medical professionals who competition, and the growth of managed care dur-
practice in other more affluent communities. ing the past decades have led to many hospital
Additionally, several malpractice insurance crises closures across the nation. Between 1980 and
since the 1970s have discouraged providers from 2004, the total number of hospitals in the nation,
practicing in certain communities or in certain including community and specialty hospitals,
medical specialties, such as obstetrics. declined from 6,959 to 5,759. The majority of
In response to the gaps in the distribution of closures occurred among community hospitals,
physicians in underserved communities, physician which declined from 5,830 to 4,919; similarly,
assistants and nurse practitioners have been given not-for-profit hospitals decreased from 3,322 to
more latitude with regard to the healthcare ser- 2,967, and the number of state and local govern-
vices they can provide. While this approach may ment hospitals declined from 1,778 to 1,117. On
be necessary in poor communities with physician the other hand, the number of for-profit hospitals
shortages, there are discussions within professional in the nation increased during this period from 730
medical organizations regarding the optimal mix to 835.
of these adjuncts to the physician labor force. Since the initiation of community health centers
in 1965, the number of federally funded health
centers has grown to more than 1,000. More than
Access to Facilities
one third of the patients seen in these centers in
In 2004, of all the practicing physicians in the 2004 were Latino; another quarter were African
nation, 700,287 provided direct patient care. Of American. The health centers serve as a major
these, 77% worked in an office-based practice, source of care for the uninsured and those on
while 23% worked in a hospital-based practice. As Medicaid. While the number of community health
such, in discussing the issue of access to physicians, centers has increased by 58% between 1997 and
one must also look at medical facilities as a place 2004, this growth has not kept up with the rising
where services are provided. rate of the uninsured during the same period.
Several federal policies have been developed to
foster the equitable distribution of medical facili-
Access to Resources to Pay for Care
ties across the nation. These policies include the
construction and expansion of hospitals under the Like the issue of access to providers and medical
Hospital Survey and Construction Act of 1946, facilities for services, access to a means to pay for
also known as the Hill-Burton Act, and the devel- care continues to play a critical role in ensuring
opment of community health centers to provide that consumers obtain access to care. Access to
care for the poor. resources is a function of both having healthcare
The Hill-Burton Act was passed to promote the insurance and having adequate insurance cover-
modernization of nonprofit hospitals in the nation. age as the lack of insurance coverage translates
Access to Healthcare 19
into barriers to getting to see a provider. As noted Recent trends, however, indicate that some large
by the Kaiser Commission on Medicaid and the companies have elected to not provide health insur-
Uninsured in 2003, 42% of those who were unin- ance for their employees, and this practice changes
sured did not have a regular source of care. In workers’ expectations for job-based coverage at
contrast, only 9% of individuals with insurance large organizations. For example, between 2001
reported not having a medical home, a provider, and 2005, the percentage of poor employees who
or a facility to go to when needing care. Nearly had employer-based health insurance coverage
half, 47%, of those who were uninsured had to dropped from 37% to 30%, while the percentage
delay seeing a medical-care provider because of of near-poor employees who had employer-based
the costs of care, compared with 15% of those health insurance dropped from 59% to 52%. It
who had healthcare insurance. should be noted that the number of persons who
On the surface, one can address the first issue are uninsured all year is typically less than that of
by simply noting whether or not the consumer can those who were uninsured at any time during the
pay for care out of pocket or whether he or she has year. At the same time, the number of adults who
some form of insurance to pay for care. Public have some limitations in coverage is often higher
health insurance programs, including Medicare, than the number of uninsured adults. One of the
Medicaid, State Children’s Health Insurance underlying reasons for the number of underinsured
Program (SCHIP), Veterans Health Administration, adults is the lack of parity between types of insur-
TRICARE, and private insurance can be individual ance coverage, such as health, dental, substance
coverage plans or employer-sponsored health ben- abuse, and mental health coverage. Because deduct-
efits that can be used to pay for care. Both the ibles are traditionally higher for dental, substance
scope of coverage and limitations of services need abuse, and mental health coverage, patients often
to be considered, which affect the type of care delay seeking services and care in these areas.
patients can seek and receive. Types of coverage
include preventive care, chronic condition care,
outpatient care, inpatient care, long-term care, Use of Services
mental health, substance abuse services, and pre-
scription drug benefits. Similarly, insurance premi- While the availability of medical providers, medical
ums, deductibles, coinsurance, caps on coverage, facilities, and health insurance coverage are critical
and exclusions help determine whether an indi- parts of access to healthcare, it is the actual utiliza-
vidual has adequate health insurance or not. tion of medical services that demonstrates the extent
With regard to the first issue, the extent of the to which persons are actually getting to see their
gap in access to availability of care is usually deter- provider when they need care. Overall nation trend
mined by identifying the number of people who are data on the number of patient visits, including those
uninsured at any given point of the year, the num- for ambulatory care, inpatient stays, dental, mental
ber who are uninsured all year long, or the number health, and substance abuse services, have shown
who were uninsured for more than a year. In 2005, that the majority of Americans are gaining access to
there were 46 million Americans without health these services and the average volume of visits has
insurance coverage at some point during the year, increased. For example, 61% of the nation’s popu-
which amounts to about one in five adults. Two lation made at least one visit to a physician in 1964,
thirds of the uninsured are low income, and 8 in 10 while 84% of the population made one visit to a
come from working families. Poor families are physician in 2002. In 1964, 43% of Americans
twice as likely as other groups to be uninsured. made at least one visit to a dentist, compared with
Latinos and Native Americans are the most likely 65% in 2002. Additionally, hospital admissions
to be uninsured, followed by African Americans, grew from 11 per 100 persons in 1964 to 12 per
Asian Americans, and Whites. Adults between the 100 persons in 2002. The average number of physi-
ages of 19 and 34 are more likely to be uninsured cian visits for Americans per year increased from
than those of other age groups. Historically, employ- 4.9 in 1964 to 5.6 visits per year in 1996. In 1987,
ees of small companies are more likely to be unin- there were 3.2 visits to a psychotherapist per 100
sured than those who work for large companies. persons. This rate remained unchanged in 1997.
20 Accreditation
Between 1992 and 1999, significant increases in Aday, Lu Ann, Charles E. Begley, David R. Lairson, et al.
hospital emergency department use were noted Evaluating the Healthcare System: Effectiveness,
among persons 55 to 64 years of age and unem- Efficiency, and Equity. 3d ed. Chicago: Health
ployed adults. During this time period, the volume Administration Press, 2004.
of emergency department visits increased from 89.2 Gulliford, Martin, and Myfanwy Morgan, eds. Access to
million to 102.8 million annually. This increase was Health Care. New York: Routledge, 2003.
a result of more illness-related visits as opposed to Hall, Allyson G., Christy Harris Lemak, Heather
injury-related visits. There were an estimated 85 Steingraber, et al. “Expanding the Definition of
Access: It Isn’t Just About Health Insurance,” Journal
million visits made to outpatient departments in
of Health Care for the Poor and Underserved 19(2):
2004. In 2003, federally qualified health centers
625–38, May 2008.
(FQHCs) reported 50 million patient encounters for
Millman, Michael, ed. Access to Health Care in America.
12 million patients. Of these patients, 90% had
Washington, DC: National Academies Press, 1993.
incomes below 200% of the federal poverty level Morgan, Myfanwy. “What Is the Goal of Access to
(FPL), 39% were uninsured, and 64% were of an Health Care?” Journal of Law and Medicine 15(5):
ethnic or racial minority. 742–51, May 2008.
Future Implications
Web Sites
The availability of healthcare providers and facili-
ties and the availability of resources to pay for http://www.ahrq.gov
care and the utilization of services are interrelated Bureau of Health Professions (BHPr): http://bhpr.gov
measures of access because they reflect the com- Centers for Medicare and Medicaid Services (CMS):
plexities of obtaining care. For example, having a http://www.cms.hhs.gov
regular provider is seen as important because a Henry J. Kaiser Family Foundation (KFF):
well-synchronized provider-patient relationship http://www.kff.org
can lead to appropriate utilization. Having a pro- National Center for Health Statistics (NCHS):
vider in itself, however, does not equal medical http://www.cdc.gov/nchs
utilization, but it can lead to effective medical use. Robert Wood Johnson Foundation (RWJF):
The same can be said for having a means to pay http://www.rwjf.org
for care. While having healthcare insurance is not
the same as using healthcare services, it alleviates
some of the barriers to obtaining care when
needed. Today and in the near future, access issues Accreditation
are important because of the large and growing
number of uninsured and the continuing maldis- Accreditation is a voluntary process through
tribution of physicians. which healthcare institutions and programs are
held accountable for meeting quality require-
Llewellyn J. Cornelius and Kieva A. Bankins ments or standards. Accreditation involves a
See also Access, Models of; Health Disparities; Health
rigorous evaluation carried out by an external
Literacy; Inner-City Healthcare; Rural Health; independent accrediting organization. When
Transportation; Uninsured Individuals; Vulnerable healthcare institutions and programs gain accred-
Populations itation, such accreditation can be viewed as an
endorsement resulting from having met the iden-
tified requirements. While accreditation is volun-
Further Readings tary, it may be required or accepted in lieu of
Aday, Lu Ann. At Risk in America: The Health and other requirements to be deemed eligible for par-
Health Care Needs of Vulnerable Populations in the ticipation in government healthcare plans and
United States. 2d ed. San Francisco: Jossey-Bass, funding. For example, the federal Centers for
2001. Medicare and Medicaid Services (CMS) requires
Accreditation 21
that companies participating in Medicare Part D nations. The Joint Commission has also established
prescription drug coverage have approved an international division (Joint Commission
accreditation. International) to accredit institutions and programs
outside the United States.
History
Accreditation Process
The accreditation of healthcare institutions orig-
inated in the United States in the early 20th cen- The accreditation process often begins with a self-
tury. In 1917, the American College of Surgeons assessment by the applicant institution or program.
set up a program of standards to define suitable This is followed by an on-site visit by a survey
hospitals for surgical training. This eventually team from the accrediting organization. The sur-
developed into a multidisciplinary program of vey team often consists of a multidisciplinary
standardization, which in 1951 led to the estab- group of healthcare professionals. During the sur-
lishment of the independent Joint Commission vey process, the team may visit various units of the
on Hospital Accreditation. Over time, that orga- institution, and they may conduct interviews with
nization, which today is the Joint Commission, leaders, professional staff members, and others. A
has greatly expanded its focus, and it now detailed report of the findings from the survey visit
accredits 10 types of institutions and programs, and any recommendations for improvements are
including the following: ambulatory care; assisted presented to the institution. Finally, if the institu-
living; behavioral healthcare; critical access tion or program demonstrates that it meets the
hospitals; home care; hospitals; laboratory ser- agreed standards, it is awarded accreditation.
vices; long-term care; networks; and office-based It is customary for applicant institutions and
surgery. programs to put substantial effort into the prepa-
Although the Joint Commission is the largest ration for accreditation. To help with the process,
healthcare accrediting body in the nation, many accrediting organizations often provide or sell
other accrediting organizations have been estab- materials and consultation services to help prepare
lished that accredit many types of healthcare insti- the institutions and programs for the impending
tutions and programs. For example, the American evaluations.
Osteopathic Association’s Healthcare Facilities The survey teams use specific standards to
Accreditation Program (HFAP) accredits acute- evaluate the institutions and programs. Usually
care hospitals and hospital laboratories; the developed by the accrediting organization, these
National Committee for Quality Assurance (NCQA) standards work in tandem with accreditation, as
accredits health plans, managed behavioral-health- they are the benchmarks relied on in the accredita-
care organizations, managed-care organization, tion process. The standards are revised and updated
preferred provider organizations, and disease on an ongoing basis to reflect the most current
management programs; and URAC (formerly understanding of processes, procedures, and struc-
known as the Utilization Review Accreditation tures that result in improved healthcare outcomes
Commission) accredits many institutions and and performance. Previously standards were often
programs, including case management, claims conceptualized as minimum requirements; today,
processing, disease management, drug therapy however, the standards reflect optimal achievable
management, and pharmacy benefit management. levels of quality.
Most accreditation organizations are nonprofit Accreditation is typically awarded for a limited
tax-exempt organizations. period of time. This enables the periodic evalua-
The past several decades have also witnessed the tion of the applicant institutions and programs,
establishment of many healthcare accreditation and it enables standards to be updated to reflect
organizations across the world. The number of the latest research findings and guidelines to be
such organizations has doubled every 5 years since enacted by the accrediting organizations. For
1990. For example, there are now 11 healthcare example, Joint Commission accreditation is
accreditation organizations in various European awarded for a period of 2 or 3 years, depending
22 Activities of Daily Living (ADL)
on the type of organization or program (2 years Further Readings

for laboratory accreditation, 3 years for all oth- Greenfield, David, and Jeffrey Braithwaite. “Health
ers). Starting in 2004, however, the Joint Sector Accreditation Research: A Systematic Review,”
Commission introduced a Periodic Performance International Journal for Quality in Health Care
Review component requiring some accredited 20(3): 172–83, June 2008.
institutions and programs to demonstrate continu- International Society for Quality in Health Care. Quality
ous compliance. and Accreditation in Health Care Services: A Global
Review. Geneva, Switzerland: World Health
Benefits and Limitations Organization, 2003.
Paccioni, Andre, Claude Sicotte, and Francois
Benefits of accreditation of healthcare institutions Champagne. “Accreditation: A Cultural Control
and programs include the following: the greater Strategy,” International Journal of Health Care
standardization of policies, procedures, and Quality Assurance 21(2): 146–48, 2008.
records; improved measurement of clinical and Viswanathan, Herma N., and J. Warren Salmon.
nonclinical indicators; improved quality of care “Accrediting Organizations and Quality Improvement,”
and services; improved patient safety; increased American Journal of Managed Care 6(10): 1117–30,
marketability to the public and prospective work- October 2000.
force; decreased liability expenses; eligibility to
participate in certain government programs; satis-
faction of certain government reporting require- Web Sites
ments; and compliance with certain mandated Joint Commission: http://www.jointcommission.org
regulations. National Committee for Quality Assurance (NCQA):
Limitations of accreditation include inconsis- http://www.ncqa.org
tencies between applicable regulations and URAC: http://www.urac.org
accreditation requirements, the high costs asso-
ciated with maintaining accreditation, and
mixed findings from research on the efficacy of
accreditation.
Activities of Daily
Future Implications Living (ADL)
The increasing trend toward the accreditation of
Activities of daily living (ADL) are actions per-
healthcare institutions and programs demonstrates
formed on a daily basis to maintain personal
a commitment to quality. Through the increasing
hygiene and carry out basic activities of living inde-
reliance on outcome-based methods of quality
pendently. Measuring ADL constitutes an impor-
improvement, the efficacy of accreditation is
tant element of health research programs and
beginning to be understood. Studies have shown
interventions targeting both the elderly and people
some promising findings, but the literature reports
with disabilities. Originally developed by Sidney
mixed findings on many measures of improve-
Katz in the late 1950s, the Index of Independence
ment related to healthcare accreditation, and
of Activities of Daily Living, or Index of ADL, is
more research is needed. Though accreditation is
one of the oldest and most widely used health mea-
not mandatory, it is becoming increasingly critical
sures. Over the years, Katz’s system has been
to healthcare institutions and programs.
modified and expanded.
Paul J. Erickson
Types
See also Joint Commission; Medical Errors; National
Committee for Quality Assurance (NCQA); Activities of daily living are broadly classified
Outcomes-Based Accreditation; Patient Safety; Quality into two categories: (1) basic activities of daily liv-
of Healthcare; Regulation ing (BADL) or personal activities of daily living
Activities of Daily Living (ADL) 23
(PADL) and (2) instrumental activities of daily functional assessment protocols to assess the need
living (IADL). A recently created third cate- for home, long-term, or nursing home care and
gory, advanced ADL, includes activities related hospitalization.
to occupation, recreation, and community inter-
actions. ADL and IADL are self-reported, while
advanced ADL is assessed on a case-by-case basis Functional Disability
in clinical settings.
Functional disability is a limitation in the perfor-
BADL are eating (i.e., using eating utensils,
mance of tasks of daily living such as maintaining
drinking), personal grooming (i.e., washing face,
personal hygiene and living independent of family
brushing teeth, cutting toenails, brushing hair,
or outside help. Functional impairment is not a
shaving, and bathing), using the toilet, ability to
uniform construct; it is multifaceted and can be
transfer from a chair to bed and to a toilet, sitting
measured with various clinical instruments.
and rising from a chair, getting in and out of bed,
Functional status is an important determinant of
walking inside the residence, stair climbing, being
self-rated health in the elderly. Independence in
able to lift 10 pounds, and continence of bladder
IADL is determined by physical ability as well as
and bowels.
the environmental and cultural surroundings of
IADL are more complex and require greater
the individual.
concentration, skill, and coordination, such as
Worldwide, ADL decrease steadily with age.
using the telephone, driving, grocery shopping,
People with multiple chronic conditions such as
preparing meals, doing light housework (i.e., light
cancer, diabetes, heart disease, arthritis, and
cleaning, straightening up), doing heavy house-
Parkinson’s disease are more likely to move from
work (i.e., scrubbing floors, washing windows),
complete functionality to impairment in ADL than
laundry, and managing medications and finances.
are those with a single condition or without dis-
Differentiating between BADL and IADL may
ease. Cognitive problems in older adults are pre-
not be possible due to differences in gender, age,
dictive of a decrease in functional ADL, while
and sociocultural perceptions of the variables
depression is predictive of changes in both ADL
under consideration. Performing ADL is important
and IADL. ADL functioning is positively associ-
as it engenders self-esteem and helps individuals
ated with being male, having daily contact with
maintain a place in society as a parent, employee,
relatives and close friends, receiving home care,
friend, and community member. Difficulty per-
having a higher socioeconomic status, and belong-
forming ADL is most commonly a function of
ing to a White culture. Though changes in func-
aging but can also be due to injury, congenital dis-
tionality may be reversed with timely intervention,
orders, stroke, surgery, or chronic disease.
changes in IADL are rarely reversible.
Scoring
Aging and Public Policy Issues
ADL parameters are an important tool in the area
of biopsychosocial medicine for evaluating func- Although people of all ages may have difficulty
tional impairments and quality of life in the dis- performing ADL, prevalence rates rise sharply
abled, elderly, and chronically ill. Katz formulated with advancing age and are considerably higher
the first scoring system for ADL in 1963, and M. for those 85 years of age or older. ADL rating
Powell Lawton developed an index for scoring scales often classify older people as independent
IADL in 1969, but many additions and modifica- or dependent in self-care activities. However, with
tions have led to a number of scoring systems that this type of classification system, little information
measure a range of variables. While most scoring is available on independent individuals who report
systems are based on the original Katz and Lawton some difficulty in performing self-care activities. It
indexes, no system is used universally. A variety of is standard practice to include an ADL index as a
ADL and IADL scoring systems are used in geriat- variable in public health and clinical research
rics, psychiatry, and rehabilitation programs for studies on the elderly.
24 Acute and Chronic Diseases
Evidence shows that these measures of main- Daily Living,” Journal of the American Geriatrics
taining functionality are reliable indicators and Society 31(12): 721–27, 1983.
predictors in clinical evaluations as well as in pol- Katz, Sidney, A. B. Ford, R. W. Moskowitz, et al.
icy planning at all levels of elderly care. ADL “Studies of Illness in the Aged. The Index of ADL: A
scores are significant predictors of nursing home Standardized Measure of Biological and Psychosocial
admissions, use of hospital and physician services, Function,” Journal of the American Medical
living arrangements, insurance coverage, and mor- Association 185: 914–19, 1963.
tality. An increasing number of private long-term Lawton, M. Powell, and Elaine M. Brody. “Assessment
of Older People: Self-Maintaining and Instrumental
care insurance policies rely on ADL measures to
Activities of Daily Living,” Gerontologist 9(3):
establish eligibility for benefits. Public insurance
179–86, 1969.
programs such as Medicare and Medicaid also use
McDowell, Ian. Measuring Health: A Guide to Rating
ADL scores extensively to establish criteria for
Scales and Questionnaires. 3d ed. New York: Oxford
long-term care. IADL scores usually assess the University Press, 2006.
need for home care, while compromised ADL mea-
sures determine the need for nursing home admis-
sion. Nationally, one in two residents needs help Web Sites
with three or more ADLs, compared with three in
four nursing facility residents. A more impaired Cochrane Collaborative: http://www.cochrane.org
residential-care population is likely the product of Gerontological Society of America (GSA):
complex interactions between state-level (licens- http://www.geron.org
ing, reimbursement, etc.), facility-level (organiza- National Center for Health Statistics (NCHS):
tional characteristics and service capacity), and http://www.cdc.gov/NCHS
individual-level (resources, functional status, etc.) National Quality Measures Clearinghouse (NQMC):
http://www.qualitymeasures.ahrq.gov
factors. In general, about two thirds of people who
U.S. Social Security Administration (SSA):
receive long-term care live in the community, while
http://www.ssa.gov
the other third live in an institutional setting. For
every older adult living in a nursing home, there
are two living in the community, often in a family
setting, who may need equal levels of assistance.
Acute and Chronic Diseases
Karen E. Peters
Healthcare providers, public health professionals,
See also Acute and Chronic Diseases; Chronic Care
Model; Disability; Katz, Sidney; Long-Term Care; and health services researchers classify diseases
Nursing Homes; Public Policy; Quality of Life, in various ways. Some use general classification
Health-Related (HRQOL) schemes, while others use more specific schemes.
Diseases may be classified by their cause (e.g.,
bacteria, viral), whether they are communicable
Further Readings or noncommunicable, and whether they are infec-
tious or chronic in nature. Infectious diseases may
Covinsky, Kenneth E., Joan Hilton, Karla Lindquist,
et al. “Development and Validation of an Index to
be further classified by their specific mode of
Predict Activities of Daily Living Dependence in transmission, incubation period, and portal of
Community-Dwelling Elders,” Medical Care 44(2): entry into the body. Chronic diseases may also be
149–57, February 2006. further classified by which organ system in the
Desai, Abhilash K., George T. Grossberg, and Dharmesh body is affected, disease outcomes, and types of
N. Sheth. “Activities of Daily Living in Patients with intervention. Other schemes classify diseases into
Dementia: Clinical Relevance, Methods of Assessment whether they are congenital and hereditary, aller-
and Effects of Treatment,” CNS Drugs 18(13): gies and inflammatory, cancer and neoplastic,
853–75, 2004. metabolic, or degenerative and chronic in nature.
Katz, Sidney. “Assessing Self-Maintenance: Activities of Many of the various disease classification
Daily Living, Mobility, and Instrumental Activities of schemes often overlap, and there is no single
Acute and Chronic Diseases 25
“right” or perfect way of classifying diseases. come to mind when you say acute disease, they say
However, one of the most commonly used schemes acute abdomen, acute pain, and acute respiratory
of classifying disease is to divide them into two disease; and for chronic disease they say chronic
broad categories: (1) acute and (2) chronic disease. cholecystitis, diabetes, and cancer.
The current standard for classifying diseases as
acute or chronic is the International Classification
Meaning of Acute and Chronic Disease
of Diseases (ICD), now in its 10th revision (ICD-10).
Throughout recorded history, diseases have been Originally published in the 1850s, the ICD was
classified by different means and classification taken over by the World Health Organization
schemes. What we now think of as acute and (WHO) in 1948 and has become the standard for
chronic diseases have been documented by the international diagnostic classification.
primitive hunter-gatherers of 10,000 years ago
and in ancient civilizations from 6,000 years ago
in Egypt, Mesopotamia, and the Indus Valley. Why Definitions Are Inadequate
The etymologic basis for the words acute and
Epidemiology texts often tend to simplify the dif-
chronic is from the Latin. The word acute origi-
ference between acute and chronic diseases by
nates from the Latin acutus, meaning sharp or to
stating that acute diseases are caused by patho-
sharpen. Over the years, the term has been
genic microorganisms, whereas chronic diseases
applied to disease states and has taken on three
are caused by lifestyle, certain behaviors, and the
parameters: conditions (1) of short duration,
environment. While they are often true, these are
(2) of rapid onset, and (3) of severity. In contrast,
not hard and fast definitions and are incorrect in
the word chronic is derived from the Latin
many cases. Many diseases are not even defined
chronicus and means continuous or constant.
using these terms. The term chronic is sometimes
Chronic diseases are conditions that are of long
commonly used in some disease areas, such as
duration, slow onset, and less severity. Some
cancers of the circulatory system and diseases of
expectations of chronic diseases are that they
the heart, but absent when describing other types
cannot be cured and they do not spontaneously
of cancer. In many cases, diseases will have acute
resolve or disappear.
phases but become quiescent or go into remission
The early designation of a disease as acute or
in between. Some infectious diseases are remit-
chronic was based on its duration. Although no
tent in nature or have clinical and subclinical
actual time frame was designated, one thought of
phases.
acute disease in terms of days or weeks, whereas
chronic disease was thought of as lasting months,
years, or for an entire lifetime. The National
Disease Statistics and the
Center for Health Statistics (NCHS) now uses 3
Study of Morbidity and Mortality
months as the dividing line. Acute diseases are
conditions lasting less than 3 months, while The concept of classifying diseases has, at its roots,
chronic diseases are conditions lasting for more the collection of health information from popula-
than 3 months. However, it is important to note tions. Collection of statistical information by sites
that the terms acute and chronic disease, and their was well-known in Florence and Venice in the
use, vary in medicine and public health. 1300s, but not as a tool for analysis of health
There is also a wide range of definitions of the problems. John Graunt (1620–1674) analyzed the
words acute and chronic, depending on the audi- causes of death recorded in London’s Bills of
ence questioned. For example, if you ask people in Mortality. In 1662, he published the results of his
the general public what terms come to mind when analysis in Natural and Political Observations
you say the words acute and chronic, for acute Made Upon the Bills of Mortality. He created the
they frequently say acute angle, acute shortage, concepts of life expectancy and life tables, and he
acute sense of smell; and for chronic they say divided causes of death as being acute or chronic.
chronic complainer and chronically late. If you ask In 1796, Per Wargentin (1717–1783) published the
people in healthcare and public health what terms first mortality tables for an entire country, in this
26 Acute and Chronic Diseases
case Sweden. William Farr (1807–1883), the regis- there are too many immature blood-forming cells
trar general in England, was responsible for devel- in the blood and bone marrow. If untreated, it
oping the first modern vital statistics system. A progresses rapidly. If treated, it may be forced into
very important observation made by Farr was that remission or become recurrent in nature.
diseases, especially chronic diseases, seemed to Although cancer is considered a chronic disease,
involve many factors or a multifactorial etiology. some cancer victims are said to be cured if their
Pioneers in advancement of epidemiology and cancers do not recur or metastasize after specific
an understanding of disease in the United States lengths of time. In other words, there is no differ-
were Lemuel Shattuck (1793–1859), who in 1850 ence in causes of death in the “cured” population
reported on sanitation and public health prob- as compared with those who never had that cancer.
lems in Massachusetts, and Edgar Sydenstricker Examples would be testicular cancer, Hodgkin’s
(1881–1936), who in the early 1920s advanced the disease, and many types of leukemia. However, in
study of disease statistics. The ability to define some types of cancers, such as cancers of the lung,
diseases as acute or chronic depends on a complete colon, breast, and prostate, there can be recurrence
understanding of the cause or etiology of these many years or decades after the original cancer. In
diseases and their morbidity and mortality. this case, the cancers are treated and controlled.
Although it is assumed by most that cancer is a
chronic disease because of the time frame involved
The Role of Microbes in Chronic Disease
and because in the past there was seldom a cure,
Through the nation’s media, the general public is it is interesting that the term chronic is not usually
increasingly aware of human papillomavirus associated with cancer. In certain circumstances,
(HPV), a group of viruses that are sexually trans- the word acute is associated with cancer, such as
mitted. There is an association of this virus with in acute myeloid leukemia and acute lymphocytic
cell changes that may lead to cervical cancer. In leukemia. But this is not generally the case. In
fact, a new vaccine is available that will immunize part, this appears to be due to the fact that there
individuals against HPV. The Advisory Committee are many types of cancers, that it is such a com-
on Immunization Practices (ACIP) had recom- plex set of diseases, and that each individual with
mended to the U.S. Centers for Disease Control the various types of cancers responds differently
and Prevention (CDC) that the vaccine be given to to treatment.
11- to 12-year-old girls and also recommended it
for 13- to 26-year-old females who have not yet
Mental Illness as a Chronic Disease
received or completed the vaccine series.
Other chronic diseases once thought to be due The terms acute and chronic are not often used in
primarily to lifestyle factors, such as peptic ulcer describing mental illness. Perhaps because mental
disease, have been shown to be associated with illness is so poorly understood, often stigmatized,
microorganisms. It seems that most peptic ulcers and underfunded, it has escaped the more typical
are caused by Helicobacter pylori infection, which disease classification schemes. Recently, mental
can be treated with antibiotics. A report by the illness has taken on major significance, especially
American Academy of Microbiology lists more since the World Bank and the World Health
than 40 other diseases, including schizophrenia Organization Global Burden of Disease report
and Alzheimer’s disease, that may have a microbial was published in 1996. The report created three
cause. scenarios for what illness and disability would
look like in 2020. In all three scenarios, unipolar
major depression, alcohol use, and dementia
Acute and Chronic Concepts and Cancer
ranked in the top 10 causes of illness and disabil-
In general, cancer is considered a chronic disease. ity. In addition, 6 of the top 10 causes of disease
However, some cancers can be considered acute, if and disability listed by the Organization for
they progress rapidly enough. An example is acute Economic Co-operation and Development (OECD)
myeloid leukemia. This is a condition in which are mental illness.
Acute and Chronic Diseases 27
The Three Epidemiological Revolutions “killing bacteria, or battling an infection.” In con-

trast, we do not describe chronic diseases in terms
The United States and other advanced nations
of war but in terms of management. For example,
have gone through three epidemiological revolu-
physicians often encouraged their patients to daily
tions, which have shifted attention and concern
manage their diabetes and hypertension. Further
from acute, infectious diseases, to chronic, degen-
more, most chronic diseases have some level of
erative diseases, to the cultural and socioeconomic
stigmatization associated with them, with HIV/
causes of disease. The first epidemiological revolu-
AIDS being the prime example.
tion began in the late 1800s and early 1900s. At
that time, acute infectious diseases such as pneu- James C. Hagen
monia, tuberculosis, and diarrhea were the main
causes of death. Public health methods such as See also Disease; Epidemiology; Farr, William; Infectious
increased sanitation (e.g., sewage systems) and Diseases; International Classification of Diseases
immunizations eventually led to the significant (ICD); Morbidity; Mortality; National Center for
decline of these diseases. The second epidemio- Health Statistics (NCHS)
logical revolution began in the mid-20th century.
At that time, with the dramatic decline of acute Further Readings
infectious diseases, chronic degenerative diseases
such as cancer, heart disease, and stroke became Graunt, John. Natural and Political Observations
Mentioned in a Following Index and Made Upon the
the main causes of death. The third epidemiologi-
Bills of Mortality, edited by Walter F. Wilcox. Reprint,
cal revolution began in the late 20th century. At
Baltimore: Johns Hopkins University Press, 1939.
that time, there was a realization that many dis-
Murray, Christopher J. L., and Alan D. Lopez, eds.
eases and societal problems arose because of pov-
Global Burden of Disease: A Comprehensive
erty, prejudice, and changing cultural issues. Public
Assessment of Mortality and Disability from Diseases,
health would now attempt to address the problems Injuries, and Risk Factors in 1990 and Projected to
of violence, drug abuse, and teenage pregnancy. 2020. Cambridge, MA: Harvard University Press, on
behalf of the World Health Organization and the
World Bank, 1996.
Difference in Societal Perceptions National Association of Chronic Disease Directors.
of Acute and Chronic Diseases Public Health Advances Through Chronic Disease
There is no firm line between those diseases that Prevention: 1986–2006. Atlanta, GA: National
are termed acute and chronic. Acute diseases may Association of Chronic Disease Directors, 2007.
Rosen, George. A History of Public Health. 2d ed.
become chronic as new treatments and therapies
are developed to maintain patients with a disease,
Scutchfield, F. Douglas, and C. William Keck. Principles
or the disease itself may change into a form that is
of Public Health Practice. 2d ed. Clifton Park, NY:
longer lasting or recurrent in nature. One example
Delmar Learning, 2003.
is HIV/AIDS. In the 1980s, HIV/AIDS was an
Terris, Milton. “The Complex Tasks of the Second
acute disease that, once diagnosed, would kill rap- Epidemiological Revolution: The Joseph W.
idly through causing opportunistic infections. Mountain Lecture,” Journal of Public Health Policy
Since the early 1990s, with the development of 4(1): 8–24, March 1983.
powerful antiviral drugs, HIV/AIDS has become a Timmreck, Thomas C. An Introduction to Epidemiology.
chronic disease. 3d ed. Sudbury, MA: Jones and Bartlett, 2003.
Cultural and societal biases may also help define
acute and chronic disease. Beyond the time frame
usually used to differentiate acute from chronic Web Sites
disease, our culture and society tend to approach Advisory Committee on Immunization Practices (ACIP):
acute diseases as if in war, saying that “viruses http://www.cdc.gov/vaccines/recs/ACIP/default.htm
invade, bacteria attack, and parasites infest.” We American Society of Microbiology (ASM):
also tend to describe treatment as consisting of http://www.asm.org
28 Aday, Lu Ann
Centers for Disease Control and Prevention (CDC): editions, including At Rick in America: The Health
http://www.cdc.gov and Health Care Needs of Vulnerable Populations
National Center for Health Statistics (NCHS): in the United States; Designing and Conducting
http://www.cdc.gov/nchs Health Surveys: A Comprehensive Guide; and
World Health Organization (WHO): http://www.who.int Evaluating the Healthcare System: Effectiveness,
Efficiency, and Equity.
Aday has served on many multinational, fed-
eral, and state boards, commissions, and commit-
Aday, Lu Ann tees, including the Institute of Medicine, the
Agency for Healthcare Research and Quality
Lu Ann Aday is a health services researcher who (AHRQ), the national Institute of Medicine (IOM),
has spent much of her academic career studying and the National Cancer Institute (NCI).
the indicators and correlates of health services During her academic career, Aday has received
utilization and access to healthcare. She has con- numerous awards and honors for research and
ducted a number of major national and commu- teaching. She was inducted as a member of the
nity health surveys, and evaluations of national IOM of the National Academy of Sciences in
demonstration projects, and she has published 1998. She received the John P. McGovern
many scholarly articles and books addressing the Outstanding Teacher Award in 1993 and the
conceptual and empirical aspects of health ser- Minnie Stevens Piper Foundation Award for
vices research on access to healthcare. Teaching Excellence in 2000. And she received an
Born and raised in the small Texas town of honorary doctorate of social sciences from Purdue
Waxahachie, Aday received her bachelor’s degree in University in 2004.
agricultural economics from Texas Tech University In terms of her future research, Aday is plan-
in 1968. She then went to Purdue University to ning to examine the perspectives, principles, and
study and earned a master’s degree in sociology in policies that would be encompassed within the
1970. After completing her master’s degree, she field of population health ethics, in contrast to
joined Volunteers in Service to America (VISTA) clinical medical ethics and public health ethics.
and served in a poor rural county in Georgia. This
experience motivated her to carry out health ser- Ross M. Mullner
vices research on the access to healthcare for vul-
See also Access, Models of; Access to Healthcare;
nerable populations. She completed her doctorate Andersen, Ronald M.; Anderson, Odin W.; Health
in sociology at Purdue University in 1973. Surveys; Measurement in Health Services Research;
After completing her doctorate, Aday began her Medical Sociology; Vulnerable Populations
academic career as a research associate at the
Center for Health Administration Studies (CHAS)
at the University of Chicago. At CHAS, she worked Further Readings
closely with the noted health services researchers
Aday, Lu Ann. At Risk in America: The Health and
and medical sociologists Ronald M. Andersen and
Health Care Needs of Vulnerable Populations in the
Odin W. Anderson. Aday later became senior
United States. 2d ed. San Francisco: Jossey-Bass,
researcher and finally associate director for research 2001.
at the center. In 1986, Aday left CHAS to become Aday, Lu Ann, ed. Reinventing Public Health: Policies
an associate professor at the University of Texas and Practices for a Healthy Nation. San Francisco:
School of Public Health. In 1991, she was appointed Jossey-Bass, 2005.
professor at the University of Texas Health Science Aday, Lu Ann, Charles E. Begley, David R. Lairson,
Center at Houston, School of Public Health, et al. Evaluating the Healthcare System: Effectiveness,
Health Services Organization. In 2001, Aday Efficiency, and Equity. 3d ed. Chicago: Health
became the Lorne D. Bain Distinguished Professor Administration Press, 2004.
at the school. Aday, Lu Ann, and Llewellyn J. Cornelius. Designing
Aday has published a number of books. Many and Conducting Health Surveys: A Comprehensive
of them have been published as second and third Guide. 3d ed. San Francisco: Jossey-Bass, 2006.
Administrative Costs 29
Web Sites medical supplies, and equipment for the cardiac-

University of Texas School of Public Health: care unit. Indirect costs, then, are the remaining
http://www.sph.uth.tmc.edu costs, which are more general in nature. The cost
of utilities for the cardiac-care unit, for instance,
cannot readily be distinguished from the cost of
utilities for the orthopedic surgery unit or the
intensive-care unit.
Administrative Costs Administrative costs and support costs are the
two main categories of indirect costs. Administrative
Administrative costs stem from resources used to costs stem from the managerial activities that are
manage or administer an organization. While they necessary for an organization to operate effec-
are common to all organizations, administration tively, while support costs arise from other general
costs are of particular importance in the U.S. activities needed for the smooth functioning of an
healthcare sector because of the complex nature organization. In a hospital, for example, costs of
of health services and the interaction between the human resources and quality assurance depart-
public and private insurers and providers of care. ments and salaries of upper management would be
Another indication of the importance of adminis- classified as administrative costs, while support
trative costs is that virtually all proposals for costs would include expenses for facilities mainte-
reforming the U.S. healthcare system include nance and housekeeping services.
reducing the administrative burden as a key com-
ponent. It is essential to note, however, that
administrative costs are not always negative. Even Magnitude
the most efficient and productive organization Administrative costs in the nation’s healthcare
must incur a certain level of administrative costs. sector are substantial. At the broadest level,
The challenge is to eliminate only administrative healthcare organizations can be categorized as
costs that are wasteful or unnecessary. Specifically, being either providers of patient care or insurers.
this entry defines administrative costs, discusses Healthcare providers include hospitals, physician
the magnitude and types of administrative costs, practices, nursing homes, home health agencies,
and reviews health policy issues related to admin- and many others. Insurers include public pro-
istrative costs. grams, such as Medicare and Medicaid, and many
private insurers, such as Blue Cross and Blue
Shield. Organizations in the healthcare sector
Definition
incur numerous costs stemming from the complex
Organizations produce outputs, which are goods nature of health services, the fragmented payment
and services sold to individuals or other organiza- system, and the extensive regulation of health
tions. For example, a hospital produces services services.
such as cardiac care or orthopedic surgeries. In On the provider side, administrative costs account
producing these outputs, organizations use inputs, for a considerable proportion of total costs. For
which are resources such as labor, capital, and example, administrative costs for hospitals and phy-
supplies. A hospital, for example, uses nursing sician practices typically account for approximately
care, medical supplies, equipment, and facilities to 25% of total costs, while the percentage of total
provide cardiac care. An organization’s costs costs going to administrative costs in nursing homes
depend on the quantity of inputs used and the is usually of the order of 20%. Using estimates of
price of the inputs. Nursing costs, for instance, health expenditures from the Centers for Medicare
depend both on how many nurses are employed and Medicaid Services (CMS), administrative costs
and on the wages they earn. in the nation’s hospitals were of the order of $150
Costs can be categorized as direct costs or indi- billion in 2005, while for physician practices and
rect costs. Direct costs can be linked precisely to a nursing homes, administrative costs were about
given output. For example, direct costs for cardiac $100 billion and $25 billion, respectively. Another
care in a hospital would include nursing salaries, way to measure the magnitude of administrative
30 Administrative Costs
costs for providers is to examine the percentage of arise from special characteristics of the healthcare
employee time spent on non-patient-care activities. sector. For most organizations, administrative
Case studies indicate that in hospitals, for example, costs related to payment would be considered
as much as 30% of staff time is devoted to docu- operational or an aspect of financial management.
mentation and recording, with more routine man- For healthcare providers, however, payment is
agement activities, such as budgeting and supervision, complex and administratively burdensome. A sin-
accounting for about 7% of staff time. gle, large physician practice, for example, may
For insurers, administrative costs typically are have separate contracts with more than 100 insur-
measured as a proportion of premiums and range ers, each of which may have a different set of
from about 5% for Medicare to 10% to 12% requirements for submitted claims, resulting in
for private insurers. However, estimates for Medi substantial resources needed to obtain payment for
care and other public programs typically exclude services rendered.
important components of administrative costs, Healthcare providers also incur substantial reg-
such as the costs of Medicare peer-review organi- ulatory administrative costs associated with gov-
zations and other quality-reporting requirements. ernment mandates, as well as requirements set by
Moreover, estimates using data from the national accrediting bodies. A hospital, for example, must
health accounts calculate the net cost of private comply with standards for state licensure and,
insurance as the difference between premiums depending on the state, certificate of need (CON)
received and claims expenditures, the resulting regulations, numerous federal regulations such as
residual including taxes and profits, as well as those set by the Occupational Safety and Health
actual administrative costs. In addition, compari- Administration (OSHA) and the Americans with
sons between public and private insurers do not Disabilities Act (ADA), and the requirements for
take into account the fact that private health insur- accreditation by the Joint Commission. The Health
ance plans, which are voluntary, must incur mar- Insurance Portability and Accountability Act of
keting costs to attract customers. Public insurance 1996 (HIPAA), in particular, has imposed wide-
programs such as Medicare, on the other hand, are ranging requirements related to the privacy of
mandatory for the most part and do not encounter patient information, with an accompanying increase
the same level of expenses for marketing and pro- in administrative costs to comply with these
motion. Finally, even comparisons across private requirements.
insurers are complicated by variations in an insur- More generally, other researchers have
er’s mix of small and large employer groups and proposed a systemwide categorization of admini
differences in methods of reporting administrative s trative costs as transaction-related, benefits man
costs. agement, selling and marketing, and compliance
with regulatory requirements. Using insurers
as an example, transaction-related costs stem
Types of Costs
primarily from the collection of premiums
In examining types of administrative costs, it is and the processing of claims, with the costs of
again useful to distinguish between providers of benefits management being due to the activities
patient care and insurers. Researchers have associated with health plan design. Selling and
proposed a framework for analyzing provider marketing costs would include expenses from
administrative costs, using three categories: underwriting and marketing health plans mainly
(1) operational, (2) payer-related, and (3) regula- to employers but also to individuals. Finally,
tory costs. Operational administrative costs, which reserve requirements and premium taxes are
are common to all organizations, stem from man- examples of costs due to compliance with regula-
agement activities related to human, financial, and tory requirements.
facility resources. To operate effectively, an orga-
nization must use resources to hire and manage
Health Policy Issues
staff, to set budgets and pay bills, and to purchase
and maintain the plant and equipment. Proposals for reforming the U.S. healthcare system
The other two categories of provider adminis- typically include recommendations that adminis-
trative costs, payer-related and regulatory costs, trative costs be reduced, and most would agree
Administrative Costs 31
that reductions in these costs could release resources example, a study in 1976 by the Hospital
that could be devoted to providing more health Association of New York reported that 164 dif-
services or increased health insurance coverage. ferent agencies regulated 109 different areas of
Although recommendations to reduce administra- hospital operations. Since that time, these differ-
tive costs are common, less common are specific ing, and sometimes competing, regulatory require-
proposals for how to accomplish this objective. ments have soared. Increased collaboration among
One study that estimated healthcare administra- regulatory agencies, perhaps mandated by federal
tive costs in the United States and Canada con- legislation, could both decrease administrative
cluded that administrative costs are considerably costs and insure improved coordination of regu-
higher in the United States than in Canada and latory activities.
argued that the United States should adopt a New regulatory programs typically are designed
Canadian-like single-payer system of universal cov- to improve the safety or quality of healthcare. For
erage. However, others have pointed out that defi- example, the CMS is moving toward mandatory
nitions of administrative costs differ between the reporting of quality information as part of its pay-
United States and Canada. For example, U.S. esti- for-performance initiative. New regulatory pro-
mates typically include administrative costs associ- grams, however, typically entail additional costs,
ated with research, while estimates for Canada do resulting in an even greater administrative burden
not. In addition, single-payer systems may have for providers. Unfortunately, coordination between
hidden social costs due to longer patient waiting existing and new regulations is rare, leading to
times and the unavailability of some services. Yet increased, and sometimes even contradictory,
another criticism is that while moving to a Canadian- administrative requirements.
like system might reduce administrative costs, total
expenditures on healthcare would likely increase Future Implications
due to greater utilization because more people
would have health insurance coverage. Administrative costs in the nation’s healthcare
At the organizational level, the real challenge is sector are a continuing source of policy concern.
to distinguish between necessary and unnecessary While all organizations incur costs associated with
administrative costs. Even the most efficient and managerial or administrative activities, organiza-
productive provider or insurer must incur a certain tions in the healthcare sector face a complex sys-
level of administrative costs. Thus, efforts to contem of payments, with each provider payment
trol administrative costs must focus on eliminating being from public programs (primarily Medicare
costs due to waste and other forms of inefficiency and Medicaid) and many different private insurers
rather than on simply reducing overall costs. For and with each payer having separate and often
providers, in particular, adverse effects could result quite different paperwork requirements. Further
from a simple proportionate decrease in adminis- more, organizations in the healthcare sector face
trative costs because costs associated with certain regulations set by numerous government agencies
administrative activities are essential for the provi- at all levels—local, state, and federal—with differ-
sion of safe, effective, high-quality patient care. ing agencies having sometimes conflicting require-
For the nation’s healthcare system as a whole, ments. Reducing administrative costs clearly has
policy changes have the potential to result in sub- the potential to constrain the growth of health
stantial reductions in unnecessary administrative expenditures in the nation, but cost control pro-
costs. For providers, the multitude of payers, each grams must carefully distinguish between neces-
having specific, and often quite different, paperwork sary and unnecessary administrative costs to avoid
requirements, is an obvious target. Policy changes potentially adverse effects on the effectiveness,
aimed at standardizing the methods of billing for safety, and quality of patient care.
and collecting payment could lead to significant Niccie L. McKay
reductions in payer-related administrative costs.
Regulation is another area in which broad- See also Cost Containment Strategies; Cost of Healthcare;
based policy changes could have a big impact, Health Economics; Health Insurance; Hospitals;
given the remarkable number and scope of regu- International Health Systems; Payment Mechanisms;
lations affecting providers and insurers. For Regulation
32 Adverse Drug Events
Further Readings and/or the U.S. Food and Drug Administration

Broyles, Robert W., Narine Lutchmie, and Madeline J. (FDA). The WHO defines an adverse drug event
Robertson. “Assessing Administrative Costs of as any response to a drug that is noxious and
Mental Health and Substance Abuse Services,” unintended in doses normally used in people for
Administration and Policy in Mental Health 31(5): diagnosis, prevention, and treatment. The FDA
393–408, May 2004. describes serious adverse drug events as events that
McKay, Niccie L., Christy Harris Lemak, and Annesha result in patient death, life-threatening outcomes,
Lovett. “Variations in Hospital Administrative hospitalization, disability, congenital anomaly, and
Costs,” Journal of Healthcare Management 53(3): outcomes requiring healthcare interventions.
153–66, May–June 2008. Adverse drug events include both preventable
Sarpel, Umut, Bruce C. Vladeck, Celia M. Divino, et al. and unavoidable events, the latter of which are
“Fact and Fiction: Debunking Myths in the U.S. also known as adverse drug reactions. An adverse
Healthcare System,” Annals of Surgery 247(4): drug reaction is an unintended, undesired, and
563–69, April 2008. unexpected response to a drug that negatively
Woolhandler, Steffie, Terry Campbell, and David H. affects a patient. It may result in the need to change
Himmelstein. “Costs of Health Care Administration in drug therapies and/or other treatments; hospital-
the United States and Canada,” New England Journal ization or other institutional admission or pro-
of Medicine 349(8): 768–75, August 21, 2003. longed stay; and patient complications, including
disability or death. Common side effects of phar-
maceutical drugs are not generally considered to
Web Sites be adverse drug reactions.
American Medical Association (AMA): Adverse drug events include the following:
http://www.ama-assn.org unexpected, injurious adverse drug reactions expe-
Centers for Medicare and Medicaid Services (CMS): rienced during use of the medicine; and harmful
http://www.cms.hhs.gov outcomes secondary to preventable medication
Healthcare Financial Management Association (HFMA): errors, including errors of omission or commis-
http://www.hfma.org sion. The causes of medication errors (i.e., prevent-
National Coalition on Health Care (NCHC): able adverse drug reactions) are multifactorial and
http://www.nchc.org can be related to drug prescribing, order commu-
nication, dispensing, administration, monitoring,
product packaging and labeling, product nomen-
clature, education, monitoring, and other product
Adverse Drug Events use. Medication errors result from failed systems,
lack of knowledge, and lapses in performance or
The use of medications (pharmaceutical drugs con- mental processes—regardless of whether the medi-
sisting of prescription and over-the-counter drugs, cation is under the control of the patient, caregiver,
biologics, vaccines, and/or dietary supplements) or healthcare practitioner. Medication errors may
generally results in beneficial, defined therapeutic be caused by defective systems involving patients
outcomes when these drugs and related medica- and caregivers, healthcare practitioners, regula-
tions are taken properly and appropriately monitors, manufacturers, healthcare organizations, and
tored. Nevertheless, there are inherent risks in using other entities.
any medications. Adverse drug events are frequent In addition to physical afflictions, adverse drug
and costly consequences of medication use. They events impose a significant economic burden on
are widely reported to be a significant cause of society. The number of people who reportedly died
patient morbidity and mortality, and they cost bil- from medication errors increased 2.5-fold from
lions of dollars in annual healthcare expenditures. 1983 to 1993. The national Institute of Medicine
There is no universally accepted definition for (IOM) estimated that approximately 106,000 indi-
an adverse drug event, and numerous definitions viduals died from an adverse drug event in 1994,
exist. Most definitions are similar to those put and an estimated 2.2 million individuals were hos-
forth by the World Health Organization (WHO) pitalized with a serious adverse drug event. In
Adverse Drug Events 33
2006, the IOM concluded that at least 1.5 million USP/Institute for Safe Medication Practices
preventable adverse drug events occur in the (ISMP)—Medication Error Reporting Program.
United States annually, and the true number might The U.S. FDA’s MedWatch program is a volun-
be much higher. The IOM conservatively estimates tary reporting system for healthcare providers or
the 2006 national hospital costs associated with consumers regarding serious adverse events, prod-
adverse drug events at $3.5 billion. uct quality problems, or product use errors.
In 1995, Johnson and Bootman developed a Reportable products under MedWatch include
probability pathway model to estimate the direct FDA-regulated drugs, biologics, medical devices,
cost of managing drug-related morbidity and mor- cosmetics, and special nutritional products.
tality in the ambulatory-care setting in the United The VAERS is a cooperative program of the
States. Their results showed that drug-related mor- U.S. FDA and the Centers for Disease Control and
tality and morbidity cost $76.6 billion per year. An Prevention (CDC). The VAERS system tracks
updated analysis based on that 1995 model showed adverse events believed to be associated with a
that the cost of drug-related problems among given vaccine, which are voluntarily reported, ana-
ambulatory Americans more than doubled in 2000 lyzed, and made available to the public.
to an estimated $177.4 billion, with hospital The USP is a private, quasi-regulatory organiza-
admissions accounting for $121.5 billion or 69% tion. It administers MEDMARX®, an Internet-
of the total costs. These costs are borne by patients, accessible medication error and adverse drug
families, health insurers, government, healthcare reaction reporting system for participating hospi-
providers, employers, and others. tals and healthcare systems. The USP national
database includes records on more than 1.1 million
events and consists of proprietary data compiled
Reporting Systems
from participating institutional subscribers. The
Identification and reporting of adverse drug USP/ISMP-Medication Errors Reporting Program
events is a crucial first step in improving patient (MERP) collects and reviews reports of actual and
safety. For optimal risk communication and qual- potential medication errors submitted by health-
ity improvement purposes, it is worthwhile to care professionals. The USP/ISMP-MERP attempts
track potential as well as the actual adverse drug to determine the causes of medication errors, includ-
events since they can all lead to patient injury in ing name label and packaging hazards.
the future. The major active governmental surveillance sys-
There are a number of national surveillance systems for adverse drug events include the following:
tems for reporting errors, adverse events, and near U.S. FDA-Adverse Event Reporting System (AERS),
misses. These systems vary with respect to scope National Electronic Injury Surveillance System-
and whether they use active or passive surveillance Cooperative Adverse Drug Events Surveillance
mechanisms. Passive systems rely on the spontane- System (NEISS-CADES), and the Substance Abuse
ous, voluntary reporting of observed adverse events and Mental Health Services Administration-Drug
by clinicians and others who are involved with the Abuse Warning Network (DAWN).
event, while active reporting involves the regular, The U.S. FDA-AERS includes data from adverse
periodic collection of event data or medical records drug reaction reports submitted by pharmaceutical
from healthcare providers or facilities. Spontaneous manufacturers (as required by regulation) and vol-
voluntary reporting has long been the primary untary submissions through MedWatch. The AERS
mechanism to identify adverse events; however, it includes the FDA-regulated drugs and biologics.
is believed that spontaneous reports can identify The NEISS-CADES is a collaborative, multi-
only 1 in 20 adverse drug events. agency program administered by the CDC, the
The major passive adverse drug event reporting Consumer Product Safety Commission, and the
and surveillance systems include the following: U.S. FDA. This system includes survey data on
U.S. FDA—MedWatch program, U.S. Department injuries and adverse drug effects that are extracted
of Health and Human Services—Vaccine Adverse from the medical records from emergency depart-
Event Reporting System (VAERS), United States ment visits at 64 selected U.S. hospitals. The FDA
Pharmacopeia (USP)—MEDMARX®, and the and CDC analyze these data with the goal of
34 Adverse Drug Events
developing interventions for preventing future adverse event occurrence, lack of standardization,
adverse drug events. and individual event reports that cannot be
The Substance Abuse and Mental Health combined and/or generalized. The use of adminis-
Services Administration-DAWN collects drug- and trative data, such as claims and discharge data,
alcohol-related data from emergency department represents another major method for measuring
visits and medical examiner records in 22 U.S. cit- adverse drug events. Limitations of only using
ies regarding adverse events associated with the administrative data include incomplete informa-
nonmedical use of legal or illegal drugs and other tion that is bereft of clinical detail and potential
substances. bias in coding reimbursable conditions. More opti-
Although not limited to adverse drug events, mal systems combine methods from multiple
there are also a number of state adverse-event- sources to estimate the incidence and prevalence of
reporting programs. In 2008, 26 states and the adverse drug events within systems as well as to
District of Columbia had laws or regulations for determine causes and outcomes.
the mandatory reporting of adverse events to state
agencies by hospitals and other healthcare facili-
Research and Strategies
ties. These include very serious events that could
result in patient death, harm, or serious injury, Research studies examining adverse drug events
such as “never events” or “sentinel events” as cat- have accumulated since the 1960s, and findings
egorized by the National Quality Forum or the demonstrate considerable variations in incidence
Joint Commission. rates, risk factors, and definitions. Identification
In the private sector, the Health Maintenance of adverse drug events is a crucial first step in
Organizations Research Network (HMORN) con- improving patient safety. One reason why it is dif-
ducts an active surveillance system. The HMORN ficult to study them is that reliable identification
researches and disseminates information about and classification of events is difficult. The neces-
adverse events reported through managed-care sary prerequisite to studying adverse drug events
health plans’ defined populations, providers, deliv- is to identify them accurately and consistently.
ery systems, and data. In 2008, 15 large managed- The main methods of detecting adverse drug
care plans were included in the network events are through direct observation by trained
consortium. observers, voluntary reporting, and chart review.
A few commercial online event-reporting sys- More optimal use of information technologies
tems exist for spontaneous reporting in acute-care should aid future research.
settings, and one healthcare alliance (Premier, Most existing studies have focused on adverse
Inc.) developed a proprietary incident reporting drug events among hospitalized patients rather
system for pharmacy, infection control, and inci- than outpatients (including those in community
dent management. Benchmarking capabilities settings). Most articles on hospital-based safety
from such online incident reports is a helpful pro- systems rely on incident reports by clinicians, case
cess, albeit limited by insufficient database link- studies, events detected by local computer systems,
ages. Current reporting systems in acute-care and review of the chart or clinical record. Published
settings may have the capability to include UB-92, information on event detection in hospitals is
UB-04, or equivalent electronically transmitted typically available from individual reports, which
billing submission discharge data (e.g., age, gen- renders it difficult or impossible to compare
der, diagnosis, and procedures) for inpatients, but study results and evaluate rates to explore charac-
are limited by lack of clinical indications, double teristics and causes. As strategies for preventing
counting of patients, unknown linkages between and reducing the impact of adverse drug events in
prescriber/drug and drug/indication, and other the outpatient setting are developed, an important
issues. component will be the newly implemented
The described adverse drug events–reporting Medicare’s Medication Therapy Management
systems provide numerous advantages. Yet the Services (MTMS).
ability to learn from most of them is hindered by The prevalence of prescription medication use
underreporting, limited scope, unknown rates of among the ambulatory adult population increases
Adverse Drug Events 35
with advancing age. Even though most medica- Further Readings

tion errors do not result in injury, the extensive Bates, David W. “Drugs and Adverse Drug Reactions:
use of medications by the geriatric population How Worried Should We Be?” Journal of the
suggests that sizeable numbers of older persons American Medical Association 279(15): 1216–17,
are affected. Previous studies on risk factors April 15, 1998.
associated with adverse drug events in elderly Committee on Identifying and Preventing Medication
populations documented that demographic and Errors, Phillip Aspden, Julie Wolcott, et al., eds.
socioeconomic characteristics, multiple chronic Preventing Medication Errors: Quality Chasm Series.
disease condition, recent hospitalization, previous Washington, DC: National Academies Press, 2007.
adverse drug event history, and specific medica- Edwards, I. Ralph, and Jeffrey K. Aronson. “Adverse
tions can affect the occurrence of adverse drug Drug Reactions: Definitions, Diagnosis, and
events. MTMS is part of the Medicare Prescription Management,” Lancet 356(9237): 1255–59, October
Drug, Improvement and Modernization Act of 7, 2000.
2003, which provided (among other provisions) a Gurwitz, Jerry H., Terry S. Field, Leslie R. Harrold, et al.
voluntary outpatient prescription drug benefit to “Incidence and Preventability of Adverse Drug Events
Medicare beneficiaries starting in January 2006. Among Older Persons in the Ambulatory Setting,”
Local or regionally based MTMS are intended for Journal of the American Medical Association 289(9):
a targeted Medicare population, which is defined 1107–16, March 5, 2003.
as those individuals who have multiple chronic Johnson, Jeffrey A., and J. Lyle Bootman. “Drug-Related
diseases, are taking multiple prescription drugs, or Morbidity and Mortality: A Cost-of-Illness Model,”
Archives of Internal Medicine 155(18): 1949–56,
are likely to incur high medication expenses. The
October 9, 1995.
purpose of MTMS is to optimize therapeutic out-
Kellogg, Victoria A., and Donna Sullivan Havens.
comes and decrease costs by improving medica-
“Adverse Events in Acute Care: An Integrative
tion use and reducing adverse drug events in the
Literature Review,” Research in Nursing and Health
targeted population.
26(5): 398–408, October 2003.
Patients, healthcare providers, and private and Milch, Catherine E., Deeb N. Salem, Stephen G. Pauker,
government organizations should work together to et al. “Voluntary Electronic Reporting of Medical
enhance the identification and reporting of adverse Errors and Adverse Events: An Analysis of 92,547
drug events. Greater analysis of adverse drug event Reports From 26 Acute Care Hospitals,” Journal of
reports will help in information dissemination and General Internal Medicine 21(2): 165–70, February
education to prevent and minimize their occur- 2006.
rence and associated problems. Various recom- Wood, Kathryn E., and David B. Nash. “Mandatory
mendations to prevent adverse drug reactions and State-Based Error-Reporting Systems: Current and
medication errors have been posited. These include Future Prospects,” American Journal of Medical
encouraging patients to take a more active role Quality 20(6): 297–303, November–December 2005.
in their healthcare, increasing communication
between patients and healthcare providers, using
more effective information technologies in the Web Sites
medication-use process, increasing the monitoring Drug Abuse Warning Network (DAWN):
of patient safety, and calling for the U.S. FDA and http://dawninfo.samhsa.gov
other regulators to work with pharmaceutical HMO Research Network (HMORN):
manufacturers and others to improve drug product http://www.hmoresearchnetwork.org
packaging and labeling. Joint Commission, Sentinel Event Policy and Procedures:
http://www.jointcommission.org/SentinelEvents/
Stephanie Y. Crawford and Xiaoyan Ying
PolicyandProcedures
See also Benchmarking; Medical Errors; Medicare United States Pharmacopeia (USP), Medmarx:
Part D Prescription Drug Benefit; Patient Safety; http://www.usp/hqu/patientSafety/medmarx
Pharmaceutical Industry; Pharmacoeconomics; U.S. Department of Health and Human Services (HHS),
Pharmacy; U.S. Food and Drug Administration Vaccine Adverse Event Reporting System (VAERS):
(FDA) http://vaers.hhs.gov
36 Adverse Selection
U.S. Food and Drug Administration (FDA), Adverse comprehensive insurance policies. In contrast, if
Event Reporting System (AERS): http://www.fda.gov/ potential risks are common information for both
cder/aers/default.htm parties, then high-risk individuals may face barri-
U.S. Food and Drug Administration (FDA), MedWatch: ers to coverage of predictable expenditures because
http://www.fda.gov/medwatch insurers will exclude likely events from an insur-
ance policy.
Adverse Selection The Lemon’s Principle

The concept of adverse selection was first formally
Adverse selection arises in markets where there is introduced by George A. Akerlof in his 1970
asymmetric information between buyers and sell- seminal article titled “The Market for Lemons:
ers. Asymmetric information occurs when one Quality Uncertainty and the Market Mechanism.”
party in a transaction or contract has information In the article, Akerlof presents adverse selection in
that is not observable to the other party. Adverse the context of a used car market where the sellers
selection is a term commonly used by economists, know the quality of the car they are selling and the
insurers, statisticians, and policymakers to explain buyers are only aware of the distribution of the
what happens when individuals have unobserved quality of the cars for sale. The quality of a used
characteristics and make their choices based on car could vary from good to bad (a lemon), but
those characteristics. Moral hazard is another the buyers have no way of identifying the quality
important aspect of health insurance markets and of each car, especially if all cars are sold at the
is often studied in the same context as adverse same price.
selection. Moral hazard defines the situation where Consider a market where there are five used cars
the cost of one’s action is shared with another with varying quality levels for sale. For simplicity,
party (e.g., insurer), and this causes one to behave we will assign a cardinal index of values to each of
differently than one otherwise would if one were these cars: 0, 0.25, 0.5, 0.75, and 1. Assume that
responsible for the full cost of one’s action. For the seller’s reservation sale price (i.e., lowest price)
example, an insured person may consume more of each car is equal to $2,000 × quality. If the mar-
healthcare with insurance than he or she would if ket price is set at $2,000 initially, then all five cars
he or she paid out of pocket. In contrast, adverse would be offered for sale. However, since the
selection occurs when an individual enters a con- buyer only knows the distribution of the quality of
tract based on his or her private and unobservable cars, his offer price will be equal to $2,000 × aver-
information. An example of this is an expectant age quality (0.5), or $1,000. Thus, no cars would
mother choosing an employer that offers generous sell for $2,000. If the market price is then brought
maternity benefits over one that does not. down to $1,000 to accommodate the buyer’s offer,
Insurance is designed to provide protection then the two best cars would exit the market since
from unexpected risks. However, an individual the new market price is lower than their reserva-
may have a better understanding of his or her tion value. The withdrawal of the two best cars
future healthcare needs than a health insurer. results in a drop in the average quality of the
Individuals may know their expected health expen- remaining cars to 0.25, and the buyer’s offer price
ditures through their parents’ medical histories or would then fall to $500. Again, no cars would be
from genetic tests. Adverse selection occurs when sold. If the market price falls further to match the
they choose insurance coverage with this in mind. buyer’s offer at $500, the next best car would exit
If insurance companies are not aware of individual the market, leading to a further drop in the average
risk levels, then insurance markets may experience quality of the remaining cars in the market. A con-
adverse selection as a result of high-expected-cost tinuation of this pattern leads to bad cars driving
individuals purchasing more comprehensive cover- the good cars from the market, leaving no market
age. This will likely lead to higher premiums and in the end. This example, known as the lemon’s
could drive low-expected-cost individuals to less principle, is an extreme case of adverse selection.
Adverse Selection 37
However, in most cases, trade is not totally elimi- insurance and high-risk individuals choose full cov-
nated, though market allocations may result in erage. An example of partial coverage might be a
economic inefficiencies. plan with an extremely high deductible.
Adverse selection is a common consideration in Adverse selection may lead to a distortion in the
health insurance markets. Individuals with higher quality of services offered. Richard Frank and his
expected healthcare costs prefer more generous colleagues examined adverse selection in managed-
health insurance plans than do individuals with care markets, where health plans offer coverage
lower expected healthcare costs. Thus, more gen- for different types of diseases. They show that as a
erous health insurance plans will offer higher pre- consequence of adverse selection, health plans
miums to profitably provide generous coverage. have an incentive to distort the quality of (or
This is analogous to Ackerlof’s lemon’s principle. access to) certain types of care in order to attract
A health insurance company offers premiums low-risk enrollees and deter high-risk ones. They
designed to cover the average cost of health expen- predict that a health plan will avoid high-cost
ditures as well as fixed costs. If at this premium enrollees by offering limited coverage for chronic
low-risk individuals decline health insurance, the (i.e., predictable) conditions, especially when they
premium will rise to reflect the higher expected are highly correlated with other types of health
expenditures of the individuals who select the expenditures.
plan. This cycle results in high-risk individuals
driving the low-risk individuals from the health
Asymmetric Versus Imperfect Information
plan. In the context of insurance, this is called an
adverse selection “death spiral” if it continues In the lemon’s problem, the sellers had more
until no insurer can profitably offer a policy. The information about the cars than did the buyers,
empirical evidence on the existence of adverse and in the health insurance market, the buyers
selection death spirals is mixed. In 2002, Thomas had more information about their future health-
Buchmueller and John DiNardo found no evidence care expenditures than did the insurers. If both
of a death spiral when insurers were restricted to parties had the same information about the prod-
offering the same premium to groups of individu- uct being exchanged, then adverse selection would
als by community rating laws. not occur. This is true even if it is not perfect
information. This is important because if both
parties have the same information regarding aver-
Pooling and Separating Contracts
age expected health expenditures, all beneficiaries
In the above example, a pooling contract was may be willing to join a plan that protected
offered. Under adverse selection, a pooling contract against unexpected expenditures at the average
will lead low-risk individuals to decline coverage. It expected price, and pooling would occur.
is possible for the insurance company to offer two
health plans: one targeted at high-risk individuals
Addressing Adverse Selection
and the other targeted at low-risk individuals. This
is known as a separating contract, which could lead Many research studies have explored ways to
to a separating equilibrium where both types of overcome market inefficiencies due to adverse
individuals accept some form of coverage against selection. Michael Spence introduced the concept
future expenditures. The term equilibrium refers to that there are ways in which an individual can
a market equilibrium (price equilibrium) where the send a signal regarding his or her risk type. High-
number of contracts offered by the insurer at a quality producers of a product will find a mecha-
given price is equal to the number of contracts nism to reveal their unobserved quality to buyers
sought by individuals at that price. A health plan in a way that low-quality producers cannot profit-
may offer partial coverage at a reduced premium ably replicate. Although signaling is common in
and a second contract with full coverage. Under other markets, individuals tend to reveal verifiable
certain conditions, an equilibrium could be sus- private information to obtain better coverage in
tained where low-risk individuals select partial health insurance markets.
38 Agency for Healthcare Research and Quality (AHRQ)
It is common for disability insurers to require Henry J. Kaiser Family Foundation (KFF):
a comprehensive medical examination and http://www.kff.org/insurance/snapshot/
detailed health information before providing dis- chcm1110060th2.cfm
ability coverage. They then design a contract that National Association of Health Underwriters (NAHU):
takes the person’s medical history into account http://www.nahu.org
and may exclude certain causes of disability. National Bureau of Economic Research (NBER):
Health insurance companies respond to adverse http://www.nber.org
selection by excluding preexisting conditions The Economist: http://www.economist.com/research/
Economics
during the 1st year of newly acquired coverage.
Furthermore, the companies tend to offer a set of
health plans with varying amounts of premiums
and deductibles so that individuals can select an Agency for Healthcare
appropriate plan based on their risk type. For
example, a healthy person may prefer to be in a
Research and Quality (AHRQ)
low-premium, high-deductible plan rather than
The Agency for Healthcare Research and Quality
in a high-premium, low-deductible health insur-
(AHRQ), which is part of the U.S. Department
ance plan.
of Health and Human Services (HHS), is one of
Jayani Jayawardhana and Richard Lindrooth the nation’s largest supporters of health services
research initiatives. AHRQ’s broad mission is to
See also Health Economics; Health Insurance; Medicaid; improve the quality, safety, efficiency, and effec-
Medicare; Moral Hazard tiveness of healthcare for all Americans. To fulfill
its mission, AHRQ conducts and supports health
Further Readings services research, both within the agency and
through grants and contracts to universities,
Akerlof, George A. “The Market for Lemons: Quality healthcare systems, hospitals, and physicians’
Uncertainty and the Market Mechanism,” Quarterly offices. AHRQ also works closely with its sister
Journal of Economics 84(3): 488–500, 1970. agency the National Institutes of Health (NIH),
Buchmueller, Thomas, and John DiNardo. “Did
which conducts biomedical research.
Community Rating Induce an Adverse Selection
Death Spiral? Evidence from New York,
Pennsylvania, and Connecticut,” American Economic Background
Review 92(1): 280–94.
A number of federal organizations preceded the
Folland, Sherman, Allen Goodman, and Miron Stano.
AHRQ. The federal Omnibus Budget Reconciliation
The Economics of Health and Health Care. Upper
Act of 1989 established its immediate predecessor,
Saddle River, NJ: Pearson Education, 2000.
Pauly, Mark V. “Overinsurance and Public Provision of
the Agency for Health Care Policy and Research
Insurance: The Roles of Moral Hazard and Adverse (AHCPR). The purpose of AHCPR was to enhance
Selection,” Quarterly Journal of Economics 88(1): the quality, appropriateness, and effectiveness of
44–62, 1974. healthcare services and access to healthcare. At the
Rothschild, Michael, and Joseph Stiglitz. “Equilibrium in time, the AHCPR was the successor to the National
Competitive Insurance Markets: An Essay on the Center for Health Services Research and Health
Economics of Imperfect Information,” Quarterly Care Technology Assessment. As a research agency,
Journal of Economics 90(4): 629–49, 1970. the AHCPR supported studies and reviews to
Spence, Michael. “Job Market Signaling,” Quarterly improve the quality of healthcare. One of its major
Journal of Economics 87(3): 355–74, 1973. responsibilities was to use research to develop,
review, and update clinical practice guidelines to
advise healthcare practitioners in the prevention,
Web Sites
treatment, and management of specified health
America’s Health Insurance Plans (AHIP): conditions. This guideline development program
http://www.ahip.org continued until 1996. Some of the clinical practice
Agency for Healthcare Research and Quality (AHRQ) 39
guidelines issued by the agency were highly contro- Specifically, the centers include the following:
versial, and specific medical societies lobbied their (a) quality improvement and patient safety;
legislators to end the funding of the AHCPR. (b) outcomes and effectiveness of care; (c) clinical
In 1999, the U.S. Congress passed legislation practice and technology assessment; (d) healthcare
reauthorizing the AHCPR but changed its name to organization and delivery systems; (e) primary
the Agency for Healthcare Research and Quality. care (including preventive services); and (f) health-
This change was strategic and intentional because care costs and sources of payment. The staff in
it confirmed the agency’s dedication to scientific these centers accomplish the work using a variety
research. Removal of the word policy clarified that of funding mechanisms, such as grants and
the agency does not determine healthcare policy. contracts, and in-house research. Through these
While the AHRQ does not direct policy, it contin- various strategies, the agency forms effective part-
ues to support research and inform policymakers. nerships with other government agencies, aca-
Although the AHRQ is no longer obligated to demic institutions, and industry.
develop clinical practice guidelines, the agency
retains many critical functions. Specifically, the
AHRQ must (a) meet the information needs of its Specific Projects
consumers (patients, practitioners, health system
The AHRQ supports 12 EPCs. The functions of
leaders, and policymakers) so that they can make
the EPCs are to review and synthesize available
more informed decisions; (b) build the evidence
knowledge of various healthcare topics and
base for what works and does not work in health-
describe the quality and the strength of that
care and develop the information, tools, and strat-
evidence—specifically research findings. The syn-
egies that decision makers need; (c) continue the
thesized information is then made available to
national Medical Expenditure Panel Survey (MEPS)
providers, insurers, and others for use in deter-
to evaluate various cost-related issues, including
mining their own practices and policies. Topics
the types of healthcare services Americans use, the
can be nominated by various public or private
access and frequency of healthcare service use, and
organizations as well as the agency and are exam-
the amount of money Americans pay for care; (d)
ined to determine whether or not there exists a
develop a database that provides information to
sufficient scientific base to warrant the synthesis
states on their residents’ access to healthcare ser-
and review. The importance of the topic to large
vices and on the quality and use of those services;
segments of the population, such as those receiv-
(e) establish the Centers for Education and Research
ing Medicare or Medicaid, or those associated
on Therapeutics (CERTs) as a permanent program;
with high costs or chronic illnesses are typical
and (f) support the use of clinical practice guide-
subject areas.
lines through Evidence-Based Practice Centers
The AHRQ provides core support for 14 CERTs
(EPCs), National Guidelines Clearinghouse, and
and their coordinating centers. The U.S. Food and
the U.S. Preventive Services Task Force.
Drug Administration (FDA) also provides funding,
During its transition from the AHCPR to the
and individual centers may receive funding from
AHRQ, John M. Eisenberg provided pivotal lead-
other public or private sources. Broadly, the CERTs
ership that positioned the agency for its current
are to develop and disseminate knowledge about a
functions. Like its predecessor, the AHRQ contin-
range of products that may be used to prevent or
ues to have a well-educated multidisciplinary staff.
treat disease. The desired result is that patients and
Scholars from disciplines such as health services
providers will use such information to determine
research, dentistry, medicine, nursing, and public
appropriate use—not over- or underutilization.
health work to support other scholars and investi-
Specifically, the program objectives are (a) to
gators in the pursuit of knowledge.
increase awareness of both the uses and risks of
new drugs and drug combinations, biological
Current Centers and Programs
products, and devices, as well as of mechanisms to
AHRQ’s organizational structure supports its key improve their safe and effective use; (b) to provide
mission through a number of focused centers. clinical information to patients and consumers,
40 Agency for Healthcare Research and Quality (AHRQ)
healthcare providers, pharmacists, pharmacy Web site. The HCUP is also a good example of how
benefit managers, purchasers, health maintenance the AHRQ does not make policy but provides
organizations (HMOs) and healthcare delivery important resources for those who do.
systems, insurers, and government agencies; and The HIV Research Network (HIVRN) is spon-
(c) to improve quality while reducing the cost of sored by the agency and several other organiza-
care by increasing the appropriate use of drugs, tions of the federal government. The network
biological products, and devices and by preventing includes 18 member practices that treat about
their adverse effects and the consequences of these 14,000 patients and report conditions of HIV
effects (such as unnecessary hospitalizations). patients, therapeutic interventions, and services
Another mandate is to convene the U.S. delivered. Combining these data provides a resource
Preventive Services Task Force (USPSTF), an inter- for understanding patterns in management. While
disciplinary group of clinicians and scientists with data are made public through HIV Net, the net-
expertise in primary-care services. This group uses work does not release information that can poten-
established guidelines to review evidence about tially identify participating practices, individual
preventive services and makes recommendations, patients, or locations.
mostly directed at those who provide primary care. To provide information to its many consumers,
Agency staff works closely with one EPC, which the AHRQ supports a number of other projects.
focuses on this assignment, to develop materials for Over the years, AHRQ has invested millions of
consideration by the panel. Other federal agencies dollars to implement and improve the nation’s
also contribute to the scientific effort. Additionally, health information technology. To share the expe-
other experts and organizations review draft docu- rience and knowledge of its health information
ments to obtain the best and clearest guidance. The technology grantees, the agency developed the
statements in the published guidelines become the National Resource Center for Health Information
standard of care nationwide. Technology (Health IT). Through this center and
In existence since 1996, the Medical Expenditure its Web site, the agency provides resources for
Panel Survey (MEPS) provides a unique resource organizations to use in assessing their health-
on the cost and use of healthcare and health insur- related information technology. The center’s Web
ance coverage in the nation. Information is col- site contains a wealth of information, including a
lected on two components: (1) households and compendium of surveys and a tool kit.
(2) insurance. Over a 2-year study period, data are The Patient Safety Network (PSNet) is a compi-
collected on all members of selected households, lation of articles and recent findings related to
including their health conditions, access to care, patient safety issues. It is funded by the agency and
health insurance coverage, and employment. By guided by a national advisory board. Individuals
interviewing respondents over the 2-year study may receive the updates online through a registra-
period, data about changes in health conditions, tion process.
employment, and other factors can be examined Another important agency project is the National
for their potential impacts. The health insurance Consumer Assessment of Healthcare Providers and
component is also known as the Health Insurance Systems (CAHPS). Individuals and organizations
Cost Study and obtains data from employers on can use CAHPS to assess the patient-centeredness
the coverage provided to their employees, its costs, of care, compare and report on performance, and
and what benefits are provided. improve the quality of care. The health plan survey
Since 1988, the Healthcare Cost and Utilization component of CAHPS, which began in 1998, now
Program (HCUP) has been the largest all-payer col- anchors this group of surveys that organizations
lection of hospital inpatient-care statistical informa- can use to evaluate their own performance in com-
tion in the nation. It gathers longitudinal data on parison to the national database.
hospital costs, including all-payer and encounter- The AHRQ maintains an excellent series of
level data. These data are available to scholars and Web sites, and personal contact and support from
others and are useful particularly to those who are agency staff are easily available.
examining statewide data. Like most AHRQ prod-
ucts, the information is available on the agency’s Ann R. Bavier
Aiken, Linda H. 41
See also Clancy, Carolyn M.; Clinical Practice Guidelines; Evidence-Based Practice Centers (EPC):
Eisenberg, John M.; Evidence-Based Medicine (EBM); http://www.ahrq.gov/clinic/epc
Health Services Research, Origins; Patient Safety; Healthcare Cost and Utilization Project (HCUP):
Quality of Healthcare; U.S. Food and Drug http://www.ahrq.gov/data/hcup
Administration (FDA) Medical Expenditure Panel Survey (MEPS):
http://www.meps.ahrq.gov
National Consumer Assessment of Healthcare Providers
Further Readings and Systems (CAHPS): http://www.caphs.ahrq.gov
National Resource Center for Health Information
Clancy, Carolyn M. “AHRQ: A Tradition of Evidence.
Technology (Health IT): http://healthit.ahrq.gov
Federal Agency Carries a Rich History of Involvement
Patient Safety Network (PSNet): http://psnet.ahrq.gov
in Today’s Evidence-Based Medicine Movement,
U.S. Preventive Services Task Force (USPSTF):
Focusing on the ‘Evidence Inside’ Healthcare IT,”
http://www.ahrq.gov/clinic/uspstfix.htm
Health Management Technology 24(8): 26–29,
August 2003.
Clancy, Carolyn M., Jean R. Slutsky, and Larry T.
Patton. “Evidence-Based Health Care 2004: AHRQ
Moves Research to Translation and Implementation,” Aiken, Linda H.
Health Services Research 39(5): xv–xxiv, October
2004. Linda H. Aiken is an influential nurse leader and
Clancy, Carolyn M., Daniel Stryer, and John M.
researcher in the field of nursing outcomes research.
Eisenberg. “From Publication to Public Action:
Aiken is the Claire M. Fagin Leadership Professor
Agency for Healthcare Research and Quality (AHRQ)
of Nursing, professor of sociology, and director of
Perspectives on Ethnicity and Race-Related Outcomes
the Center for Health Outcomes and Policy Research
Research,” Ethnicity and Health 7(4): 287–90,
at the University of Pennsylvania. She is also a
November 2002.
Elixhauser, Anne, Mamatha Pancholi, and Carolyn M.
senior fellow at the Leonard Davis Institute for
Clancy. “Using the AHRQ Quality Indicators to Health Economics, and research associate in the
Improve Health Care Quality,” Joint Commission Population Studies Center, and she codirects the
Journal on Quality and Patient Safety 31(9): 533–38, National Council on Physician and Nurse Supply.
September 2005. Aiken conducts research on healthcare outcomes
Meyer, Gregg S., James Battles, James C. Hart, et al. and health workforce policy. She is the principal
“The U.S. Agency for Healthcare Research and investigator of a five-country study of hospital-care
Quality’s Activities in Patient Safety Research,” outcomes in the United States, Canada, England,
International Journal for Quality in Health Care Scotland, and Germany and is involved in evaluat-
15(Suppl. 1): 25–30, December 2003. ing the impact of 90 healthcare partnerships funded
Mullican, Charlotte A., and Carolyn M. Clancy. by the United States Agency for International
“Partnerships for Quality: Results of the AHRQ Development (USAID) in Eurasia.
Council of Partners Co-Action Across Projects,” Joint Prior to joining the faculty of the University of
Commission Journal on Quality and Patient Safety Pennsylvania in 1988, Aiken was vice president of
33(Suppl. 12): 4–6, December 2007. the Robert Wood Johnson Foundation (RWJF),
Zafar, Atif. “The AHRQ National Resource Center for where she directed the research and evaluation
Health Information Technology (Health IT) Public program. While at the foundation, she designed a
Web Resource,” American Medical Informatics $100 million demonstration initiative to improve
Association Symposium Proceedings 1154: 2006. care for the chronically mentally ill, for which she
received a unique Joint Secretarial Commendation
from the Secretary of the U.S. Department of
Web Sites Health and Human Services and the Secretary of
Agency for Healthcare Research and Quality (AHRQ): the U.S. Department of Housing and Urban
http://www.ahrq.gov Development.
Centers for Education and Research on Therapeutics Aiken has received many awards and honors for
(CERTs): http://www.ahrq.gov/clinic/certsovr.htm her work. She received the William B. Graham
42 Allied Health Professionals
Prize for Health Services Research, the Ernest A. Further Readings

Codman Award from the Joint Commission, the Aiken, Linda H. “U.S. Nurse Labor Market Dynamics
Baxter Episteme Award from Sigma Theta Tau Are Key to Global Nurse Sufficiency,” Health
International, the Barbara Thoman Curtis Award Services Research 42(3 pt. 2): 1299–1320, June 2007.
from the American Nurses Association (ANA), Aiken, Linda H., James Buchan, Julie Sochalski, et al.
and the Distinguished Investigator awards from “Trends in International Nurse Migration,” Health
AcademyHealth. Aiken is also the recipient of three Affairs 23(3): 69–77, May–June 2004.
American Academy of Nursing Media Awards. Aiken, Linda H., Sean P. Clarke, Robyn Cheung, et al.
Aiken is an elected member of the national “Education Levels of Hospital Nurses and Surgical
Institute of Medicine (IOM), where she is a mem- Patient Mortality,” Journal of the American Medical
ber of the Board on Health Care Services. She is a Association 290(12): 1617–23, September 24, 2003.
fellow and former president of the American Aiken, Linda H., Sean P. Clarke, Douglas M. Sloane,
Academy of Nursing and an Honorary Fellow of et al. “Hospital Nurse Staffing and Patient Mortality,
the Royal College of Nursing of the United Nurse Burnout, and Job Dissatisfaction,” Journal of
Kingdom. Aiken is also an elected fellow of the the American Medical Association 288(16): 1987–93,
American Academy of Arts and Sciences, and the October 23, 2002.
National Academy of Social Insurance, and a Aiken, Linda H., Ying Xue, Sean P. Clarke, et al.
Distinguished Fellow of the Academy for Health “Supplemental Nurse Staffing in Hospitals and
Services Research and Health Policy. In addition, Quality of Care,” Journal of Nursing Administration
she is a member of the Council on the Economic 37(7/8): 335–42, July–August 2007.
Impact of Health System Change, and she has
served on the Medicare Physician Payment Review
Commission (PPRC) for 6 years. Web Sites
Aiken received her bachelor’s (1964) and mas- University of Pennsylvania School of Nursing Faculty
ter’s (1966) degrees in nursing from the University Profile: http://www.nursing.upenn.edu/faculty/
of Florida, Gainesville, and her doctorate degree profile.asp?pid=107
(1973) in sociology and demography from the
University of Texas at Austin. She was a postdoc-
toral research fellow (1973–1974) in medical soci-
ology at the University of Wisconsin, Madison. Allied Health Professionals
Aiken has made many notable contributions to
public health through innovative health services Allied health professionals are the staff involved
research, and she has had a significant impact on with the delivery of healthcare or related services
the way healthcare is delivered. Her work has pertaining to the identification, evaluation, and
greatly influenced nursing policies and practices, prevention of diseases and disorders. They are also
including nurse recruitment and retention, nurse involved in dietary and nutrition services, reha-
work force supply, patient-care practices, and bilitation, and health system management. In the
staffing. Aiken’s work continues to be recognized United States, there are more than 6 million allied
by scholars and practitioners for her many contri- health professionals from a myriad clinical sup-
butions to improving health and medical care port and technical occupations in healthcare ser-
nationally and internationally. vices. According to the U.S. Department of Labor,
about 60% of the nation’s healthcare workforce is
Lubina Perez composed of allied health professionals.
See also American Nurses Association (ANA); Health Allied health professionals represent more than
Professional Shortage Areas (HPSAs); Health 70 areas of expertise, and they are trained in more
Resources and Services Administration (HRSA); than 2,500 higher-level educational institutions in
Hospitals; International Health Systems; Nurse the nation. These professionals include dental
Practitioners (NPs); Nurses; Robert Wood Johnson hygienists, diagnostic medical sonographers, dieti-
Foundation (RWJF) tians, medical technologists, occupational therapists,
Allied Health Professionals 43
physical therapists, radiographers, respiratory ther- Issues Facing Allied Health Professionals
apists, and speech-language pathologists.
Certification and/or licensure differ for each allied
Although there is no standard definition or
health profession, and specialized training and
number of health professions that consistently fall
education are required for all types of allied health
under the term allied health professionals, it is
professionals. Accreditation is a process in which
clear that these professionals have an important
educational programs in schools of allied health
impact on the nation’s healthcare system. They are
professions are reviewed so that standards, guide-
actively engaged in the provision and delivery of
lines, and requirements remain consistent between
health services, working alongside physicians,
schools and programs. Not all programs of allied
nurses, pharmacists, dentists, optometrists, and
health professions are accredited, so it is impor-
podiatrists.
tant for prospective students to assess the charac-
teristics of educational programs through the
Need for Allied Health Professionals Commission on Accreditation of Allied Health
Education Programs (CAAHEP).
The widespread field of allied health became well-
Allied health professionals have struggled for
known after the passage of the federal Allied
autonomy from other health professionals, and
Health Professions Personnel Training Act of
not all allied health professionals have the same
1966. This act specifically identified the growing
requirements and restrictions in their practices.
need for standardized education and support for
For example, insurance companies may only cover
allied health professionals.
services of an allied health professional, such as a
Today, because of the aging of the nation’s
physician assistant, when working under a physi-
population, the increase in the number of people
cian’s direct supervision. Some practitioners may
with chronic diseases, and the development of new
oppose competition from allied health profession-
medical technology, there is a growing demand for
als who provide similar healthcare services; espe-
allied health professionals. These professionals
cially as allied health education becomes more
increase the efficiency of clinicians by providing
sophisticated. As allied health education continues
support services.
to build on higher-quality programs that increase
Schools of allied health professions are attempt-
the scope of knowledge and expertise for allied
ing to meet the need for quality education of this
health professionals, patients may seek services
broad professional group by fostering research,
exclusively from them. Limitations currently exist
creating professional networks, and providing
for a patient to see a physician assistant, but this
early exposure to high school students of the var-
may change in the future. An ongoing discussion is
ied allied health professions available. The federal
currently taking place in terms of federal legislative
government provides funds for individuals needing
policy regarding the scope of privileges available to
financial assistance for education in allied health
allied health professionals.
professions. The government also recruits and
trains professionals to work in shortage areas.
Because of the nation’s changing demographics,
there is a need to address disparities in higher-level
Future Implications
education based on ethnicity, socioeconomic sta- The U.S. Department of Labor, Bureau of Labor
tus, and area of residence. For example, the chang- Statistics, predicts that more than 90% of allied
ing ethnic composition of the nation will result in health professionals will grow at or above the
an increasing need for culturally competent health- average of all occupations through the year 2014.
care providers who are bilingual and bicultural. In These statistics indicate a projected shortage of
particular, individuals from traditionally underrep- allied health professionals based on the need for
resented ethnic populations in higher education their specialized services.
need to be recruited to diversify the allied health Healthcare is often viewed as being strictly
professional workforce. Shortages in rural areas under the domain of physicians and nurses.
also need to be addressed. Promoting a greater understanding of the diverse
44 Altman, Drew E.
range of health professionals will likely result in policy and health communications. Located in
higher levels of enrollment in schools of allied Menlo Park, California, with major facilities in
health professions, reducing their expected short- Washington, D.C., the Kaiser Family Foundation
age. Faculty of schools of allied health professions is a leading independent voice and source of
are currently engaged in research concerning the research and information on healthcare in the
factors related to the productivity, learning needs, United States. The foundation serves as a nonpar-
and administration of allied health professionals tisan source of facts, information, and analysis to
and current issues facing their students and inform policymakers, the healthcare community,
workforce. and the public. It runs its own research and com-
munications programs, often in partnership with
Michelle Choi Wu other organizations. In 1991, Altman oversaw a
complete overhaul of the foundation’s mission and
See also Access to Healthcare; Hospitals; Nurses;
Nursing Homes; Physician Assistants; Physicians; operating style that served as a catalyst to enhance
Public Health its standing today as a premier health policy and
communications foundation.
Altman received his bachelor’s degree from
Further Readings Brandeis University and a master’s degree in politi-
Jones, Robert, and Fiona Jenkins, eds. Developing the cal science from Brown University. He later com-
Allied Health Professional. Ames, IA: Blackwell, pleted his doctorate degree in political science at
2006. the Massachusetts Institute of Technology (MIT),
Miller, Thomas W., and Vincent S. Gallicchio. “Allied where he later taught graduate courses in public
Health Professionals With 2020 Vision,” Journal of policy. Altman went on to do postdoctoral work at
Allied Health 36(4): 236–40, Winter 2007. the Harvard School of Public Health before enter-
Pybus, Beverly E., and Carol S. Cairns. A Guide to AHP ing public service.
Credentialing: Challenges and Opportunities to Altman is a former commissioner for the
Credentialing Allied Health Professionals. 2d ed. Department of Human Services for the state of
Marblehead, MA: HCPro, 2004. New Jersey, under Governor Thomas H. Kean,
Scriven, Angela, ed. Health Promoting Practice: The where he developed pioneering programs in wel-
Contribution of Nurses and Allied Health fare reform, Medicaid managed care, school-based
Professionals. New York: Palgrave Macmillan, 2005. services, and services for homeless people. From
1981 to 1986, he served as a vice president at the
Web Sites Robert Wood Johnson Foundation (RWJF). At the
Association of Schools of Allied Health Professions RWJF, he developed model national demonstration
(ASAHP): http://www.asahp.org programs for HIV services and health services for
Bureau of Health Professions (BHPr): http://bhpr.gov homeless people. During President Carter’s admin-
Bureau of Labor Statistics (BLS): http://www.bls.gov istration, Altman served as a special assistant in
Commission on Accreditation of Allied Health Education the Office of the Administrator of the Health Care
Programs (CAAHEP): http://www.caahep.org Financing Administration (HCFA) (now the Centers
for Medicare and Medicaid Services [CMS]). Prior
to joining the Kaiser Family Foundation in 1990,
Altman served as the director of the Health and
Altman, Drew E. Human Services program at the Pew Charitable
Trusts.
Drew E. Altman is a leading expert on national Altman is a member of the national Institute of
health policy issues and an innovator in the pri- Medicine (IOM), where he serves on the governing
vate foundations. He currently serves as the presi- council, and the American Academy of Arts and
dent and chief executive officer of the Henry J. Sciences.
Kaiser Family Foundation, one of the nation’s
largest private foundations devoted to health Lubina Perez
Ambulatory Care 45
See also Kaiser Family Foundation; Public Policy; Robert issues. A general medical examination, however,
Wood Johnson Foundation (RWJF); Vulnerable was the specific reason most often cited for a physi-
Populations cian visit, making up about 7% of all ambulatory-
care visits. About 18% of all visits were for
preventive-care purposes, and 33% of visits were
Further Readings for new conditions or infectious diseases. Through
Altman, Drew E. “Care for the Poor,” Annals of the these visits, there are a wide variety of services that
American Academy of Political and Social Science are offered. Diagnostic or screening services were
468(1): 103–21, 1983. ordered at 87% of ambulatory visits. Health edu-
Altman, Drew E. “Foundations Today: Finding a New cation was ordered or provided at 38%, nonmedi-
Role in a Changing Health Care System,” Health cation treatment (consisting of services such as
Affairs 17(2): 201–205, March–April 1998. physical therapy, psychotherapy, or wound care)
Altman, Drew E. “The New Medicare Prescription-Drug was ordered at 18%, and surgical procedures were
Legislation,” New England Journal of Medicine ordered or performed at 6% of office visits.
350(1): 9–13, January 1, 2004.
Altman, Drew E., Carolyn Clancy, and Robert J.
Blendon. “Improving Patient Safety—Five Years After The Healthcare System
the IOM Report,” New England Journal of Medicine Ambulatory care is the primary means by which
351(20): 2041–43, November 11, 2004. medical care is provided to the U.S. population,
constituting more than 1 billion visits yearly. In
Web Sites 2003, this accounted for about 27% of the
nation’s healthcare spending. In 2005, nearly
Henry J. Kaiser Family Foundation: http://www.kff.org
60% of all visits were to primary-care specialists
(more than 22% to generalists and family medi-
cine physicians), and the remaining 40% of total
visits split nearly evenly between surgical and
Ambulatory Care medical specialists.
As the U.S. healthcare system is scrutinized and
The National Center for Health Statistics (NCHS) reassessed to improve its overall effectiveness, the
defines ambulatory care as healthcare that is pro- important role of ambulatory care in the ability to
vided to persons in physician offices, hospital improve quality and control costs is being realized.
outpatient departments, and hospital emergency In 2004, the National Quality Forum (NQF) met
departments without their admission to a health- to identify a set of performance measures that will
care facility. Ambulatory care consists of a wide be used to improve the quality of ambulatory care
array of medical and healthcare services, including in furthering this ideal. The 10 priority areas that
diagnosis, observation, treatment, rehabilitation, were identified include patient experience with
and preventive services. The term ambulatory care care; coordination of care; asthma; prevention
refers to the fact that persons who are given this (primary and secondary, including immunization);
type of care are generally able to ambulate or medication management; heart disease; diabetes;
walk about, unlike some hospital inpatients who hypertension; depression; and obesity. These mea-
may not be able to leave their beds. sures have been prioritized and focused in subse-
quent years through the Ambulatory Care Project,
which is aimed at standardizing ambulatory-care
Utilization
performance measures and, in doing so, improving
Patient concerns or medical conditions that are quality in the ambulatory setting.
addressed through ambulatory care vary widely. The Agency for Healthcare Research and Quality
Nationally, about 50% of all physician visits in the (AHRQ) estimates that by improving the quality of
United States in 2005 were due to specific symptom and access to primary care through projects such as
complaints such as respiratory or musculoskeletal the Ambulatory Care Project, the nation might be
46 Ambulatory Care
able to avoid more than 4 million hospitalizations Rapid advances in information technology may,
each year. This could result in billions of saved as well, transform the concept of ambulatory care
healthcare dollars by enhancing access to effective in novel ways. The electronic health record will
treatments and focusing on prevention in an ambu- contribute to efficiency, accuracy, and continuity in
latory setting in regard to chronic illnesses such as patient care and will be central to the impact that
diabetes, congestive heart failure, asthma, and ambulatory care may provide in improved out-
hypertension. It is estimated that in 2004, a total of comes. Information technology may also alter the
$29 billion was spent on inpatient care for 12 current practice model significantly through a
potentially preventable conditions, including $2.6 greater ability to provide comprehensive services
billion for kidney damage due to long-standing in home visits and greater access to patient educa-
uncontrolled diabetes and $8.3 billion for compli- tion and ease of patient self-management coaching
cations involving congestive heart failure. Chronic and patient empowerment, in addition to potential
illness visits currently make up a significant por- development of e-visit consultations. Electronic
tion of ambulatory-care visits, constituting about prescribing or e-prescribing will ensure more accu-
40% of visits in 2005. However, chronic care can rate and reliable medication management, cutting
be greatly improved, and illness exacerbations and costs and greatly decreasing medical errors.
secondary complications can be avoided, through In addition to the philosophy of ambulatory
enhanced access to primary-care settings. care of striving to provide high-quality, patient-
centered care within the community, ambulatory
care, as well, offers significant cost savings and
Future Implications
improved patient outcomes. Ambulatory care in
As medical care in the nation continues to evolve the United States currently offers a wide range of
and factors such as cost, quality, and attention to services and is positioned to be a central compo-
health promotion and chronic disease control nent in the future direction of its evolving health-
have an impact on shaping the healthcare system, care system.
the idea and manifestation of ambulatory care J. Andrew Dykens
will, as well, continue to change. Primary care will
likely become more central, and a more patient- See also Access to Healthcare; American Medical
centered approach will take shape. A currently Association (AMA); Cost of Healthcare; E-Health;
perceived strength of ambulatory care, in consid- Hospital Emergency Departments; Physicians; Primary
eration of patient preference and health outcomes, Care; Quality of Healthcare
is continuity of care. This is evidenced by the fact
that in 2005, 87% of ambulatory visits in the Further Readings
nation were by established patients at that loca-
Chan, Paul D., David M. Thomas, and Elizabeth K.
tion and about 50% of all physician visits were
Stanford. Outpatient and Primary Care Medicine.
with the patient’s primary-care physician. The
Blue Jay, CA: Current Clinical Strategies, 2008.
strength of continuity of care is central to the idea
Fiebach, Nicholas H., David E. Kern, Patricia A.
of patient-centered medical home, which will
Thomas, et al., eds. Barker, Burton and Zieve’s
become a crucial aspect in comprehensive, person- Principles of Ambulatory Medicine. 7th ed.
alized, high-quality care coordinated through a Philadelphia: Lippincott Williams and Wilkins, 2006.
team approach. The idea, initially introduced by Griffin, Don, and Polly Griffin. Outside the Hospital:
the American Academy of Pediatrics (AAP) in The Delivery of Healthcare in Non-Hospital Settings.
1967, has undergone revision and is now being Sudbury, MA: Jones and Bartlett, 2009.
promulgated as a comprehensive plan by the Hing, Esther, and Catharine W. Burt. Characteristics of
American Academy of Family Physicians (AAFP), Office-Based Physicians and Their Practices: United
the AAP, the American College of Physicians States, 2005–2006. Vital and Health Statistics Series
(ACP), and the American Osteopathic Association 13, no. 166. HHS Pub. No. (PHS) 2008–1737.
(AOA) to improve outcomes, increase value, and Hyattsville, MD: National Center for Health
help defragment the U.S. healthcare system. Statistics, April 2008.
American Academy of Family Physicians (AAFP) 47
Web Sites to the public. Over the years, the academy has
Ambulatory Care Quality Alliance: expanded its purpose to also include (a) providing
http://www.ambulatoryqualityalliance.org advocacy for the education of patients and the
National Association for Ambulatory Care (NAFAC): public in all health-related matters; (b) preserving
http://www.urgentcare.org and promoting quality cost-effective healthcare;
National Center for Health Statistics (NCHS): (c) promoting the science and art of family medi-
http://www.cdc.gov/nchs cine; (d) preserving the right of family physicians
National Quality Forum: http://www.qualityforum.org to engage in medical and surgical procedures;
(e) providing advocacy, leadership, and representa-
tion; and (f) maintaining and providing an organi-
zation to represent the needs of its members.
The academy was instrumental in the establish-
American Academy of ment of family medicine as medicine’s 20th pri-
Family Physicians (AAFP) mary specialty in 1969. The specialty was created
to fulfill the generalist function in medicine.
The American Academy of Family Physicians
(AAFP) is the national professional association for
The Profession
family physicians. Representing nearly 94,000
physicians and medical students in the United Family physicians provide the majority of primary
States, it is one of the nation’s largest medical care in the United States. In fact, annually nearly
associations. The AAFP’s mission is to improve one in four of all physician office visits in the
the health of patients, families, and communities nation are made to general and family physicians.
by serving the needs of its members with profes- And family physicians provide the majority of
sionalism and creativity. Its vision is to transform care for America’s underserved rural and urban
healthcare to achieve optimal health for all. populations.
Decades of research clearly show that health- Providing patients with a personal medical
care systems based on the patient-centered primary home, family physicians deliver a wide range of
care that family physicians provide results in better acute, chronic, and preventive medical-care ser-
health outcomes, lower costs and more equitable vices. Unlike some physicians who are limited to a
healthcare than systems based on fragmented and particular organ, disease, age, or gender, family
over-specialized care. The American Academy of physicians integrate care for patients of both gen-
Family Physicians (AAFP) is leading the charge to ders across the full spectrum of ages. Family physi-
bring necessary improvements, conveniences, and cians are dedicated to providing patients with a
modernizations in how medicine is practiced and medical home where patients experience seamless,
coordinated. The academy is working with policy- coordinated care with caring. They treat the whole
makers and business leaders to demonstrate the person and foster an ongoing, trusting, personal
efficacy of a patient-centered, primary-care-focused physician–patient relationship.
healthcare system and to bring about needed Like other medical specialists, family physicians
national reform. complete a 3-year residency program after gradu-
ating from medical school. As part of their resi-
dency, they participate in integrated inpatient and
History
outpatient learning and receive training in six
Headquartered in Leawood, Kansas, the AAFP major medical areas: (1) pediatrics, (2) obstetrics
was originally known as the American Academy of and gynecology, (3) internal medicine, (4) psychia-
General Practice. In 1971, its name was changed to try and neurology, (5) surgery, and (6) community
reflect more accurately the changing nature of pri- medicine. They also receive instruction in many
mary healthcare. The original purpose of the acad- other areas, including geriatrics, emergency medi-
emy was to promote and maintain high quality for cine, ophthalmology, radiology, orthopedics, oto-
family physicians who provide comprehensive care laryngology, and urology.
48 American Academy of Family Physicians (AAFP)
Organization Physician. Other publications include Family

Practice Management and a bimonthly research
The AAFP is governed by a Congress of Delegates
journal, Annals of Family Medicine. In addition to
composed of two delegates from each of the asso-
its peer-reviewed journals, the academy also pub-
ciation’s 55 constituent chapters, as well as dele-
lishes AAFP News Now, an all-member news and
gates from residents and student groups, new
features publications available online, via e-mail,
physicians, and special constituencies groups. The
and by postal mail service.
congress meets annually and establishes the acad-
emy’s policies and programs. The academy’s board Sarah Thomas
of directors and other standing and special com- See also Access to Healthcare; Patient-Centered Care;
missions and committees then carry out these Physicians; Primary Care; Primary-Care Case
policies and programs. Delegates to the congress Management (PCCM); Primary-Care Physicians;
elect the board, which in turn appoints commis- Starfield, Barbara; Vulnerable Populations
sion and committee members.
To support its advocacy efforts, the academy Further Readings
maintains a Government Relations office in
Washington, D.C., for liaison with the U.S. Bodenheimer, Thomas, Edward Wagner, and Kevin
Congress and the federal government. Grumbach. “Improving Primary Care for Patients With
Chronic Illness,” Journal of the American Medical
Association 288(14): 1775–79, October 9, 2002.
De Maeseneer, Jan M., Lutgarde De Prins, Christiane
Activities and Services
Gosset, et al. “Provider Continuity in Family
Family medicine was the first medical specialty to Medicine: Does It Make a Difference for Total Health
require its physicians to pursue continuing medical Care Costs?” Annals of Family Medicine 1: 144–48,
education (CME). A primary responsibility of the September–October 2003.
academy is to develop and provide its members Ferrer, Robert L., Simon J. Hambidge, and Rose C.
with CME programs aimed at ensuring family phy- Maly. “The Essential Role of Generalists in Health
sicians remain educated on the latest medical tech- Care Systems,” Annals of Internal Medicine 142(8):
nologies, treatments, and techniques. To maintain 691–99, April 19, 2005.
active membership, the academy requires its mem- Future of Family Medicine Project Leadership
bers to earn 150 credits of CME every 3 years. The Committee. “Future of Family Medicine,” Annals of
annual Scientific Assembly is the academy’s largest Family Medicine 2(Suppl. 1): S3–S32, 2004.
meeting for continuing education, drawing more Macinko, James, Barbara Starfield, and Leiyu Shi. “The
Contribution of Primary Care Systems to Health
than 17,000 physicians and visitors.
Outcomes Within Organization for Economic
To facilitate communication with its members
Cooperation and Development (OECD) Countries,
and with patients, the academy also operates two
1970–1998,” Health Services Research 38(3):
Web sites, www.aafp.org and www.familydoctor.
831–65, June 2003.
org. The academy’s physician-focused Web site,
Shi, Leiyu, and Barbara Starfield. “The Effect of Primary
www.aafp.org, provides resources for members, Care Physician Supply and Income Inequality on
including the full text of the academy’s publica- Mortality Among Blacks and Whites in U.S.
tions. The physician-reviewed patient Web site, Metropolitan Areas,” American Journal of Public
www.familydoctor.org, features searchable, easy- Health 91(8): 1246–50, August 2001.
to-understand information on more than 500 Shi, Leiyu, Barbara Starfield, Robert Politzer, et al.
medical conditions and illnesses. The site also “Primary Care, Self-Rated Health, and Reductions in
includes Spanish language content, a drug data- Social Disparities in Health,” Health Services
base, and self-diagnosis flow charts. Research 37(3): 529–50, June 2002.
To advance the discipline and provide resources Starfield, Barbara, Leiyu Shi, and James Macinko.
for its members, the AAFP also publishes several “Contribution of Primary Care to Health Systems and
peer-reviewed journals, including the nation’s lead- Health,” Milbank Quarterly 83(3): 457–502,
ing primary-care clinical journal, American Family September 2005.
American Academy of Pediatrics (AAP) 49
Web Sites district chairpersons. Members also vote each year

American Academy of Family Physicians (AAFP): for a national vice president, who also serves as
http://www.aafp.org president-elect. The executive committee, consist-
American Academy of Family Physicians (AAFP), Family ing of the president, president-elect, vice president,
Doctor: http://www.familydoctor.org and executive director, conducts AAP business on
a daily basis.
At the state level, there are AAP chapters, which
are individually incorporated, have their own
American Academy of bylaws, and further the aims of the national orga-
nization as well as their local priorities.
Pediatrics (AAP) More than 30 national committees develop
many of the AAP’s policies and programs, under
The American Academy of Pediatrics (AAP) is a the direction of the board of directors, to help
membership and child advocacy organization, achieve the academy’s goals and objectives.
supporting the professional needs of its 60,000 Examples of national committees include the
members and advocating for children’s health and Committee on Nutrition, the Committee on Early
safety in a broad range of venues. The AAP’s mis- Childhood, Adoption and Dependent Care, and
sion is to attain optimal physical, mental, and the Committee on Injury, Violence and Poison
social health and well-being for all infants, chil- Prevention.
dren, adolescents, and young adults. In addition to being involved with the commit-
Members of the AAP, who are largely in the tees, members can participate in 1 of 46 sections
United States, Canada, and Latin America, com- pertaining to specific pediatric subspecialties, sur-
prise pediatricians, pediatric medical subspecialists gical specialties, or multidisciplinary areas. Section
(such as pediatric cardiologists or adolescent health members are instrumental in providing educational
specialists), and pediatric surgical specialists. sessions at the AAP’s annual National Conference
Members are board certified and called Fellows of and Exhibition, as well as assisting with develop-
the American Academy of Pediatrics, or FAAPs. ment of statements and practice guidelines, and
Board certification is accomplished through the many other projects. Examples of current AAP sec-
American Board of Pediatrics. tions include Bioethics, Critical Care, Dermatology,
The central office of the organization is in Elk Perinatal Pediatrics, and Uniformed Services, to
Grove Village, Illinois, a suburb of Chicago. It is a name a few.
not-for-profit Illinois corporation. The AAP’s The AAP also has a small number of councils
Department of Federal Affairs is located in that incorporate many of the functions of commit-
Washington, D.C. tees and sections but provide for a broader vision
The AAP was founded in 1930 by 35 pediatri- and wider array of activities. Examples of councils
cians in response to the need for an independent include Communications and Media, Community
pediatric forum to address children’s needs. At that Pediatrics, and Sports Medicine and Fitness.
time, the idea that children had unique develop-
mental and health needs was new. Preventive
Policy and Clinical Guidance
health practices now accepted as standard child
healthcare (i.e., immunization, regular health The AAP provides guidance to its members
exams) were only just beginning to change the and the public on a wide range of issues. Its
custom of treating children as “miniature adults.” “Recommendations for Preventive Pediatric Health
Care” form the basis of preventive care for each
age, and the AAP is one of three organizations that
Organization collaborate to produce the annual Recommended
Today, the AAP is governed by a board of direc- Immunization Schedule for children and adoles-
tors consisting of 10 members, who are elected cents, which is used by schools, public health agen-
by their regional districts and, thus, also serve as cies, and private pediatric practices. In addition,
50 American Academy of Pediatrics (AAP)
the AAP has issued statements of policy as well as drug-labeling bill that requests drug companies to
technical reports on a vast array of topics, and study their drugs in children, as well as the State
practice guidelines on clinical issues. Children’s Health Insurance Program (SCHIP), an
expansion of Medicaid that enables children from
limited-income families to access comprehensive
Advocacy
healthcare.
The AAP advocates access to care for pediatric AAP staff also assists members in advocating
patients encompassing all aspects of accessibility, for their patients at the state level by monitoring
including financial, geographic, physical, and child health legislation and facilitating participa-
communicative access. The AAP believes that all tion in the legislative and regulatory process. Issues
children, women, and their families must have that may be addressed at the state level include
adequate health insurance regardless of income. Medicaid, injury and violence prevention, immuni-
All health insurance plans should have a compre- zations, and many others.
hensive age-appropriate benefits package.
The AAP also believes that each child should
Research
have a “medical home”—a place where care is
accessible, family centered, continuous, compre- The AAP is home to several long-term research
hensive, coordinated, compassionate, and cultur- programs to enhance the delivery of healthcare to
ally effective. The AAP works with government, children. Its Pediatric Research in Office Settings
communities, and other national organizations to program conducts studies using a network of 1,800
help shape these and many other child health and pediatricians working in office-based practices.
safety issues.
Publications, Public
Priorities Information, and the Media
As 2010 approaches, priority issues for the AAP The academy has the largest pediatric publishing
include (a) universal healthcare coverage for all program in the world, with 120 titles for consum-
children; (b) increased efforts to prevent and ers and 400 for physicians and other healthcare
reduce childhood obesity; (c) expanded education professionals. In addition, AAP works extensively
about childhood health issues for parents and with the media and carries out public information
pediatricians; (d) greater understanding and campaigns to ensure that timely, accurate and
research in human genetics; (e) increased efforts to focused messages and information reach families
reduce prematurity; and (f) improvements in vac- and professionals. The AAP publicizes the latest
cine efficacy and delivery. Mental health and oral research in its journal, Pediatrics, as well as the
health services are also priorities. latest AAP policies, campaigns, and partnerships
with other organizations.
Engaging Government
Community-Based Initiatives
The AAP’s Office of Federal Affairs has been the
academy’s link to federal legislative activities in The AAP works with community-based organiza-
Washington, D.C., for nearly 40 years, giving tions on many programs, including numerous
pediatricians the information and tools necessary grant-funded projects. For example, the Com
to become effective child advocates through munity Access to Child Health (CATCH) Program
Congress and/or federal agencies. This office supports pediatricians and communities that are
works on issues affecting children’s healthcare involved in community-based efforts for children.
coverage, immunizations, pediatric drugs The Healthy Tomorrows Partnership for Children
and medical devices, and much more. The Program is a cooperative agreement between the
academy was the driving force behind a pediatric federal Maternal and Child Health Bureau and
American Association of Colleges of Nursing (AACN) 51
the AAP, with federal grants awarded to support

community-based child health projects that improve American Association of
access to health services for mothers, infants, chil- Colleges of Nursing (AACN)
dren, and adolescents.
The American Association of Colleges of Nursing
Member Education (AACN) is a nonprofit institutional membership
association dedicated exclusively to furthering
Recognizing that ongoing education of pediatri- nursing education in America’s universities and
cians is a cornerstone of promoting optimal care 4-year colleges. The AACN represents schools of
for children, one of AAP’s major activities is con- nursing at more than 600 public and private insti-
tinuing medical education (CME), with numerous tutions of higher education. Its mission is to serve
opportunities for learning, including the annual as the national voice of baccalaureate and gradu-
National Conference and Exhibition and AAP’s ate-degree nursing education. The association also
scientific journal, Pediatrics (which is printed in includes the Commission on Collegiate Nursing
English and five other languages, including Education (CCNE), which accredits baccalaureate
Chinese). Member pediatricians are offered printed and graduate nursing programs.
and online learning products such as PREP: The
Course. The AAP’s online Pedialink service con-
nects members to courses all over the country. The Background
latest news from the organization is delivered In 1965, the American Nurses Association (ANA)
through its monthly publication, AAP News. took the position that nursing education should
take place at institutions of higher education. At
Gina Steiner
the time, most nurses were trained in hospital-
See also Access to Healthcare; Child Care; Physicians; based diploma programs. The ANA policy even-
Primary Care; State Children’s Health Insurance tually led to the demise of hospital programs and
Program (SCHIP) the rise of associate and baccalaureate degree
programs in nursing at colleges and universities.
Further Readings As a result, the AACN was formed in 1969 to
establish quality standards for bachelor’s and
Baker, Carol J., ed. Red Book Atlas on Pediatric graduate-degree nursing education. It also assisted
Infectious Diseases. 27th ed. Elk Grove Village, IL: deans and directors of nursing programs to
American Academy of Pediatrics, 2006. implement its standards and promoted public
Baker, Jeffrey, and Howard A. Pearson, eds. Dedicated
support of baccalaureate and graduate education
to the Health of Children. Elk Grove Village, IL:
of nursing.
American Academy of Pediatrics, 2005.
Cosby, Arthur G., Robert E. Greenberg, Linda Hill
Southward, et al., eds. About Children: An Membership
Authoritative Resource on the State of Childhood The AACN is composed primarily of institutional
Today. Elk Grove Village, IL: American Academy of
members. Membership in the association is open
Pediatrics, 2004.
to any institution offering a baccalaureate or
Pickering, Larry K., Carol J. Baker, Julia McMillan,
higher-degree nursing program. The dean or other
et al., eds. Red Book: 2006 Report of the Committee
chief administrative nurse in the nursing program
on Infectious Diseases. 27th ed. Elk Grove Village,
serves as the institutional representative in the
IL: American Academy of Pediatrics, 2006.
association. Other categories of individual mem-
bership include the following: Emeritus, Honorary,
Web Sites
and Honorary Associate. Individual membership
American Academy of Pediatrics (AAP): is conferred at the discretion of the board of direc-
http://www.aap.org tors of the association.
52 American Association of Colleges of Nursing (AACN)
Organization and Structure produces legislative updates on issues effecting

nursing education. It tracks and monitors nursing
An 11-member board of directors governs the
bills in the U.S. Congress, and it often submits
AACN. Each of the members of the board repre-
written congressional testimony. The association
sents a member institution. The board consists of
actively works with Congress and the federal gov-
four officers and seven members-at-large, all
ernment to increase funding of nursing workforce
elected by the membership for 2-year terms.
development programs, nursing graduate stu-
Much of the association’s work is conducted
dents, schools of nursing, academic health centers
through the efforts of various committees and task
that provide nursing education, and loan pro-
forces, represented by nurse faculty and nurse
grams to increase nursing faculty.
leaders from across the country. Its committees
include Finance, Government Affairs, Membership, Michelle Choi Wu
Nominating, Program, and Project Evaluation and
an educational benchmarking survey advisory See also American Nurses Association (ANA); Health
group. Its task forces include Academic Careers, Professional Shortage Areas (HPSAs); Health
Clinical Nurse Leader, and Revision of the Essentials Resources and Services Administration (HRSA);
of Baccalaureate Nursing Education and a cultural Health Workforce; Hospitals; Nightingale, Florence;
Nurse Practitioners (NPs); Nurses
competency advisory group.
Further Readings
Products and Services
American Association of Colleges of Nursing. Faculty
The AACN is very active in terms of professional Shortages in Baccalaureate and Graduate Nursing
networking and providing key updates to its mem- Programs: Scope of the Problem and Strategies for
bers concerning nursing higher education. To keep Expanding the Supply. Washington, DC: American
its membership informed, the association pub- Association of Colleges of Nursing, 2005.
lishes the Journal of Professional Nursing six American Association of Colleges of Nursing. Annual
times a year for nurse educators, researchers, and State of the Schools, 2007. Washington, DC:
practitioners and the Syllabus, a bimonthly news- American Association of Colleges of Nursing, 2007.
letter that provides information and updates on Auerbach, David L., Peter I. Buerhaus, and Douglas O.
the status of nursing higher education. It also Stalger. “Better Late Than Never: Workforce Supply
holds semiannual meetings in Washington, D.C., Implications of Later Entry Into Nursing,” Health
offering nursing deans and faculty the opportunity Affairs 26(1): 178–85, January–February 2007.
to discuss important issues facing nursing legisla- Kalisch, Philip A., and Beatrice J. Kalisch. American
tion and education. Nursing: A History. 4th ed. Philadelphia: Lippincott
In 1996, the association established the Williams and Wilkins, 2003.
Moyer, Barbara A., and Ruth A. Wittman-Price, eds.
Commission on Collegiate Nursing Education
Nursing Education: Foundations for Practice
(CCNE). The CCNE, which is an autonomous
Excellence. Philadelphia: F. A. Davis, 2008.
arm of the association, has the sole purpose of
Watson, Jean. Nursing: The Philosophy and Science of
accrediting baccalaureate and graduate nursing
Caring. Boulder: University Press of Colorado, 2008.
education programs.
Web Sites
Current Activities
American Association of Colleges of Nursing (AACN):
The AACN continues to emphasize the need for http://www.aacn.nche.edu
baccalaureate education in nursing, versus an American Nurses Association (ANA):
associate’s degree in nursing or a nursing diploma. http://nursingworld.org
The association is also actively involved with Bureau of Health Professions (BHPr):
health policy. It aggressively seeks federal funds http://bhpr.hrsa.gov/healthworkforce
for nursing education and research. It frequently National League for Nursing (NLN): http://www.nln.org
American Association of Preferred Provider Organizations (AAPPO) 53
informing and educating the public policy com-

American Association of munity about the PPO delivery model; (b) facili-
Preferred Provider tating PPO best practices by developing and
advancing PPO industry practices and guidelines;
Organizations (AAPPO) (c) promoting PPO networks and benefit products
as the preferred healthcare solution; and (d) sup-
The American Association of Preferred Provider porting professional growth through comprehen-
Organizations (AAPPO) is the leading national asso- sive PPO training programs to meet ongoing
ciation of preferred provider organizations (PPOs) employee needs for organizations that use, develop,
and affiliate organizations. It was established in and support PPO networks and products.
1983 to advance awareness of the benefits—greater The AAPPO prides itself in being responsive to
access, choice, and flexibility—that PPOs bring its members and providing programs and activities
to American healthcare. The AAPPO has 400 mem- to specifically support their business needs. The
bers representing 125 different organizations. association promotes the visibility, clarity, aware-
ness, value, and benefits of the PPO delivery
Definition and Popularity of PPOs model. These efforts educate and inform all mar-
A PPO is a healthcare delivery system where pro- ketplace sectors that regulate, use, and support the
viders contract with the PPO at various reim- PPO delivery system. In this era of constant
bursement levels in return for patient steerage into change, demonstrating the value the PPO model
their practices and/or timely payment. PPOs differ brings to U.S. healthcare is essential.
from other healthcare delivery systems in the way Specifically, AAPPO’s mandate is (a) to provide
they are financed and provide more choice, benefit PPOs with the information they need, when they
flexibility, and enrollee access to providers and need it; (b) to represent the industry’s interests and
medical services both in- and out-of-network. concerns in government; and (c) to improve health-
PPOs are widely popular with consumers and care professionals’ industry knowledge and business
healthcare purchasers. In 2007, more than 158 acumen through a variety of educational programs.
million individuals in the nation were enrolled in a
PPO program, which indicates that 64% of Providing Critical Information to PPOs
Americans with healthcare coverage receive their
healthcare services through a PPO delivery system. The AAPPO provides a broad array of information
The fact that PPOs have delivered exactly what the to meet PPO business needs and help PPOs achieve
public has called for—choice, flexibility, and a bal- their goals. White papers and webinars are one
ance between the delivery of appropriate care and source of information in which issues of the day
cost control—is the primary reason for this strong are researched, analyzed, and summarized from
market share. the perspective of PPOs. Another source is
RapidResource, a comprehensive source of PPO
information. RapidResource is published annually
Mission and Mandate of AAPPO and contains three critical products: (1) the market
Since its inception, the AAPPO has been the only and industry trend report, which provides stake-
association advocating solely on behalf of PPOs holder perspectives on the industry; (2) current
and continues to lead the way in the promotion, statistics and trends; and (3) insightful analysis and
support, and advocacy of the PPO industry. The future strategies for PPOs. The PPO DataSource is
association’s vision is to continue to be the most- a national database, including executive contact
valued trade association for organizations that information, office locations, and more. The direc-
use, develop, and support PPO networks and tory of operational PPOs is a quick online connec-
products. Its mission is to advance and promote tion to find the location, geographic coverage, and
the PPO industry for AAPPO members and their specific details of any PPO nationwide. The AAPPO
stakeholders, providers, and consumers by (a) also organizes the Annual Forum, an informational
54 American Association of Preferred Provider Organizations (AAPPO)
and networking conference where attendees can and in person throughout the year to help further
exchange ideas, share perspectives, and discuss the mission of the association. The association’s
solutions specific to PPOs. Another type of infor- committee members work to set the association’s
mation is iState, which monitors state regulation public policy goals, guide communication initia-
and legislation in all 50 states and provides the tives, and identify and address important issues.
information in an online, sortable format. The Business and Membership Development
Committee works to promote the association’s
business initiatives and recruitment goals. The
Advocating for PPOs Education Advisory Committee is responsible for
The AAPPO represents the industry’s interests and the oversight of course curriculum, course develop-
concerns in legislative and regulatory issues in sev- ment, and policies and procedures to support the
eral ways. Capital Caucus is an annual event in association’s Academy. The Medical/Provider
Washington, D.C., used to facilitate two-way Affairs Committee develops the association’s poli-
exchange between policymakers and the adminis- cies on issues relating to building and maintaining
tration and PPO business leaders. Through its legis- effective relationships with providers and their rep-
lative outreach, the AAPPO continually educates resentative organizations. The Political Action
individuals in the national and state regulatory Committee (PAC) is crucial for building relation-
arena about PPO business practices. With memberships with state and federal legislators, and it edu-
ship in healthcare coalition and programs, the ben- cates the association’s membership about the
efits and value of the PPO healthcare delivery model fundamental operations of the PAC and the impor-
are represented within healthcare coalitions and tance of contributing to it. The Public Policy
other healthcare programs. The AAPPO also pro- Committee supports the association’s goal to edu-
vides state-level advocacy, in which it monitors and cate policymakers about the PPO industry and the
acts on critical issues occurring at the state level. unique role PPOs play in the healthcare delivery
system. The Rules, By-Laws and Nominations
Committee provides oversight for the association’s
Educating PPO Professionals governance, rules, and nominations. The Executive
Committee, Compensation Committee, and the
The AAPPO is dedicated to advancing the educa- Audit Committee provide support to the board of
tion of healthcare professionals. In addition to the the association.
information provided to members, the association
has also developed the academy, a high-quality, Lynn Huls
online education program. Students learn at their
own pace, anywhere they can access a computer See also Access to Healthcare; Healthcare Financial
with an Internet connection. Courses include an Management; Health Insurance; Hospitals; Managed
overview of the PPO industry as well as in-depth Care; Physicians; Preferred Provider Organizations
(PPOs); Public Policy
courses related to four key study areas: (1) cus-
tomers, (2) medical management, (3) providers,
and (4) claims. The association’s academy bestows Further Readings
certifications to students who successfully com-
American Association of Preferred Provider
plete all required classes in a study area.
Organizations. PPO Outlook—2007 Market and
Industry Report. Louisville, KY: American Association
Organization and Committee Structure of Preferred Provider Organizations, 2007.
Greenrose, Karen, J. Stephen Ashley, American
The AAPPO has established a number of innova- Association of Preferred Provider Organizations, et al.
tive committees to serve as working groups to pur- Rise to Prominence: The PPO Story. Arlington, VA:
sue areas of specific interest to the association and American Association of Preferred Provider
its members. These committees meet electronically Organizations; Washington, DC: URAC, 2000.
American College of Healthcare Executives (ACHE) 55
Web Sites six districts, there are 53 locally led chapters. Two
American Association of Preferred Provider affiliated groups, (1) the Women’s Healthcare
Organizations (AAPPO): http://www.aappo.org Executive Networks (WHENs) located in the
United States and (2) the Healthcare Executive
Groups (HEGs), represented in India, Mexico,
Saudi Arabia, Turkey, and the United Arab
American College of Emirates, were established, along with local chap-
ters, to provide members access to networking,
Healthcare Executives education, and career development at the local
(ACHE) level and to address local, national, and interna-
tional healthcare management needs.
The American College of Healthcare Executives The central office of ACHE is located in
(ACHE) is an international professional society of Chicago and houses the administration, including
more than 30,000 healthcare executives who lead the president and chief executive officer, executive
hospitals, healthcare systems, and other health- vice president, and other vice presidents of the
care organizations. The ACHE’s mission is to organization.
advance its members and healthcare management The chapter board or board of directors is com-
excellence through high ethical standards, perti- posed of annually elected officers and directors
nent knowledge, and a relevant credentialing from each chapter. The chapter board manages
program. While achieving this mission, the organiza general chapter operations and ensures that the
tion promotes the values of integrity through high chapter meets its goals and objectives. The board
ethical conduct, and lifelong learning by innova- of governors, also elected and voluntary, operates
tion and continuous organizational and pro like a traditional board of directors in that it has
fessional improvement, leadership training by the authority to manage and control the affairs
example and mentorship, and diversity via inclu- and funds for the overall organization. The highest
sion and embracing the differences of its members organizational authority resides with the Council
and of the healthcare communities served. of Regents, which provides guidance and advice
for the board of governors, representing the mem-
bers and chapters. The Council of Regents has
History eight specific powers, including the right to elect
ACHE was originally founded in 1933 as the the chairman, officers, and members of the board
American College of Hospital Administrators. of governors and to approve or to disapprove rec-
The founders of the society were concerned that ommendations, reports, actions, or resolutions
individuals with little or no training or experience placed before the council.
in hospital administration were managing many
of the nation’s hospitals. The goal of the society Membership and Credentialing
was to elevate the standards of competence of
hospital administrators through the process of The eight categories of membership in ACHE are
education and training. In 1985, the society’s those of (1) Members, (2) Fellows, (3) Life Fellows,
name was changed to the American College of (4) Honorary Fellows, (5) Student Associates, (6)
Healthcare Executives to more accurately describe Faculty Associates, (7) International Associates,
its diverse membership and its expanded scope. and (8) Retired Affiliates. A professional certifica-
tion designated by ACHE is as a Fellow of the
American College of Healthcare Executives
Structure and Leadership (FACHE). To become board certified in healthcare
The ACHE membership is divided into six administration as a FACHE, members must pass
districts: five geographical districts and a sixth the Board of Governors Examination in Healthcare
district composed of military affiliates. Within the Management as well as fulfill other rigorous
56 American College of Healthcare Executives (ACHE)
requirements such as completing 40 hours of con- career-planning assistance. Additionally, HECRC

tinuing education credit, 3 years of tenure as an offers guidance in mentoring and executive
ACHE member, 5 years of healthcare management coaching.
experience (with a postbaccalaureate degree, 8
years if applying without) and demonstrating par- Policy Campaigns
ticipation in civic and leadership activities.
ACHE encourages its members and affiliates to
advocate organ and tissue donation through the
Education
U.S. Department of Health and Human Services’
ACHE is well-known for organizing and sponsor- Gift of Life program. Because ACHE also recom-
ing educational events, such as the annual Congress mends that all healthcare executives work to sup-
on Healthcare Leadership, which draws approxi- port access to healthcare services for all people,
mately 4,000 participants each year. Quality ACHE is raising awareness through two pro-
improvement, physician relations, information grams: (1) Covering Kids & Families and (2)
technology, and governance are examples of top- Cover the Uninsured Week.
ics covered at the ACHE Congress. It is through Public policy statements are developed at the
the Congress on Healthcare Leadership, con- ACHE committee level that address current issues
ferences, seminars, and special programs, such as such as executive responsibility (a) to foster health-
the Board of Governors Examination Review care access, (b) to serve the community, (c) to ensure
Course and the Senior Executive and Leadership organizations are following emergency prepared-
Development Institutes, that ACHE provides its ness plans, and (d) to strengthen healthcare employ-
members with continuing education and national ment opportunities for persons with disabilities.
networking opportunities. Distance-learning
options such as audio/Web conferences, online Research
seminars, self-study courses, and audio conference
CDs are also available. ACHE conducts research on a number of health-
care management areas, including factors affect-
ing the career attainments of healthcare executives
Publishing
as well as trends and recommended practices
The Health Administration Press (HAP) is a divi- affecting the profession. Topics of study outcomes
sion of the Foundation of the American College recently addressed include a comparison of the
of Healthcare Executives. Founded in 1972 with career attainments of men and women healthcare
support from the W. K. Kellogg Foundation, the executives, top issues confronting hospitals, and
HAP is one of the largest publishers of books and the impact of hospital chief executive officer turn-
journals on all aspects of health services manage- over in U.S. hospitals.
ment, including textbooks for use in undergradu-
ate and graduate courses. The press also publishes Laurie A. Hensley
the Journal of Healthcare Management, Frontiers See also American Hospital Association (AHA); Diversity
of Health Services Management, and Healthcare in Healthcare Management; Healthcare Financial
Executive Magazine. It also produces courses for Management; Hospitals
the ACHE Self-Study Program.
Further Readings
Career Services
Barry, Robert, Amy C. Smith, and Clifford E. Brubaker.
ACHE’s Healthcare Executive Career Resource Going Lean: Busting Barriers to Patient Flow.
Center (HECRC) offers career services, includ- Chicago: Health Administration Press, 2007.
ing leadership assessment tools, career develop- Christianson, Jon B., Michael D. Finch, Barbara Findlay,
ment programs and resources, and personalized et al. Reinventing the Patient Experience: Strategies
American Enterprise Institute for Public Policy Research (AEI) 57
for Hospital Leaders. Chicago: Health Administration private enterprise, vital cultural and political insti-
Press, 2007. tutions, and a strong foreign policy and national
Gapenski, Louis C. Healthcare Finance: An Introduction defense—through scholarly research, open debate,
to Accounting and Financial Management. 4th ed. and publications.
Chicago: Health Administration Press, 2007.
Harris, Dean M. Contemporary Issues in Healthcare
Law and Ethics. 3d ed. Chicago: Health
History
Administration Press, 2007. Founded in 1943, the AEI is home to some of
Kipnis, Ira A. A Venture Forward: A History of the America’s most accomplished public policy experts.
American College of Hospital Administrators. Chicago: AEI scholars strive to elevate the public policy
American College of Hospital Administrators, 1955. debates regarding the nation’s most pressing issues,
Nowicki, Michael. The Financial Management of educate the public, and contribute sound recom-
Hospitals and Healthcare Organizations. 4th ed. mendations for reform. Their research is dissemi-
Chicago: Health Administration Press, 2007. nated to a broad audience of domestic and
Nowicki, Michael. Practice Problems and Case Study to
international policymakers, academics, business
Accompany the Financial Management of Hospitals
executives, the media, and the general population,
and Healthcare Organizations. 4th ed. Chicago:
through various publications, conferences, semi-
Health Administration Press, 2007.
nars, working groups, and government testimony.
Sherman, V. Clayton, and Stephanie G. Sherman. Gold
Standard Management: The Key to High-Performance
The AEI employs nearly 190 individuals and
Hospitals. Chicago: Health Administration Press, 2007.
works with approximately 70 adjunct scholars.
Showalter, J. Stuart. The Law of Healthcare The institute’s work is supported through finan-
Administration. 5th ed. Chicago: Health cial contributions from foundations, individuals,
Administration Press, 2007. and corporations as well as through earnings from
Sussman, Jason H. The Healthcare Executive’s Guide to an endowment. The AEI’s president, in consulta-
Allocating Capital. Chicago: Health Administration tion with the institute’s Council of Academic
Press, 2007. Advisers, sets its research agenda. In addition,
Thomas, Richard K., and Michael Calhoun. Marketing each year, the Council of Academic Advisers
Matters: A Guide for Healthcare Executives. Chicago: awards AEI’s Irving Kristol Award to an individual
Health Administration Press, 2007. who has made a notable contribution to improv-
ing public policy and social welfare.
Web Sites
The AEI has three main research divisions:
(1) Economic Policy Studies, (2) Social and Political
American College of Healthcare Executives (ACHE): Studies, and (3) Defense and Foreign Policy Studies.
http://www.ache.org There are also several specialized programs, among
them the W. H. Brady Program on Culture and
Freedom, the National Research Initiative, the AEI
American Enterprise Press, and The American magazine.
Institute for Public
Policy Research (AEI) Health Policy Studies Program
One of the AEI’s most important research efforts
The American Enterprise Institute for Public is its Health Policy Studies Program. AEI spon-
Policy Research (AEI) is a private, nonpartisan, sors a robust program of original research to
not-for-profit organization dedicated to the address some of the most contentious issues in
research of government, economic, political, and the current health policy debates, such as costs,
social welfare issues. Located in Washington, economic incentives, the role of government and
D.C., AEI’s purpose is to preserve and strengthen the market, and the medical well-being of
the foundations of freedom—limited government, patients. AEI’s health policy scholars possess a
58 American Health Care Association (AHCA)
wealth of knowledge and experience, along with Further Readings

extensive worldwide contacts among policymak- Antos, Joseph R., and Alice M. Rivlin, eds. Restoring
ers, academics, and business executives. Several Fiscal Sanity 2007: The Health Spending Challenge.
of the program’s experts have served in top posi- Washington, DC: Brookings Institution Press, 2007.
tions in various parts of the federal government Boyum, David, and Peter Reuter. An Analytic
and the U.S. Congress, including the Food and Assessment of U.S. Drug Policy. Washington, DC:
Drug Administration (FDA), the Centers for AEI Press, 2005.
Medicare and Medicaid Services (CMS), the Cogan, John F., R. Glenn Hubbard, and Daniel P.
President’s Council of Economic Advisers (CEA), Kessler. Healthy, Wealthy, and Wise: Five Steps to a
the U.S. Department of Health and Human Better Health Care System. Washington, DC: AEI
Services (HHS), and the Congressional Budget Press/Hoover Institution, 2005.
Office (CBO). Gingrich, Newt. The Opportunity to Create a 21st-
Scholars in the AEI’s Health Policy Studies Century Medicare System of More Choices With
Program have been among the leaders in the recent Higher Quality at Lower Cost. Washington, DC:
debates on Medicare reform, the reimportation of American Enterprise Institute, 2003.
prescription drugs, health coverage for the unin- Miller, Richard D., Jr., and H. E. French III. Health Care
sured, the role of the FDA, the development of Matters: Pharmaceuticals, Obesity, and the Quality
vaccines, and the effects of price controls on phar- of Life. Washington, DC: AEI Press, 2004.
maceutical research and development. AEI health Ohsfeldt, Robert L., and John E. Schneider. The Business
policy scholars, along with a network of academic of Health: The Role of Competition, Markets, and
Regulation. Washington, DC: AEI Press, 2006.
experts at affiliated universities and institutions
Rettenmeier, Andrew J., and Thomas R. Saving. The
across the country and abroad, will likely continue
Diagnosis and Treatment of Medicare. Washington,
to make major contributions to these and other
DC: AEI Press, 2007.
debates. They aim to (a) establish a healthcare and
Satel, Sally, and Jonathan Klick. The Health Disparities
public health agenda centered on the themes of
Myth: Diagnosing the Treatment Gap. Washington,
competitive markets, personal choice, and prog- DC: AEI Press, 2006.
ress in science, technology, and practice; (b) con-
struct reform proposals that apply the best
economic thinking to the dynamics of healthcare; Web Sites
and (c) provide policymakers, the media, and the
American Enterprise Institute for Public Policy Research
broader public with an objective assessment of
(AEI): http://www.aei.org
the private sector’s contributions to innovation in
the delivery and financing of medical care and
insurance coverage.
The AEI’s health policy scholars work at the
juncture of policy and practice. They strive to
American Health Care
improve government policy through scholarly Association (AHCA)
research, and an array of publications, confer-
ences, seminars, as well as through discussions The American Health Care Association (AHCA) is
with government officials, academic experts, and a federation of affiliated state health organizations,
industry leaders. Their work has helped to shape— together representing more than 10,000 nonprofit
and will likely continue to shape in the years to and for-profit assisted living, nursing homes, devel-
come—important policy debates. opmentally disabled, and subacute-care providers
that care for more than 1.5 million individuals in
Véronique Rodman the nation. The AHCA represents the long-term
See also Centers for Medicare and Medicaid Services care community to government, business, and the
(CMS); Cost of Healthcare; Health Economics; Health general public. It also serves as a force for change
Insurance Coverage; Medicare; Pharmaceutical within the long-term community, providing infor-
Industry; U.S. Food and Drug Administration (FDA) mation, education, and administration tools.
American Health Care Association (AHCA) 59
Background The AHCA relies on its members’ clinical exper-

tise, especially members of their Clinical Practice
Since 1949, the AHCA has been working to
Committee, to guide the association’s efforts to
improve the standards of the long-term care pro-
ensure that long-term care settings have the most
fession and to promote a better understanding of
appropriate clinical protocols and Web site resources.
what constitutes a supportive, quality-focused
The association also collaborates with a variety of
care environment. Since its founding, the AHCA’s
key partners and clinical experts in promoting best
objectives have remained consistent, with only
practices. For example, the association partnered
minor changes. Specifically, the association’s objec-
with the Alzheimer’s Association to improve clini-
tives, which were codified in 1946, include improv-
cal-care standards. This partnership resulted in the
ing the standards of service and administration of
Alzheimer’s Association issuing its publication
member nursing homes; securing and meriting
Dementia Care Practice Recommendations for
public and official recognition and approval of the
Assisted Living Residences and Nursing Homes,
work of nursing homes; and adopting and pro-
which focuses on end-of-life care.
moting programs of education, legislation, better
Whether the AHCA is working with other
understanding, and mutual cooperation.
healthcare professionals on clinical issues, with the
Together with its 50 state affiliates and in con-
federal government on initiatives to enhance qual-
cert with other key stakeholders, the AHCA cur-
ity, or with the U.S. Congress to preserve much-
rently seeks to encourage (a) a stable financing
needed funding for long-term care and services, the
system that enhances long-term care quality; (b) an
association recognizes that 80% of long-term care
oversight system that is fair, consistent, and rewards
residents rely on Medicare and/or Medicaid to pay
quality; and (c) a workforce that can meet the
for the care they need. This means that the organi-
growing needs of the long-term care profession
zation’s membership cares for some of our coun-
and the nation.
try’s most vulnerable citizens. In fact, the average
nursing home resident is an 85-year-old grand-
mother with cognitive or functional impairments
Products and Services and multiple comorbidities that typically require
In 2002, the AHCA helped launch Quality First, a nine medications per day. With this membership in
profession-wide quality improvement initiative. mind—along with the fact that 77 million baby
Quality First was followed by the Centers for boomers are edging toward retirement—the AHCA
Medicare and Medicaid Services’ (CMS) Nursing remains focused on ways to create a better, more
Home Quality Initiative (NHQI), which began to stable workforce that can meet the growing needs
track progress on specific clinical measures of of all healthcare consumers.
nursing home care quality. In 2006, the associa- The AHCA actively works to educate elected
tion cofounded and is leading a coalition of officials and their staff members about the long-
healthcare providers, caregivers, medical and qual- term care needs of America’s seniors so that our
ity improvement experts, government leaders, “Greatest Generation” and others will continue to
consumers, and other stakeholders who are work- have access to the most appropriate care in the
ing to improve care quality through the voluntary most appropriate setting. The AHCA’s legislative
Advancing Excellence in America’s Nursing team also calls on policymakers and government
Homes campaign. Advancing Excellence is a qual- officials from the White House, the Centers for
ity initiative that is designed around measurable Medicare and Medicaid Services (CMS), the U.S.
quality goals, which are supported by the cam- Department of Health and Human Services (HHS),
paign’s coalition of providers, caregivers, consum- the Department of Labor (DOL), and congressio-
ers, and key stakeholders. More than 6,600 nal offices on both sides of the aisle to address the
providers—predominantly AHCA members— many challenges confronting today’s long-term
already participate in this important initiative, care system.
which the association and its state affiliates Underpinning the association’s education
strongly endorse. and advocacy efforts are several important
60 American Health Planning Association (AHPA)
components—public affairs and both grassroots Further Readings

and grass-tops outreach. The association’s public American Health Care Association. Intermediate Care
affairs team directs positive media attention to Facility for Persons With Mental Retardation and
the work of its membership and generates media Developmental Disabilities. Washington, DC:
interest that supports its advocacy, which can American Health Care Association, 2007.
spur on its quality and other initiatives. The American Health Care Association. Trends in Publicly
organization’s grassroots and grass-tops support- Reported Nursing Facility Quality Measures.
ers assist the advocacy arm and allow the asso- Washington, DC: American Health Care Association,
ciation’s legislative and public affairs teams to 2007.
demonstrate just how important each member is Jurkowski, Elaine Theresa. Policy and Program Planning
to the collective advocacy agenda. One of the for Older Adults: Realities and Visions. New York:
grassroots activities that the association pro- Springer, 2008.
motes with its membership is the facility tour. A Miller, R. “AHCA Chair Looks to the Future,” Provider
facility tour is an extremely effective way for 34(1): 29–30, January 2008.
providers to educate U.S. congressional members Pratt, John R. Long-Term Care: Managing Across the
about long-term care and related issues. Touring Continuum. 2d ed. Sudbury, MA: Jones and Bartlett,
a facility also presents a positive media opportu- 2004.
nity—for the facility, for the elected official, and Sullivan-Marx, Eileen, and Deanna Gray-Miceli.
for the long-term care profession. Leadership and Management Skills for Long-Term
The AHCA’s political action committee (AHCA- Care. New York: Springer 2008.
Tilly, Jane, Peter Reed, Elizabeth Gould, et al., eds.
PAC) adds even more depth to its advocacy efforts.
Dementia Care Practice Recommendations for
AHCA-PAC hosts a number of fund-raising events
Assisted Living Residences and Nursing Homes:
and has helped establish several mini-PACs that
Phase 3. End-of-Life Care. Washington, DC:
concentrate on more regional and state-level PAC
Alzheimer’s Association, 2007.
outreach.
The AHCA and the National Center for Assisted
Living (NCAL) continue to join forces to promote
member communication as well as increase the Web Sites
number of positive stories about long-term care in Advancing Excellence in America’s Nursing Homes:
the mainstream news media. Member feedback http://www.nhqualitycampaign.org
has also helped shape some of the communica- Alzheimer’s Association (ALZ): http://www.alz.org
tions, including a recent Web redesign and upgrades American Health Care Association (AHCA):
to the association’s management system, which http://www.ahca.org
will further enhance AHCA staff’s ability to serve National Center for Assisted Living (NCAL):
its membership better. http://www.ncal.org
The AHCA’s public affairs team also ensures that
long-term care has a presence in major newspapers
and broadcast media throughout the year. The asso-
ciation has been quoted or featured in The New York
Times, The Wall Street Journal, and The Washington
American Health Planning
Post as well as numerous local newspapers. The Association (AHPA)
AHCA has contributed to national news programs
as well, including NBC Nightly News, the CBS The American Health Planning Association
Evening News, and PBS’s Nightly Business Report. (AHPA) is a national organization whose mem-
bers are agencies and individuals engaged in some
Katherine Lehman aspect of the broad and sometimes controversial
See also Disability; Long-Term Care; Long-Term Care field of health planning and capacity regulation,
Costs in the United States; Medicaid; Medicare; such as Certificate of Need (CON). Since its
Nursing Home Quality; Nursing Homes; Skilled- founding in 1971 (as the American Association of
Nursing Facilities Comprehensive Health Planning, and it changed
American Health Planning Association (AHPA) 61
its name to the present in 1977), the membership, (d) a balanced and more holistic view of health-
focus, and activities of the association have care that recognizes that an effective healthcare
shifted, reflecting the changing scope and role of system requires a wide range of services from
health planning in the United States. Today, the basic primary care to technologically sophisti-
association is perhaps best known for its Web site cated and highly specialized services; (e) a con-
and annual publication of a directory of state cern for the efficient delivery of healthcare and
CON programs. cost containment; and (f) a necessary role for the
legislative policy process at the federal and state
government levels.
The Rise of Health Planning
When the AHPA was founded, health planning
National Health Planning Program
was starting to be viewed by national policymak-
ers as offering a possibility of both slowing down Health planning reached its full maturity in the
the escalating rise in healthcare costs and ensur- United States with the passage of the National
ing that healthcare resources were better allo- Health Planning and Resource Development Act
cated based on community need. Health planning of 1974. PL 93–641, as it came to be known in
had been in place on a smaller scale since the health-planning circles, established a federally
early 1960s, when Kodak and Blue Cross and directed system of 50 state and more than 200
Blue Shield formed a joint effort in Rochester, local health systems agencies (HSA), each with
New York. It was also part of several federal regulatory authority to conduct health planning
health programs and adopted by a number of enforced by state-level CON laws and federal
states as both a regulatory and voluntary mea- regulations. The law tasked the U.S. Department
sure to control the expansion of institutional of Health, Education, and Welfare (DHEW) (fore-
healthcare services, most frequently hospitals runner of the U.S. Department of Health and
and nursing homes. Most prominent among the Human Services [HHS]) to develop extensive
early federal programs was the Partnership for national guidelines for how the health-planning
Health Act of 1966, which set up a network of agencies were to be composed, operate, and make
state-level (Comprehensive Health Planning decisions.
CHP-A) and within-state regional (Comprehensive The AHPA’s membership grew dramatically
Health Planning CHP-B) voluntary health-planning during this period, with many members coming
agencies. At the state level, New York led the from newly established health-planning agencies.
way on both the regulatory and voluntary plan- Driven by PL 93–641, AHPA took on the role of a
ning fronts by enacting the first state CON legis- professional trade association focusing much of its
lation, and in the Rochester area, a council of efforts on lobbying the U.S. Congress in support of
hospital and industry attempted to plan the continuing federally sponsored and funded health
expansion of hospital services to meet commu- planning, along with monitoring rules issued by
nity needs. DHEW on how the health-planning law should be
As health planning gained momentum, repre- implemented. Beyond the focus on federal health
sentatives from these scattered experiments planning, the AHPA also served as a clearinghouse
formed the AHPA to create a focus and organize for state-level CON laws, advanced the develop-
a professional movement to support health plan- ment and use of health-planning technical meth-
ning. The association was organized around sev- ods, and became a forum for the growing number
eral principles common to most health-planning of health planners across the nation. The forum
efforts that are still in place today: (a) community function culminated each year with a national con-
participation in decision making regarding the ference that often drew hundreds of health plan-
allocation of healthcare resources; (b) equity in ners, planning agency directors and board members,
access to healthcare services regardless of income academics, and healthcare administrators along
and insurance status; (c) the use of population with lawyers and consultants involved in a cottage
need as the underlying rationale for deterring industry, which specialized in assisting healthcare
the quantity and location of healthcare resources; institutions navigating the approval process for
62 American Health Planning Association (AHPA)
expansion, new construction, and purchase of of Competition, authored by the Federal Trade
expensive medical technology. Commission and the U.S. Department of Justice),
During this period, membership in the associ- which called for its elimination. One of the asso-
ation gravitated to several spheres of interest: ciation’s major activities is the publication of an
(a) national health policy and the role of a federal annual national directory, which inventories each
health-planning program; (b) health planning as a state’s CON program.
mechanism for community involvement in health Beyond CON, the association’s leadership also
system decisions; (c) the technical aspects of health sought to rediscover and promote the broader value
planning; and (d) the use of data and analysis in of health planning reflected in its original principles
decision making. and to document the need for health planning to
deal with the growing national concern that the
healthcare system was under great strain. The
After National Health Planning
broader interest overlapped into public health, and
As the 1970s drew to a close, federal health plan- the association sought a closer affiliation with the
ning fell out of favor with national policymakers American Public Health Association’s Community
as a more conservative political climate took hold, Health Planning and Policy Development (CHPPD)
and the use of market mechanisms to control section, whose members shared AHPA’s interest in
healthcare costs and structure the healthcare sys- health reform and population health.
tem gained support. The AHPA found itself fight- Today, the AHPA and the CHPPD section regu-
ing a losing political battle to save the national larly cosponsor professional presentations at the
health-planning program and PL 93–641 was American Public Health Association’s annual meet-
repealed at the urging of the Reagan Administration ing, and they jointly publish a bibliography on
in 1986. Without the federal sponsorship and health planning. The AHPA continues to serve as a
funding, many state and local health-planning forum for health planning in all its diverse forms.
agencies closed, redirected their efforts, or were The association maintains an active board of direc-
absorbed into related organizations. The retrench- tors, but its presence is largely through its Web
ment was most dramatic at the local level, where site, where health-planning activities from across
the majority of local health-planning agencies sim- the nation are tracked and reported; issue papers
ply disbanded. on health planning, regulation, and public health
The lack of a federal health-planning program are posted; and informational resources relevant to
and the demise of many health-planning agencies health planning are linked.
both reduced the membership base of the associa-
tion and changed its focus. The change in member- Patrick Lenihan
ship was most dramatic in the loss of organizational
members, formerly the federally sponsored local See also American Public Health Association (APHA);
Certificate of Need (CON); Health Planning; Health
health systems agencies and state health-planning
Systems Agencies (HSAs); Hospitals; Public Health;
and development agencies. The association’s mem- Regulation; Technology Assessment
bership became less institutional, and the associa-
tion became more a professional society of
individuals working or having an interest in health
planning. CON, which was retained in some form Further Readings
by almost three quarters of the states as a regula- American Health Planning Association. National
tory remnant of national health planning, took on Directory: State Certificate of Need Programs, Health
a heightened focus of the association as state CON Planning Agencies. Falls Church, VA: American
directors and their senior staff looked to it as the Health Planning Association, 2007.
principal national forum for this state-sponsored Green, Andrew. An Introduction to Health Planning for
regulatory activity. Developing Health Systems. 3d ed. New York:
The AHPA became a strong defender of CON Oxford University Press, 2007.
after a far-reaching and critical federal report was Thomas, Richard K. Health Services Planning. 2d ed.
released in 2004 (Improving Health Care: A Dose New York: Kluwer Academic/Plenum Press, 2003.
American Hospital Association (AHA) 63
Web Sites known as Blue Cross. In 1942, the AHA spear-

Agency for Healthcare Research and Quality (AHRQ): headed the establishment of the Commission on
http://www.ahrq.gov Hospital Care, which led to a huge program of
American Health Planning Association (AHPA): hospital construction known as Hill-Burton. The
http://www.ahpanet.org AHA supported efforts to pass the Medicare legis-
American Public Health Association (APHA): lation of 1965, which covered hospital care and
http://www.apha.org other services for the nation’s seniors.
The cost of medical care is a major concern
for the AHA today. The United States spends
more on medical care than does any other nation,
American Hospital and hospital care alone accounts for the largest
portion of spending—about one third. Factors
Association (AHA) associated with these costs include new treat-
ments and technology and greater demand. In
The American Hospital Association (AHA) is a addition to the increased costs to provide care,
nonprofit organization that aims to improve the hospitals often do not get paid for the care they
health of individuals and their communities. The provide. Many of the nation’s hospitals report
AHA represents, leads, and serves the institutions losing money serving Medicare and Medicaid
that deliver medical care. Its institutional mem- patients.
bership includes nearly 5,000 of the nation’s The ASA has changed significantly since its
hospitals—almost 90% of all registered hospi- inception. It has evolved from a small club for
tals—as well as healthcare networks and other hospital administrators to an effective and forceful
patient-care facilities. Its individual membership advocate for the nation’s hospitals. To achieve its
includes 37,000 health professionals such as risk goals and serve its constituents, the AHA gener-
managers, engineers, social workers, and nurse ates, collects, uses, and shares an important body
executives, who join through approximately 15 of healthcare-related information.
different personal membership groups or profes-
sional societies.
Size and Structure
When it was first founded as the Association of
History
Hospital Superintendents, the AHA was located in
The AHA was founded in 1899 as the Association Cleveland, Ohio. Although subsequently the orga-
of Hospital Superintendents by eight hospital nization was briefly headquartered in Washington,
administrators in Cleveland, Ohio. Their purpose D.C., since 1920 the AHA’s headquarters have
for establishing this association was to develop a been located in Chicago, Illinois. An office in
vehicle for discussion, analysis, and resolution of Washington, D.C., was also established to secure
common concerns and issues regarding managing better access to federal agencies for advocacy,
a hospital. In 1906, the membership was expanded policy, and communication initiatives.
beyond hospital chief executives, and the name of The AHA’s services and policies are determined
the organization was changed to the American by a governing structure that includes a board of
Hospital Association. In 1918, institutional mem- trustees, a house of delegates, and nine regional
bership was established. policy boards. The role of the regional policy
Historically, the AHA’s actions have reflected boards, comprising state hospital association exec-
the dual mission of achieving economy, efficiency, utives, is to debate and analyze important health-
and solvency in hospital management and provid- care policy issues from a local perspective prior to
ing better hospital care for all. In response to the submitting the issues to the house of delegates for
public’s inability to pay for hospital care as a result consideration.
of the Great Depression, the AHA recognized a The house of delegates comprises members from
need and defined a set of principles for hospital state associations as well as constituency sections.
insurance plans in 1937, which later became State associations are apportioned delegates to the
64 American Hospital Association (AHA)
house based on the amount of dues paid by the maintains an extensive library with collections on
institutional members in each state. The constitu- health administration, including more than 64,000
ency sections also shape policy and represent special books and historical documents.
interests among hospitals. These sections include
Health Care Systems, Small or Rural Hospitals,
Products and Activities
Metropolitan Hospitals, Federal Health Systems,
Long-Term Care and Rehabilitation, Psychiatric The AHA’s products and activities are concen-
and Substance Abuse Services, and Maternal and trated within two different arenas: (1) policy and
Child Health. After debates within the house, it is advocacy and (2) data and information.
the responsibility of the board of trustees to exercise The AHA spends approximately $15 million a
its final decision-making authority over the formal year on advocacy. The AHA has identified many
adoption and execution of AHA policy. important issues affecting the nation’s hospitals.
The AHA is broadly organized into the follow- Some of the key issues are listed below.
ing units: (a) advocacy and public policy, (b) leader- With approximately two thirds of the nation’s
ship and business development, (c) strategic policy hospitals getting paid less than it costs to care
planning, (d) member relations, (e) federal rela- for Medicare patients, the AHA seeks to achieve
tions, and (f) strategic communications. The increased Medicare payments to hospitals. Similarly,
AHA has also established numerous subsidiary the AHA opposes payment cuts to hospitals under
organizations that are critical to its business: the Medicaid program.
(a) The Health Forum; (b) AHA Financial With the uninsured using the nation’s hospitals
Solutions, Inc.; (c) the Center for Healthcare as their primary source of care, the AHA is work-
Governance; (d) the Health, Research and ing to extend healthcare access and coverage to the
Educational Trust; (e) the American Organization uninsured. Furthermore, the AHA supports medi-
of Nurse Executives; and (f) the Institute for cal liability reform to prevent further deterioration
Diversity in Health Management. The Health in patient access to care.
Forum encompasses the publishing, data, and Given recent concerns that nonprofit hospitals
education activities of the AHA. AHA Financial are not providing sufficient charity care, the AHA
Solutions, Inc., maintains a comprehensive port- is working to clarify and improve hospital billing
folio of financial products such as insurance and and collection standards.
investment vehicles for members. The Center for The AHA advocates the creation of a better
Healthcare Governance builds stronger and bet- healthcare system. For example, since providing
ter hospital boards. The purpose of the Health care to individuals with chronic diseases is increas-
Research and Educational Trust is to conduct ingly costly and fragmented, the AHA supports
innovative research on issues related to effective, changes in the payment system that reward coordi-
strategic, and improved healthcare delivery that nation of care. Also, the AHA supports eliminating
significantly affect the health of the community. racial and ethnic health disparities in medical-care
The American Organization of Nurse Executives treatment and outcomes. Finally, underscoring the
is a professional association for nurses in leader- immense potential of health information technol-
ship and management positions. The Institute for ogy to improve the quality of care, the AHA is
Diversity in Health Management works to achieve seeking regulatory relief and increased funding
diversity in healthcare settings. for the nation’s hospitals for health technology
To provide education and serve as a source of improvements.
information for healthcare leaders, the AHA main- The AHA is pursuing continued funding to
tains a resource center. This unit responds to the achieve disaster and emergency readiness among
information needs of its members, libraries, the the nation’s hospitals.
public, healthcare researchers, and others on a The AHA is working to facilitate the adoption
broad range of healthcare issues such as health of new standards for the management of patient
professional planning, healthcare financing, and health information as embodied in the Health
regulatory issues by providing statistical and ana- Insurance Portability and Accountability Act of
lytic reports and documents. The resource center 1996 (HIPAA).
American Medical Association (AMA) 65
The AHA offers many data- and information- Web Sites

related products. Among its many management American Hospital Association (AHA):
publications are Health Facilities Management, http://www.aha.org
Hospitals & Health Networks, H&HN’s Most
Wired Magazine, Materials Management in Health
Care, and AHA News, a weekly newspaper for
hospital managers. The AHA also produces mate-
rials related to patient education, staff develop-
American Medical
ment, and many other areas related to hospital Association (AMA)
administration.
The AHA’s research and statistical publications The American Medical Association (AMA) is a
include the journal Health Services Research and nonprofit organization that seeks to promote the
two annual reports, the Guide to the Health Care art and science of medicine and the betterment of
Field (a detailed listing of all hospitals in the public health. The AMA works to “help doctors
nation) and AHA Hospital Statistics (a detailed help patients” through aggressive advocacy of
statistical report for states and geographic regions important healthcare issues, publishing an exten-
in the nation). In addition, the AHA publishes (in sive series of medical journals, and providing its
collaboration with Avalere Health) TrendWatch, a membership a variety of professional programs
series of reports that explore trends affecting hos- and activities designed to facilitate the practice of
pitals and the healthcare system. The AHA serves medicine. One of the most influential profes-
as the official U.S. clearinghouse on medical cod- sional associations of physicians in the United
ing for the proper use of the ICD-9-CM systems States, the AMA includes about one fourth of all
and Level I HCPCS (CPT-4 codes) for hospital U.S. physicians as its members and spends more
providers. The AHA also publishes a variety of than $15 million a year on its lobbying efforts.
research reports and papers on special topics such Through its main policy-making body, the House
as the healthcare system, information technology, of Delegates, the AMA gives voice to issues
financial issues, and workforce issues. affecting all physicians.
Penny L. Havlicek
History
See also Blue Cross and Blue Shield; Healthcare Financial
Management; Health Insurance; Health Insurance
The AMA was founded in 1847 to advance the
Portability and Accountability Act of 1996 (HIPAA); scientific disciplines, define and improve the stan-
Hospitals; Public Policy; Uncompensated Healthcare; dards in medical education, establish a code of
Uninsured Individuals medical ethics, and improve the public’s health. It
was officially incorporated in 1897. Founded as a
result of a resolution calling for a national medical
Further Readings convention that was submitted to the Medical
Society of the State of New York by Dr. Nathan
Risse, Guenter B. Mending Bodies, Saving Souls: A
Smith Davis (1817–1904), the initial meeting of
History of Hospitals. New York: Oxford University
Press, 1999.
the AMA was attended by 250 physicians repre-
Rosenberg, Charles E. The Care of Strangers: The Rise
senting 28 states. From the onset, membership in
of America’s Hospital System. New York: Basic the AMA was voluntary.
Books, 1987. The AMA became established as a viable insti-
Starr, Paul. The Social Transformation of American tution around the turn of the 20th century. At this
Medicine: The Rise of a Sovereign Profession and the time, a new structure of internal governance was
Making of a Vast Industry. New York: Basic Books, implemented that relied on the election of an
1982. apportioned number of delegates from each state
Stevens, Rosemary. In Sickness and in Wealth: American medical society. Each state medical society in turn
Hospitals in the Twentieth Century. Baltimore: Johns was supported by county medical societies. This
Hopkins University Press, 1999. change in governance structure served to ultimately
66 American Medical Association (AMA)
unify, enable, and effectively organize the nation’s in 1965, concerned about government’s intrusion
medical profession. into medicine. Today the AMA is advocating for
The membership of the AMA has grown from Medicare Physician Payment reform, as the cur-
around 8,000 to 10,000 in 1900 to approximately rent payment formulas are expected to lead to pay
245,000 today. During the 1960s, the membership cuts for physicians and reduced access to care for
market share of the AMA reached its zenith, rep- the nation’s seniors.
resenting about 70% of the nation’s physicians. Given the AMA’s size and influence, some-
The profusion of national specialty medical societ- times the positions it takes to protect the practice
ies has been cited as one of the reasons for the of medicine generate controversy. For example,
AMA’s decline in membership market share over the AMA has confronted the Sherman Antitrust
the past several decades, with more physicians pre- Act several times in its history: once in the 1940s
ferring to join societies representing their specific for hindering and obstructing the business of an
specialty rather than the entire profession. Res HMO, the Group Health Association, Inc., and
ponding to these membership trends, in 2004 the once in 1987 in its attempt to boycott chiroprac-
AMA launched a national advertising campaign tors on the grounds that the science on which
for the first time in its history. that profession was based was neither rigorous
The AMA has always taken strong positions on nor sound. More recently, the AMA’s decision in
a range of healthcare policy issues that it has 1997 to accept payment for endorsing commer-
believed protect physicians, their patients, and the cial healthcare products without testing them
practice of medicine. Examples of issues it has generated much debate within the medical pro-
championed throughout the years are (a) advocat- fession and the media on the subject of medical
ing against the use of patent medicines or nostrums ethics.
of dubious content and effectiveness (1900);
(b) recommending nationwide polio vaccines
Size and Structure
(1960); (c) opposing tobacco use (1971); (d) oppos-
ing discrimination against AIDS patients (1987); The AMA’s headquarters are located in Chicago,
and (e) supporting the Patients Bill of Rights legis- where it employs around 1,000 individuals. It
lation (2000). The AMA was a primary force in maintains an office in Washington, D.C., that
establishing the accrediting authority for physician focuses on advocacy and government relations,
medical education programs, and in 1942, the and it also maintains an office in New Jersey that
Liaison Committee on Medical Education and focuses on its publishing operations.
today, along with the Association of American The AMA is organized into five general areas:
Medical Colleges (AAMC), continues to sponsor (1) membership, (2) business operations, (3) core
the work of the Liaison Committee. The AMA operations, (4) governance, and (5) administration
also had an important role in establishing the Joint and operations. Membership units focus on recruit-
Commission, an organization that evaluates and ing and retaining physician members. The business
accredits approximately 15,000 hospitals, nursing operations units include publishing, database
homes, group practices, ambulatory-care centers, maintenance and products, consumer books and
hospice services, and laboratories. products, and the AMA Insurance Agency. The
A consistent priority for the AMA has been core operations units focus on developing policy
protecting physician sovereignty—that is a physi- and establishing professional standards, including
cian’s right and authority to determine how he or those related to medical education, public health
she practices medicine. Reflecting this concern, the and medical ethics; advocacy at the private sector,
AMA opposed in the early 1900s a form of medi- state, and federal levels and research to support
cal practice called “contract” practice. Similar in that advocacy; maintaining relationships with
concept to the health maintenance organizations state, county, and specialty societies; and market-
(HMOs) of today, contract practice physicians ing and communications. The governance units
agreed to care for a defined group of patients in include serving and supporting the AMA’s Board
return for a specified amount of money. The AMA of Trustees and the House of Delegates. Last, the
also initially opposed the establishment of Medicare administration and operations units provide
American Medical Association (AMA) 67
administrative and operational support for other Surgery, Archives of Pediatrics and Adolescent
AMA units. Medicine, and the Archives of Surgery), which are
The AMA’s governing structure is a federation, also available in print editions internationally. Both
with separate medical societies supporting and JAMA and the Archives Journals are peer reviewed
contributing to the political whole. Elected repre- and available online. JAMA is published weekly,
sentatives from state medical societies, national while the Archives Journals are published on a
medical specialty organizations, and the federal monthly or bimonthly basis. In addition to its jour-
health services sit in the AMA’s House of Delegates. nals, the AMA publishes a newspaper for physicians
Each society is allocated a number of representa- called American Medical News.
tives based on its level of AMA membership. The Other AMA products and services include
House of Delegates is the principal policy-making resources that support professional development
body of the AMA, debating and voting on resolu- and facilitate the practice of medicine. For exam-
tions submitted by its representatives, which ple, the AMA publishes Current Procedural
in turn provide direction for its programmatic Terminology (CPT), the guidebook for physi-
efforts. cians’ offices on how to correctly classify and
Other bodies also shape the policy and direction code medical procedures for appropriate reim-
of the AMA. Elected by the House of Delegates, bursement from Medicare. The AMA offers online
the AMA’s Board of Trustees oversees and guides continuing medical education programs. It pub-
its activities. Five different councils help shape lishes a variety of directories related to graduate
policy and focus on one of the following issues: medical education and hosts online a Fellowship
medical ethics, long-range planning, medical edu- and Residency Electronic Interactive Database
cation, socioeconomic issues affecting the practice (FREIDA) for medical students and residents to
of medicine, and medical, public health, and scien- research and compare the characteristics of resi-
tific issues affecting medicine. The AMA also dency programs. It also publishes a wide variety
incorporates the views of special groups or sec- of medically related books on topics such as
tions of physicians, including medical students, guides impairment resources, health, medical law
resident physicians, young physicians, organized and ethics, practice management, and career
medical staff, group practice physicians, women development. The AMA disseminates its policy
physicians, minority physicians, international positions through an online database called
medical graduates, senior physicians, medical PolicyFinder.
schools, and gay, lesbian, bisexual, and transgen- An important resource that supports a variety
der physicians. of the AMA’s products and services, such as its
membership development efforts, marketing activ-
ities, and outreach programs, is the AMA Physician
Masterfile. The Physician Masterfile is a large
Although considerable AMA activity is devoted to database that includes biographic, medical educa-
membership development and retention, its most tion and training, contact, and practice informa-
visible products and activities involve information tion on more than 800,000 physician records. In
and advocacy. cooperation with the Association of American
The AMA is one of the largest publishers of Medical Colleges (AAMC), data are collected on
medical information in the world. Its flagship publi- individuals from medical school through residency
cation, the Journal of the American Medical Associa training. The AMA continues to collect practice
tion (JAMA) is published in 10 languages, and print information from physicians throughout their
editions are circulated in 113 countries. In addition, entire medical careers. Data collection techniques
the AMA publishes nine specialty journals, called involve the use of primary source data (i.e., data
the Archives Journals (Archives of Dermatology, from the original source and in its original form)
Archives of Facial Plastic Surgery, Archives of collected from agencies such as licensing and
General Psychiatry, Archives of Internal Medicine, medical specialty boards as well as surveying the
Archives of Neurology, Archives of Ophthalmology, physicians directly. Data are updated continuously.
Archives of Otolaryngology—Health and Neck In addition to physician records, the Physician
68 American Medical Association (AMA)
Masterfile includes information on 125 medical establishment of a Center for Public Health
schools, 7,900 graduate medical education pro- Preparedness and Disaster Response; (e) improv-
grams, 1,600 teaching institutions, and 19,000 ing patient safety through continued support of the
medical group practices. National Patient Safety Foundation (NPSF) and
Several products are derived directly from the through continued advocacy at the national level;
Physician Masterfile. The AMA offers the online and (f) ensuring that physicians set standards for
DoctorFinder for patients. It also licenses data to quality care by convening the Physician Consortium
companies that specialize in direct mailing, mar- for Performance Improvement, with representa-
keting services, the management of complex phar- tives from more than 100 national specialty and
maceutical call reporting systems, data integration state societies, which aims to establish evidence-
services, and other health-related and research based clinical performance measures.
activities. Data from the Physician Masterfile are
also frequently used by hospitals, licensing boards, Penny L. Havlicek
group practices, and other healthcare organiza- See also Association of American Medical Colleges
tions to verify physicians’ credentials. Although (AAMC); Health Workforce; Medical Group Practice;
health services and policy researchers often use the Physicians; Physicians, Osteopathic; Physician Workforce
Physician Masterfile, the AMA itself no longer Issues; Primary-Care Physicians; Public Policy
conducts this type of research, having reduced its
capacity to do so in the 1990s.
A significant and visible activity of the AMA is Further Readings
advocating for physicians on important profes-
American Medical Association. Caring for the Country:
sional and public health issues of the day. The
A History and Celebration of the First 150 Years of
AMA has established several units to assist in this
the American Medical Association. Chicago:
effort: (a) the Grassroots Action Center, which
American Medical Association, 1997.
helps physicians communicate with their federal
Ameringer, Carl F. The Health Care Revolution: From
legislators; (b) the Advocacy Resource Center, Medical Monopoly to Market Competition. Berkeley:
which advances state legislative advocacy efforts University of California Press and Milbank Memorial
in partnership with state societies; and (c) the Fund, 2008.
American Medical Political Action Committee Campion, Frank D. The AMA and U.S. Health Policy
(AMPAC), which makes campaign contributions Since 1940. Chicago: Chicago Review Press, 1984.
to medicine-friendly candidates and provides polit- Starr, Paul. The Social Transformation of American
ical education activities. Medicine: The Rise of a Sovereign Profession and the
The top items on the AMA’s current policy Making of a Vast Industry. New York: Basic Books,
agenda are the following: (a) placing limits on non- 1982.
economic damages in medical liability cases as a Stevens, Rosemary A., Charles E. Rosenberg, and
key part of a broader effort to effect medical liabil- Lawton R. Burns, eds. History of Health Policy in the
ity reform; (b) lobbying for reforming Medicare’s United States: Putting the Past Back In. Piscataway,
physician payment system by replacing the current NJ: Rutgers University Press, 2006.
physician payment formula with a system that
combines stable increases in reimbursement for
physicians with less paperwork; (c) incrementally Web Sites
expanding coverage for the uninsured and increas- American Medical Association (AMA):
ing access to care through the implementation of a http://www.ama-assn.org
consumer-driven, market-based plan (toward this American Medical Association Advocacy Resource
end, the AMA signed on with other large organiza- Center: http://www.ama-assn.org/AMA/pub/
tions to support the Health Coverage Coalition for category/8659.html
the Uninsured [HCCU]); (d) improving the health American Medical Association Grassroots Action Center:
of the public by promoting healthier lifestyles, http://capwiz.com/AMA/home
working to eliminate health disparities, and American Medical Political Action Committee (AMPAC):
improving disaster preparedness, resulting in the http://www.ampaconline.org
American Nurses Association (ANA) 69
Nurse, and a year later, the first state nursing

American Nurses organizations were formed to help regulate the
Association (ANA) practice of nursing. In 1911, the organization
changed its name to the American Nurses
The American Nurses Association (ANA) is a per- Association. Over the decades, the number of
sonal membership society supporting the profes- ANA members has grown, and the organization
sional needs of the 2.9 million registered nurses attempts to represent the interests of all nurses in
(RNs) in the United States. The ANA comprises the nation.
54 constituent member organizations and more
than 150,000 members. Headquartered in Silver
Structure and Function
Spring, Maryland, the ANA is a nonprofit, non-
government organization, supported primarily by Governance
membership dues, the sale of publications, and The ANA is organized into constituent member
revenue from certification programs. organizations and affiliated organizations. The
The ANA promotes standards of nursing prac- ANA has constituent member organizations in
tice based on scientific evidence, the rights of every state, the District of Columbia, Guam, and
nurses in the workplace, development of new the U.S. Virgin Islands. Federal nurses also have
nursing service delivery models to respond to their own constituent member organization. These
changing healthcare demands, and policy advo- constituent members govern the association
cacy for its members on nursing and health related through the ANA House of Delegates, which con-
issues. The ANA’s stated mission is “nurses sists of members from each constituent organiza-
advancing our profession to improve health for tion. There is also an elected board of directors,
all.” The overall goals of the ANA are to foster and these two entities provide the governing struc-
high standards of nursing practice, promote the ture for the ANA.
economic and general welfare of nurses in the A key committee in the governance structure of
workplace, convey a positive image of nursing, the ANA is the Congress on Nursing Practice and
and lobby the U.S. Congress and the Administration Economics (CNPE), a deliberative body of the
on health issues affecting nursing and the health of association’s members with diverse clinical and
the public. practice experiences and perspectives. The CNPE
Current strategic priorities of the ANA include focuses on establishing nursing’s approach to
the following: (a) professional practice and excel- emerging trends within the healthcare industry by
lence, (b) healthcare and public policy, (c) knowl- identifying issues and recommending policy alter-
edge and research, (d) the unification of the natives to the ANA board of directors.
profession, and (e) advocacy for workforce and
workplace.
History Affiliate Organizations

The ANA is more than 100 years old. It was The ANA has several affiliated organiza-
founded in 1896 as the Nurses Alumnae tions, including (a) the American Nurses’
Association, with 20 nurses attending the first Foundation (ANF), (b) the American Nurses
meeting to create a professional association for Credentialing Center (ANCC), (c) the American
nurses. However, none of these attendees were Academy of Nursing (AAN), and (d) the
registered nurses, as there were no licensing regu- American Nurses Association Political Action
lations for nursing at that time. The stated goals Committee (ANA-PAC). These affiliate organi-
of the new organization were “to establish and zations are separate but related arms of the
maintain a code of ethics; to elevate the standards ANA, which take major responsibility for key
of nursing education; to promote the usefulness ANA functions.
and honor the financial and interests of nursing.” The ANF, which was established in 1955, is the
In 1900, the organization published The American research, education, and philanthropic arm of the
70 American Nurses Association (ANA)
ANA. The ANF raises funds and awards grants to Publications

support advances in nursing science, education,
The ANA produces several publications on
and practice. Since its formation, the ANF has
nursing and health policy issues. These include The
awarded more than 950 nursing research grants,
American Nurse, a monthly newspaper, American
totaling more than $3.5 million.
Nurse Today, a monthly journal, and OJIN: The
The AAN, which was established in 1973, is
Online Journal of Issues in Nursing, a peer-re-
the leadership and scholarship arm of the ANA.
viewed online journal. In addition, the ANA pub-
Academy fellows are nurse leaders in practice,
lishes a wide variety of books and policy documents,
research, and education, who are elected by their
including the ANA Scope and Standards of Nursing
colleagues for membership in the AAN. The
Practice for nursing as a whole and for a variety of
AAN aims to serve the public through the gen-
clinical specialties in nursing.
eration, synthesis, and dissemination of nursing
knowledge.
The ANCC, which was established in 1973, is Position Statements
the arm of the ANA that provides tangible recog-
nition of professional achievement and expertise The ANA represents nurses by developing guid-
in functional and clinical areas of nursing. The ance for clinicians such as established definitions
American Board of Nursing Specialties and the of the profession, educational preparation for the
National Commission for Certifying Agencies, profession, certification and credentialing, and
both well recognized throughout the certification standards and competencies. The ANA currently
healthcare credentialing community, accredit publishes 21 standards in cooperation with vari-
most of the ANCC’s examination and certifica- ous specialty nursing organizations. These stan-
tion processes. dards are updated at least every 5 years through a
The ANCC is also responsible for the Magnet process overseen by the Congress on Nursing
Recognition Program, which recognizes health- Practice and Economics (CNPE).
care organizations that meet standards of nurs- The ANA also is responsible for developing and
ing excellence. This program is based on quality promulgating the Code of Ethics for Nurses, which
indicators and standards of nursing practice as is considered one of the most important docu-
outlined in the ANA Scope and Standards for ments of the association. In addition, the ANA
Nurse Administrators. Magnet designation is forms working groups to develop position state-
intended as a benchmark for measuring the ments on issues of concern to nursing such as end-
quality of care that consumers can expect to of-life care, disaster preparedness, health system
receive in a healthcare facility. The popular reform, and quality of care.
weekly newsmagazine U.S. News and World
Report uses the Magnet designation as one of its
Political Activities
criteria for recognizing America’s best hospitals.
Of the 18 hospitals listed on the U.S. News and The ANA advocates for federal and state legis-
World Report Honor Roll for 2007, 11 were lation and regulations supporting nursing practice.
Magnet hospitals. Such political action addresses both workplace
The American Nurses Association Political issues such as safety, staffing to patient ratios,
Action Committee (ANA-PAC), which was estab- wages, and working conditions, and issues related
lished in 1974, is the lobbying arm of the ANA. to protecting the health of the public. ANA policy
The ANA-PAC raises voluntary money from mem- priorities include supporting healthcare reform
bers and contributes these funds to support candi- efforts, expanding the roles for nurses and advanced
dates for public office who have demonstrated practice nurses in healthcare delivery, increasing
their support for the legislative agenda of the federal funding for nursing education and nursing
ANA. The ANA-PAC is bipartisan and works with workforce development, and providing greater
both national parties to fund candidates who sup- workplace safety for nurses. In addition, the ANA
port nursing and the ANA’s nursing agenda. has been involved in advocating for Medicare
American Osteopathic Association (AOA) 71
reform, passing patients’ rights legislation, provid- profession. The AOA also works to promote
ing greater protection for whistle-blower nurses, public health; encourages scientific research; serves
increasing the reimbursement for healthcare as the primary certifying body for DOs; is the
services, and providing greater public access to accrediting agency for osteopathic medical col-
healthcare. leges; and has federal authority to accredit hospi-
tals and other healthcare facilities.
Susan M. Swider
See also Health Workforce; Hospitals; Nightingale, History

Florence; Nurse Practitioners (NPs); Nurses
Founded in 1897 by a group of 16 students from
the American School of Osteopathy in Kirksville,
Further Readings Missouri, the AOA aimed to organize the efforts
of individual physicians and osteopathic medical
American Nurses Association. Nurse Staffing and Patient colleges to advance the osteopathic medical pro-
Outcomes in the Inpatient Hospital Setting. Silver fession. On April 19, 1897, the committee created
Spring, MD: American Nurses Association, 2000. a constitution and permanently established the
American Nurses Association. Nursing’s Social Policy association. Originally the American Association
Statement. 2d ed. Silver Spring, MD: American
for the Advancement of Osteopathy, the name
Nurses Association, 2003.
changed to the American Osteopathic Association
American Nurses Association. Nursing: Scope and
in 1901.
Standards of Practice. Silver Spring, MD: American
Nurses Association, 2004.
American Nurses Association. Magnet Recognition Leadership
Program Instruction and Application Manual.
Silver Spring, MD: American Nurses Association, The AOA’s leadership includes a board of trustees
2005. comprising a president, president-elect, two past
Montalvo, Isis, and Nancy Dunton, eds. Transforming presidents, three vice presidents, 18 additional
Nursing Data Into Quality Care: Profiles of Quality trustees, an intern-resident representative, and a
Improvement in U.S. Healthcare Facilities. Silver student representative as well as a house of dele-
Spring, MD: American Nurses Association, 2007. gates comprising DOs representing osteopathic
medical state and regional societies and specialty
colleges, a speaker, and a vice speaker.
Web Sites
American Nurses Association (ANA): Board Certification
http://www.nursingworld.org
The AOA, through its official certifying body,
the Bureau of Osteopathic Specialists, and its
18 member certifying boards, offers 85 board
American Osteopathic certifications in specialties, subspecialties, and
areas of added qualifications. Recognition by
Association (AOA) one of the certifying boards of the AOA means
a DO has completed specific specialty or sub-
The American Osteopathic Association (AOA) is specialty training, has passed a rigorous board
a member association that represents more than examination, and has met other board-specific
61,000 (as of 2008) osteopathic physicians (DOs). requirements.
With headquarters in Chicago, the AOA has a The AOA specialty certifying boards, through
mission of advancing the philosophy of osteo- the Bureau of Osteopathic Specialists, define
pathic medicine by promoting excellence in edu- the qualifications required of DOs for certifica-
cation, research, and the delivery of quality, tion and recertification in each specialty; deter-
cost-effective healthcare within a distinct, unified mine the qualifications of osteopathic physicians
72 American Osteopathic Association (AOA)
as specialists for certification in each specialty; Accreditation

conduct examinations for certification; issue
certificates, subject to the approval of the AOA The AOA’s Commission on Osteopathic College
Bureau of Osteopathic Specialists, to those Accreditation (COCA) is recognized by the U.S.
physicians who are found qualified for certifi- Department of Education as the only accrediting
cation in each specialty; recommend revocation agency for predoctoral osteopathic medical educa-
of certificates for cause; and use every means tion in the United States. Accreditation action
possible to maintain a high standard of practice taken by the COCA means that an osteopathic
in each specialty within the osteopathic medi- medical school (a) has appropriately identified its
cal profession. mission; (b) has secured the resources necessary to
DOs can become AOA board certified in anes- accomplish that mission; (c) shows evidence of
thesiology, ophthalmology and otolaryngology, accomplishing its mission; and (d) demonstrates
dermatology, orthopedic surgery, emergency medi- that it is capable of accomplishing its mission in
cine, pathology, family practice, pediatrics, inter- the future. Accreditation of an osteopathic medi-
nal medicine, physical medicine and rehabilitation, cal school means that it incorporates the science
neurology and psychiatry, preventive medicine, of medicine, the principles and practices of osteo-
neuromusculoskeletal medicine, proctology, nuclear pathic manipulative medicine, the art of caring,
medicine, radiology, obstetrics and gynecology, and the power of touch within a curriculum that
and surgery as well as a number of subspecialty recognizes the interrelationship of structure and
and added qualification areas of medicine such as function for diagnostic and therapeutic purposes
cardiology, neurophysiology, geriatrics, and medi- and recognizes the importance of addressing the
cal toxicology. body as a whole in disease and health.
Certification requirements vary by specialty. At Accreditation signifies that an osteopathic medi-
a minimum, candidates for AOA certification must cal school has met or exceeded the AOA standards
have a valid state license to practice medicine, have for educational quality with respect to (a) mission,
completed a 1-year internship followed by comple- goals, and objectives; (b) governance, administra-
tion of an approved residency training program, tion, and finance; (c) facilities, equipment, and
have passed the board examination or examina- resources; (d) faculty; student admissions, perfor-
tions, and be members of the AOA or the Canadian mance, and evaluation; (e) preclinical and clinical
Osteopathic Association. curriculum; and (f) research and scholarly activity.
To maintain board certification, AOA board- In addition, the AOA approves osteopathic
certified physicians must complete a minimum of internship and residency training programs through
120 hours of approved and documented AOA its Program and Trainee Review Council (PTRC).
continuing medical education credits within a The PTRC receives reports and recommendations
3-year period, of which 50 hours must be in their from evaluation committees of osteopathic spe-
general specialty. The American Osteopathic Board cialty practice organizations for osteopathic intern-
of Family Physicians is an exception, requiring 150 ship and residency program approvals, denials, and
hours with 50 hours still in the general specialty. increases or decreases in size and takes final action
Board certification is a voluntary process and on all recommendations. In addition, the PTRC
is not a requirement to practice in a medical spe- also accepts requests for AOA approval of indi-
cialty. DOs who have been trained in programs vidual DO trainees’ internships or residencies that
accredited by the Accreditation Council for were not originally AOA-approved programs.
Graduate Medical Education rather than in pro- Recognizing the need for a new system to struc-
grams approved by the AOA also have the option ture and accredit osteopathic graduate medical
of certifying through the American Board of education, the AOA established the Osteopathic
Medical Specialties (ABMS). A majority of DOs Postdoctoral Training Institutions (OPTI) in 1995.
continue to be certified through the member Each OPTI is a community-based training consor-
boards of the AOA, with some of those being tium comprising at least one college of osteopathic
dually certified by both AOA and ABMS medicine and one hospital. Other hospitals and
boards. ambulatory-care facilities may also partner within
American Osteopathic Association (AOA) 73
an OPTI. Community-based healthcare facilities, healthcare facilities. On-site survey is required

such as ambulatory-care clinics, rehabilitation cen- every 2 years to validate ongoing compliance with
ters, and surgical centers, may attain the educa- HFAP standards.
tional resources and support necessary to provide
physician training with an OPTI’s assistance.
Professional Publications
The AOA also provides continuing medical
education (CME). The AOA Board of Trustees The AOA also produces two monthly publications
establishes accreditation policy for osteopathic for the osteopathic medical profession. JAOA—
CME sponsors. The AOA Council on Continuing The Journal of the American Osteopathic
Medical Education has been given authority by the Association (JAOA) is the official scientific publi-
AOA Board of Trustees to monitor osteopathic cation of the AOA as well as the scholarly, peer-
CME and to grant or deny Category 1 accredita- reviewed publication of the osteopathic medical
tion status to osteopathic CME sponsors. profession. It provides a forum for communicat-
Additionally, the AOA accredits medical facili- ing and disseminating philosophical concepts,
ties through its Healthcare Facilities Accreditation clinical-practice observations, and scientific infor-
Program (HFAP). This program has been provid- mation as well as defines the current status of the
ing medical facilities with an objective review of profession. It is directed toward the osteopathic
their services since 1945. The program is recog- primary-care physician with a broad range of
nized nationally by the federal government, state interests and provides a clinical and scientific
governments, insurance carriers, and managed- update for the osteopathic specialist.
care organizations. JAOA publishes original investigations, current
It is one of only two voluntary accreditation reviews with an expert critical viewpoint, and
programs in the United States authorized by the didactic discourses in a wide variety of clinical
Centers for Medicare and Medicaid Services fields. For the interest and information of its read-
(CMS), formerly the Health Care Financing ers, JAOA may contain medical education articles,
Administration (HCFA), to survey hospitals under editorials, columns, book reviews, abstracts, and
Medicare. The AOA accreditation program was special-interest articles at the editor-in-chief’s dis-
developed in 1943 to 1944 and implemented in cretion. These articles customarily will be of clin-
1945. Under this program, hospitals were surveyed ical-scientific interest or related to issues and
each year. In this manner, the AOA was able to trends that have a bearing on the osteopathic
ensure that osteopathic medical students received medical profession. Controversial articles and let-
their training through rotating internships and ters may, at the editor-in-chief’s discretion, be
residencies in facilities that provided high-quality published in JAOA, provided that the source or
patient care. author is clearly identified. DOs can receive a
In 1965, Medicare and Medicaid were intro- half-hour of Category 2-B continuing medical
duced, and the AOA applied to the HCFA, now education credit for each issue they read of the
CMS, for deeming authority to survey hospitals JAOA and 2 hours of Category 1-B credit each
under the Medicare Conditions of Participation. time they complete a quiz in the journal or its
In 1995, the AOA applied for and received supplements.
deeming authority to accredit laboratories within The DO magazine contains news of the osteo-
AOA-accredited hospitals under the Clinical pathic medical profession and its members; articles
Laboratory Improvement Amendments of 1988. of professional and personal interest to DOs and
The program also accredits ambulatory care/ osteopathic medical students; legislative develop-
surgery, mental health, substance abuse, physical ments; meeting coverage; clinical updates; and an
rehabilitation medicine facilities, critical access extensive listing of osteopathic continuing medical
hospitals, and long-term acute-care hospitals. education programs. DOs can earn 1 hour of
Additionally, in 2006, HFAP announced that its Category 1-B credit for each quiz they complete
first disease certification program—the HFAP from The Whole Patient supplements to The DO,
Primary Stroke Center—had been developed. This the AOA’s Women and Wellness Newsletter, and
2-year certification is limited to HFAP-accredited the AOA’s Health Watch newsletter. DOs who do
74 American Public Health Association (APHA)
not complete the quizzes can still obtain a half- myriad other issues. The APHA’s strength is
hour of Category 2-B credit for each issue and rooted in the dedication and passion of its mem-
supplement of The DO they read. bers and countless other individuals, agencies, and
foundations who are concerned about improving
American Osteopathic Association and protecting the nation’s health.
See also Accreditation; Health Workforce; Physicians;
Physicians, Osteopathic; Physician Workforce Issues History
The APHA grew out of the growing recognition
Further Readings by a physician named Stephen Smith and others
in the medical profession that squalid living con-
DiGiovanna, Eileen. An Ostoepathic Approach to ditions caused epidemics of infectious diseases,
Diagnosis and Treatment. Philadelphia: Lippincott such as typhus fever and cholera, and their frus-
Williams and Wilkins, 2004. tration with the incompetence and ignorance of
Gevitz, Norman. The DOs: Osteopathic Medicine in local officials, such as Boss Tweed and Tammany
America. 2d ed. Baltimore: Johns Hopkins University
Hall, in denying these unsanitary conditions. As
Press, 2004.
the citizenry became more interested in organiz-
Still, A. T. Philosophy of Osteopathy. 1899.
ing local boards of health and in establishing a
Still, A. T. Autobiography of A.T. Still. 1908.
national chain of communications in public
Stone, Caroline. Science in the Art of Osteopathy:
health, the APHA was formed in 1872 as the
Osteopathic Principles and Models. Cheltenham, UK:
Nelson Thornes, 2000.
vehicle to carry out these activities. Its charge was
to hold annual meetings and produce publica-
tions to awaken and maintain the active and per-
Web Sites manent interest of the people in sanitary
administration, greatly facilitate the enlighten-
American Osteopathic Association (AOA): ment of the public, and promote the appointment
http://www.osteopathic.org
of more competent health authorities. The first
meeting attracted 15 people.
Over its long history, the APHA has embraced
American Public Health numerous topics, shifting its primary focus from
laboratory aspects of water pollution, milk sanita-
Association (APHA) tion, hygiene education, control of tuberculosis,
and infectious diseases in the 1890s to eliminating
The American Public Health Association (APHA) disparities in healthcare, designing healthy com-
is the oldest, largest, and most diverse organiza- munities, obesity, smoking cessation, disaster pre-
tion of public health professionals in the world. It paredness, building the public health workforce,
has been working to improve the nation’s public and improving the public health infrastructure in
health since its inception in 1872. The association the 2000s. In this time, it has participated in some
aims to protect all Americans and their communi- of the most extraordinary achievements of modern
ties from preventable, serious health threats and times—achievements that have increased the aver-
strives to ensure that community-based health age life expectancy from 45 to more than 75 years
promotion and disease prevention activities and of age. Advances in many areas of public health
preventive health services are universally accessi- and practice have dramatically lessened the inci-
ble in the United States. The APHA represents a dence of disease and injury, adding 25 of those
broad array of health professionals and others years to our lives.
who care about their own health and the health of
their communities. It builds a collective voice for
Size and Structure
public health, working to ensure access to health-
care, protect funding for core public health ser- Today, the APHA boasts nearly 50,000 members,
vices, and eliminate health disparities, among a including its affiliates. APHA members include
American Public Health Association (APHA) 75
nurses, physicians, environmentalists, educators, professionals, registered dietitians, chiropractors,

dietitians, nutritionists, scientists, laboratory work- and dental professionals.
ers, health information specialists, dentists, podia- The APHA is a leading publisher of books pro-
trists, and students. They are supported by 24 moting sound scientific standards, action pro-
Sections and seven Special Interest Groups on a grams, and public policy to enhance health. Two
variety of professional interests, a Student Assembly, of the mainstays of the publications program are
and special membership categories, including tran- Standard Methods for the Examination of Water
sitional membership—a limited membership open and Wastewater, published continually since
only to current student members who have com- 1917, and now in its 21st edition; and the Control
pleted their degree and are transitioning into the of Communicable Diseases Manual, published
workforce; special health workers; retired mem- continually since 1920, and now in its 18th edi-
bers; and consumer members. tion—and still the most widely recognized and
Each day, APHA members, working in health used resource on infectious diseases in the
agencies, nonprofit organizations, educational set- world.
tings, and medical facilities, tackle public health The APHA’s government affairs staff represents
challenges every bit as tenacious as those faced by its members’ concerns on Capitol Hill, in regula-
their 19th-century predecessors, as longer lives, tory agencies, and in executive offices at the fed-
sedentary habits, and poor nutrition give rise to a eral, state, and local levels. The APHA is one of the
new spectrum of health problems. Environmental leading public health organizations with full-time
hazards continue to threaten public health, and advocates in the nation’s capital.
economic factors profoundly affect access to National Public Health Week each year high-
health insurance coverage and consequently to lights an area of public health concern and encour-
healthcare. And efforts by lawmakers to reduce ages nationwide participation through the sections
government spending threaten the nation’s long- and affiliates.
standing commitment to public health programs The Public Health Career Mart brings together
and education. employers and employees, offering a wide variety of
public health career opportunities. Added features
at the annual meeting include one-on-one career-
counseling sessions with professional counselors
The APHA publishes the American Journal of and interview time with prospective employers.
Public Health, a monthly, peer-reviewed journal
published continually since 1911, and The Nation’s
Health, the APHA’s award-winning newspaper, Future Implications
both communicating the latest public health sci- In the future the APHA will continue to build a
ence and practice to members, opinion leaders, collective voice for public health, working to
and the public. ensure access to healthcare, protect funding for
The APHA’s annual meeting brings together core public health services, and eliminate health
thousands of public health professionals, agencies, disparities, among a myriad other issues. The
and partners to network and share the latest public APHA’s strength will continue to be rooted in the
health data and trends, as well as set policy on dedication and passion of its members and count-
emerging public health concerns. less other individuals, agencies, and foundations
The Public Health Exposition is the showplace who are concerned about improving and protect-
for hundreds of leading organizations in the public ing the nation’s health.
health market, offering the latest in software, pro-
grams, publications, educational opportunities, Ellen T. Meyer
and more in the field of public health.
The APHA offers a large number of accredited See also Acute and Chronic Diseases; Community Health;
continuing education programs for many public Epidemiology; Infectious Diseases; Life Expectancy;
health disciplines, including registered nurses, Public Health; Public Policy; World Health
certified health educators, physicians, laboratory Organization (WHO)
76 American Society of Health Economists (ASHE)
Further Readings provide for interaction among those conducting

Brookes, Timothy J., ed. A Warning Shot: Influenza and the research, funding the research, and making use
the 2004 Flu Vaccine Shortage. Washington, DC: of the research. The society makes every attempt to
American Public Health Association, 2005. be inclusive, attracting the young and old, the
Fee, Elizabeth, and Theodore M. Brown, eds. The experienced and inexperienced, leaders in the field,
APHA: 125 Years Old—And Approaching the and graduate students preparing to enter the field.
Millennium. Washington, DC: American Public The main venue through which the mission of
Health Association, 1997. the ASHE is accomplished is its biennial confer-
Fee, Elizabeth, and Theodore M. Brown, eds. Conflict ence. The inaugural conference of the society was
and Controversy: From Medical Care Policy to the held at the University of Wisconsin, Madison, in
Politics of Environmental Health. Washington, DC: June 2006. More than 500 individuals attended
American Public Health Association, 1998. the conference, where more than 300 research
Grad, Frank P. Public Health Law Manual. 3d ed. articles were presented and 100 poster sessions
Washington, DC: American Public Health were held. Professor Joseph P. Newhouse, the John
Association, 2005. D. MacArthur Professor of Health Policy and
Landesman, Linda Young. Public Health Management of Management, Harvard University, and the inaugu-
Disasters: The Practice Guide. 2d ed. Washington, ral president of the society, presided over the con-
DC: American Public Health Association, 2005. ference along with Jody L. Sindelar, professor in
the School of Public Health at Yale University, and
the president-elect of the organization. And Michael
Web Sites Grossman, Distinguished Professor of Economics,
American Public Health Association (APHA): City University of New York Graduate Center, and
http://www.apha.org Program Director of Health Economics at the
National Bureau of Economic Research, was des-
ignated to serve as president after Sindelar’s term
of office. At the conference, the society awarded
American Society of ASHE Medals to two health economists who were
40 years of age or younger and judged by their
Health Economists (ASHE) peers to have made outstanding contributions to
the field. The medals were awarded to David M.
The American Society of Health Economists (ASHE) Cutler, Otto Eckstein Professor of Applied
is a professional organization dedicated to promot- Economics at Harvard University, and to Jonathan
ing excellence in health economics research in the Gruber, professor of economics at the Massachusetts
United States. The society’s leading mission is to Institute of Technology (MIT). The second bien-
provide a forum for emerging ideas and empirical nial conference was held at Duke University,
results of health economics research. Through a set Durham, North Carolina, in June 2008. And the
of professional activities, it aims to advance health third biennial conference will be held at Cornell
economics research in the nation, achieve wide- University, Ithaca, New York, in 2010.
spread recognition for the field of health econom- All the biennial conferences have broad themes,
ics, and enhance individual and societal health by but they are equally inclusive in topics represented
providing evidence and expertise for the develop- in the research that is presented. The society is a
ment of public and private health policies. domestic organization open to the presentation of
The academic field of health economics has research results related to domestic issues. While
experienced very rapid growth in the past three most members are from academic institutions,
decades. Commensurate with this growth has been there is substantial representation from govern-
a similar growth in research productivity and qual- ment and industry as well as other countries.
ity along with job opportunities in academe, gov- The ASHE was formed under the umbrella of
ernment, and industry. The ASHE was formed to the International Health Economics Association
respond to the excess demand for an outlet for (iHEA), with the full support of Professor Tom
health economics and policy research as well as to E. Getzen of Temple University, Philadelphia,
America’s Health Insurance Plans (AHIP) 77
Pennsylvania, executive director of the iHEA. The Association of America (HIAA) and the American
first executive director of the ASHE was Professor Association of Health Plans (AAHP).
Richard J. Arnould of the University of Illinois at Its oldest predecessor, the HIAA, was formed in
Urbana–Champaign. Memberships to ASHE were 1956. HIAA’s mission was to be the most influen-
initially offered in 2005 jointly with iHEA mem- tial advocate for the nation’s private, free-enterprise
berships. Independent memberships were first healthcare system. Throughout its history, HIAA
offered in 2007. The ASHE plans to be an inde- strongly opposed legislative efforts to regulate pri-
pendent not-for-profit organization in 2010. The vate health insurance and the establishment of
society is governed by a board of directors, initially national health insurance. It successfully helped
formed by appointment but with elections com- defeat the Clinton administration’s national health-
mencing in 2007, and it operates subject to the care reform plan of 1993. To stop the Clinton
bylaws established by the board. Currently, the plan, HIAA established a group of organizations
ASHE has approximately 800 members. that oppose the plan, created an aggressive grass-
roots campaign against the plan, and spent mil-
Richard J. Arnould lions of dollars airing a powerful television
See also Cost of Healthcare; Health Economics;
commercial criticizing the plan. The TV commer-
International Health Economics Association (iHEA); cial, Harry and Louise, depicted a middle-class
Newhouse, Joseph P. couple who were despairing over the proposed
plan’s complex bureaucratic nature. It decried the
plan as big government at its worse and featured
Web Sites the phrase, “They choose, we lose.”
Its second predecessor, the AAHP, was formed in
American Society of Health Economists (ASHE): 1996. AAHP’s mission was to present a strong, uni-
http://healtheconomics.us fied voice for the nation’s managed-care industry
and a positive image of the industry to the general
public. In the late 1990s, AAHP attempted to
America’s Health defend the managed-care industry, which was
becoming increasingly unpopular with the general
Insurance Plans (AHIP) public, and it was facing increasing scrutiny by the
U.S. Congress concerning the tactics it used to save
America’s Health Insurance Plans (AHIP) is a money.
large national trade association representing more
than 1,300 member companies that provide
health, long-term care, dental, disability, and sup Organization and Structure
plemental insurance coverage to more than 200 AHIP is governed by a board of directors. The
million people in the United States. AHIP’s prin- board, which comprises 56 individuals who repre-
cipal purpose is to represent the interests of its sent various insurance companies, works to shape
members on legislative and regulatory issues at and guide the association’s policies, programs,
the federal and state levels, and with the media, and research. It receives directions and input from
consumers, and employers. Its goal is to provide operating and product committees, the policy
a unified voice for the nation’s health insurance committee, and the executive committee as well as
industry, to expand access to high-quality, cost- issue-focused task forces, subcommittees, and
effective healthcare to all Americans, and to pro- working groups. The president of AHIP, who is
vide consumers with a wide array of health responsible for the operations of the organization,
insurance plans. also reports to the board.
Background Products and Services

Located in Washington, D.C., AHIP was formed in AHIP provides information and services through
2003, through the merger of the Health Insurance newsletters, a magazine, and online services. It also
78 America’s Health Insurance Plans (AHIP)
offers a combination of conferences, self-study purchase health insurance with pretax dollars,
courses, and programs that assist health profession- provide financial assistance to help working fami-
als in staying abreast of important issues in health- lies afford coverage, and encourage states to
care. Each year, the organization hosts a number of develop and implement access proposals. A plan
conferences that are open to AHIP members, state of this magnitude would cost the federal govern-
health insurance trade organizations, and other ment approximately $300 billion over a 10-year
leaders in healthcare. Recent conference topics period and call for some radical changes in health-
included insurance product innovation and diversi- care policies. Some of the key elements of the
fication, value-based healthcare, employer wellness AHIP plan include expanding the State Children’s
programs, and chronic-care models of care. Health Insurance Program (SCHIP) to make eli-
AHIP Solutions is a program to help members gible all uninsured children from families with
identify the most capable and expert partners for incomes less than 200% of the Federal Poverty
specific business needs. These areas of need include Level (FPL), establish a Universal Health Account
Medicare/Medicaid, the Health Insurance Portability that would allow individuals to purchase any type
and Accountability Act of 1996 (HIPAA), risk and of healthcare insurance, and establish a health tax
reinsurance, eHealth and eBusiness solutions, credit of up to $500 for low-income families who
claims processing and cost management, disaster secure health insurance for their children.
recovery and consumer-directed healthcare. Agree
ments between the partners and AHIP are struc- Gregory Vachon and Tiosha T. Goss
tured to assist in marketing partners’ services to
See also Consumer-Directed Health Plans (CDHPs);
members.
Health Insurance; Health Insurance Coverage;
Medicare; National Health Insurance; State Children’s
AHIP Foundation Health Insurance Program (SCHIP); Uninsured
Individuals
The association also has a nonprofit foundation.
The AHIP Foundation has the mission of enhanc-
ing the quality of healthcare delivery in managed-
care settings through effective treatment systems, Further Readings
evidence-based medicine, performance measure- America’s Health Insurance Plans. Employee Healthcare
ment, and quality improvement. Additionally, the Benefits: An Introduction to POPs, FSAs, HRAs, and
foundation seeks to increase the insurance indus- HSAs. Washington, DC: America’s Health Insurance
try’s ability to serve diverse populations through Plans, 2005.
the training and development of minority health America’s Health Insurance Plans. Health Insurance:
plan managers and through the support of pro- Economic Impact in the States. Washington, DC:
grams targeted toward minority populations. To America’s Health Insurance Plans, 2005.
accomplish this, the foundation has three pro- America’s Health Insurance Plans. Long-Term Insurance
grams: the Executive Leadership Program, the Products: Policy Design, Pricing, and Regulation.
Executive Leadership Program for Medical Dire Washington, DC: America’s Health Insurance Plans,
ctors, and the Minority Management Development 2005.
Program. America’s Health Insurance Plans. Employee Healthcare
Benefits: Funding Retiree Healthcare and Related
Current Efforts Benefits. Washington, DC: America’s Health
Insurance Plans, 2006.
AHIP’s latest endeavor is a proposal to expand America’s Health Insurance Plans. Guaranteeing Access
access to health insurance coverage to every to Coverage for All Americans. Washington, DC:
American. The plan would expand access to America’s Health Insurance Plans, 2007.
health insurance coverage to all children within 3 America’s Health Insurance Plans. We Believe in High-
years of age and 95% of adults within 10 years. Value Health Care: The Value of Health Insurance
According to AHIP, the plan would expand eligi- Plans. Washington, DC: America’s Health Insurance
bility for public programs, enable all consumers to Plans, 2007.
Andersen, Ronald M. 79
Web Sites framework developed in connection with that sur

America’s Health Insurance Plans (AHIP): vey served to guide the development of community-
http://www.ahip.org survey-based evaluations of the Community
America’s Health Insurance Plans (AHIP), Center for Hospital Program and Municipal Health Services
Policy and Research: http://www.ahipresearch.org Program, conducted by the CHAS, with support
America’s Health Insurance Plans (AHIP), Insurance from the Robert Wood Johnson Foundation.
Education: http://www.insuranceeducation.org Andersen was also the principal investigator for
Employee Benefit Research Institute (EBRI): subsequent projects to conduct secondary analyses
http://www.ebri.org of data collected through these and related state,
National Conference of Insurance Legislators (NCOIL): community, and national surveys.
http://www.ncoil.org Andersen also provided leadership in the study
of healthcare delivery system issues in the United
States through the design and implementation of
the National Study of Internal Medicine Manpower,
Andersen, Ronald M. a national evaluation of home-care programs for
ventilator-assisted children, studies of health
Born in Omaha, Nebraska, in 1939, Ronald Max services use by the homeless, and evaluation of
Andersen received his bachelor’s degree (1960) community-based dental programs and related
from the Santa Clara University and his master’s dental health profession needs. He extended the
(1962) and doctorate (1968) degrees from Purdue application of his empirical and conceptual inter-
University. From 1974 to 1990, Ronald Andersen ests in these areas to the design and conduct of
worked at the Center for Health Administration cross-national comparative studies of utilization
Studies (CHAS) in the Graduate School of Business and access through the World Health Organization
at the University of Chicago. From 1980 to 1990, (WHO) International Collaborative Study of Dental
he was the director of the Program for Health Manpower Systems in Relationship to Oral Health
Administration and CHAS. In 1991, he became Status.
the Wasserman Professor of Health Services and Andersen has received numerous awards and
Sociology at the University of California, Los honors. He was named the Fred and Pamela
Angeles (UCLA). In 2004, he became Professor Wasserman Professor of Health Services at the
Emeritus. UCLA School of Public Health. His contributions
During his academic career, Andersen has made were acknowledged by colleagues in the fields of
major conceptual and methodological contribu- medical sociology and health services research
tions to the study of healthcare utilization behav- through his receipt of the Leo G. Reeder
ior and access to healthcare through the design and Distinguished Medical Sociologist Award from the
conduct of large-scale community, national, and Medical Sociology Section of the American
cross-national health surveys. In 1968, he pub- Sociological Association (1994), the Association
lished a monograph introducing the behavioral for Health Services Research Distinguished
model of families’ use of health services, based on Investigator Award (1996), and the Health Services
an analysis of a 1963 national survey of healthcare Research Prize from the Baxter Allegiance
utilization and expenditures. This model, and Foundation (1999). His lifetime scholarly achieve-
Andersen and his colleagues’ successive adapta- ments were acknowledged by his receiving the
tions of it, continue to guide much of the explana- Distinguished Alumnus Award (1998) and an
tory research on healthcare utilization behavior. honorary doctorate degree (1999) from Purdue
Andersen’s subsequent work built directly on University.
these interests. He was principal investigator for Lu Ann Aday
national health surveys conducted in 1970 and
1976. The latter survey extended his earlier con- See also Access, Models of; Access to Healthcare; Aday,
ceptual and empirical work on utilization to exam- Lu Ann; Anderson, Odin W.; Health Services
ining the issues of access to healthcare. The access Research, Origins; Medical Sociology; Public Policy
80 Anderson, Odin W.
Further Readings and the federal government became interested in

Andersen, Ronald M. A Behavioral Model of Families’ funding research on the health services industry,
Use of Health Services. Chicago: University of destined to become the largest industry in the
Chicago, Graduate School of Business, Center for nation. Anderson’s career spanned these periods
Health Administration Studies, 1968. of significant growth of the health services sector
Andersen, Ronald M. “Revisiting the Behavioral Model and profoundly influenced its study.
and Access to Medical Care: Does It Matter?” Born in Minneapolis, Minnesota, in 1914,
Journal of Health and Social Behavior 36(1): 1–10, Anderson received his bachelor’s degree (1937)
March 1995. and master’s degree in sociology (1938) from the
Andersen, Ronald M., Thomas H. Rice, and Gerald F. University of Wisconsin–Madison. He then moved
Kominski, eds. Changing the U.S. Health Care to the University of Michigan, where he received a
System: Key Issues in Health Services Policy and bachelor’s degree in library science (1940) and his
Management. 3d ed. San Francisco: Jossey-Bass, 2007. doctorate degree in sociology (1948). While at
Committee on the Consequences of Uninsurance. Michigan, Anderson became the first sociologist to
Insuring America’s Health: Principles and work in a school of public health, helping establish
Recommendations. Washington, DC: National a research program in medical care and a health
Academies Press, 2004. services research library. In 1949, he accepted an
Davidson, Pamela L., Ronald M. Andersen, Roberta Wyn, associate professor position on the Faculty of
et al. “A Framework for Evaluating Safety-Net and Medicine, University of Western Ontario, Canada—
Other Community-Level Factors on Access for Low- another first for a sociologist to join the faculty of
Income Populations,” Inquiry 41: 21–38, Spring 2004.
a medical school. There, he studied the emerging
Lewis, Joy H., Ronald M. Andersen, and Lillian Gelberg.
areas of social epidemiology and also began to
“Health Care for Homeless Women: Unmet Needs
work in the utilization of physician services in a
and Barriers to Care,” Journal of General Internal
nearby medical insurance plan.
Medicine 18: 921–28, 2003.
In 1952, Odin Anderson became the research
director of the Health Information Foundation
(HIF), located in New York. This nonprofit research
Web Sites
agency was founded by pharmaceutical and chem-
University of California, Los Angeles (UCLA), ical industries in 1950 to provide information and
Center for Health Policy Research: data for public policy formulation in the United
http://www.healthpolicy.ucla.edu States. Anderson developed and directed a unique
and highly successful research program based on
national surveys of the medical-care use and
expenditures of the nation’s population and cross-
Anderson, Odin W. national comparisons of the operation of health
services delivery systems and health insurance.
Odin W. Anderson (1914–2003) is a worthy can- The HIF moved to the University of Chicago in
didate for “the father of medical sociology.” After 1962, where it was renamed the Center for Health
World War II, a few sociologists in the United Administration Studies. Anderson continued to
States began to take interest in medical sociology serve as the research director and became a profes-
(although the term had not yet been coined). In sor in the Graduate School of Business and the
1960, a section on the sociology of medicine was Department of Sociology. CHAS flourished under
established within the American Sociological Anderson’s direction, expanding its national and
Association (ASA), and quickly it became one of international health services research program
the largest sections. Anderson was a member of with support from foundations and the federal
the founding committee for this section and its government. The center served as a national model
second chair. In the following decades, other aca- and reference point for health services research.
demic disciplines, including economics, political In 1980, on reaching the mandatory retirement
science, and operations research began to study age of 65 at the University of Chicago, Anderson
health services, and philanthropic foundations returned to the University of Wisconsin–Madison
Antitrust Law 81
with a half-time professorship in the Department See also Aday, Lu Ann; Andersen, Ronald M.;
of Sociology. He also continued to teach and to Comparing Health Systems; Health Services Research,
conduct research for another 10 years at CHAS as Origins; International Health Systems; Medical
Professor Emeritus. In this last period of his career, Sociology
he continued to be incredibly productive, conduct-
ing a study of Health Maintenance Organizations
(HMOs) in Minneapolis–St. Paul and Chicago, Further Readings
writing a book on health services in several coun- Anderson, Odin W. The Uneasy Equilibrium: Private and
tries, and writing a history of the development of Public Financing of Health Services in the United
American health services since 1875. States, 1875–1965. New Haven, CT: College and
Anderson was a prolific writer, and many of his University Press, 1968.
publications are considered classics in the field. Anderson, Odin W. Health Care: Can There Be Equity?
His legacy of publications and lessons for the fields The United States, Sweden, and England. New York:
of medical sociology and health services research Wiley, 1972.
has been validated by numerous recognitions. The Anderson, Odin W. Health Services in the United States:
Section on Medical Sociology of the American Growth Enterprise Since 1875. Ann Arbor, MI:
Sociological Association cited him as a Distinguished Health Administration Press, 1985.
Medical Sociologist (1980), and the Association Anderson, Odin W. The Health Services Continuum in
for Health Services Research cited him as a Democratic States: An Inquiry Into Solvable
Distinguished Health Services Researcher (1985). Problems. Ann Arbor, MI: Health Administration
Press, 1989.
He was awarded the Baxter Alliance Distinguished
Anderson, Odin W. The Evolution of Health Services
Health Services Researcher Prize (1999). And he
Research: Personal Reflections on Applied Social
received honorary doctoral degrees from the
Science. San Francisco: Jossey-Bass, 1991.
Faculty of Medicine, University of Uppsala, Sweden
Anderson, Odin W., and Jacob J. Feldman. Family
(1977), and the College of Osteopathic Medicine, Medical Costs and Voluntary Health Insurance: A
Chicago (1979). Nationwide Survey. New York: McGraw-Hill, 1956.
His enduring research contributions for the fields Anderson, Odin W., Terry E. Herold, Bruce W. Butler, et
of medical sociology and health services research al. HMO Development: Patterns and Prospects. A
include a conceptual systems approach for under- Comparative Analysis of HMOs. Chicago: Pluribus
standing the health services enterprise; empirical Press, 1985.
data systems for actuaries, economists, and policy- Lerner, Monroe, and Odin W. Anderson. Health Progress
makers about the financial problems of healthcare in the United States: 1900–1960. Chicago: University
consumers; fundamental approaches to cross- of Chicago Press, 1963.
national comparisons and the understanding of
generic health services systems problems; and under-
standing the social, political, and economic environ- Web Sites
ments in which American health services developed.
He was a trusted advisor to more than 500 consul- American Hospital Association (AHA), Center for
tants and administrators in hospitals and medical- Hospital and Health Administration History, Papers
of Odin W. Anderson: http://www.aha.org/aha/
care plans across the nation and in numerous foreign
resource-center
countries. And he mentored many graduate students
University of Chicago, Center for Health Administration
who subsequently worked in more than 30 universi-
Studies (CHAS): http://www.chas.chicago.edu
ties in the nation and abroad and numerous others
who work in government and nongovernment agen-
cies. Anderson’s influence on these students has
been enormous, and his conceptual thinking and
approach to medical sociology and health services Antitrust Law
research continue through their efforts.
Antitrust law seeks to maintain an environment of
Ronald M. Andersen free and fair competition in markets for goods and
82 Antitrust Law
services. Its implementation is based on the assump- require the elimination of all competition. It is suf-
tion that abusive business practices that corrupt ficient that a single firm achieves sufficient market
the free market can create inefficiencies and exces- power to be able to raise prices unilaterally with-
sive costs for consumers. To this end, antitrust law out suffering competitive harm.
addresses two kinds of potential abuses, one The interplay of these two provisions of the
involving collusion among separate firms that Sherman Act can be especially problematic for
compete with one another and the other involving healthcare providers. Collaboration with competi-
willful efforts by a single firm to monopolize a tors, as may take place between physician practices
market. or between hospitals in negotiations with HMOs,
Antitrust law affects many kinds of healthcare can violate Section 1. However, merging with or
business arrangements, including the relationships acquiring a competitor to form a single larger entity
between providers and insurance companies, the to gain bargaining leverage can create liability under
functioning of professional societies, the composi- Section 2 if it creates too great a market share. The
tion of hospital medical staffs, and the growth of result of this legal dynamic can significantly limit
health systems. Its influence shapes key aspects of the strategic options available to providers.
the healthcare industry that are based on these Violations of the Sherman Act can trigger three
arrangements, such as the size of provider net- levels of enforcement. The most serious abuses
works, the structure of business collaborations, the may subject the violator to criminal penalties. Less
nature of price negotiations between providers and severe infractions may result in government-
health maintenance organizations (HMOs), and imposed fines. Private parties may also sue anti-
the disciplinary process for clinicians who violate trust violators for damages based on any economic
hospital quality standards. Health services research- harm that they have sustained. This is a particu-
ers study antitrust law to understand better the larly potent enforcement threat because a violation
economic dynamics of healthcare. The results of may affect many businesses and consumers who
these investigations and analyses provide fuel for can become plaintiffs, and if they succeed in court,
ongoing debates about the appropriate roles of they are entitled to recover treble damages, which
government and of private markets in allocating is an amount representing three times their actual
healthcare goods and services. financial loss.
The second statute is the Clayton Act, Section 7
of which (codified as 15 U.S.C. §18) prohibits
Legal Framework
mergers and acquisitions that may substantially
Three federal statutes are central to antitrust law lessen competition or tend to create a monopoly.
in the United States. The most important of these This law does not punish violators but rather per-
is the Sherman Act, which was enacted in 1890. mits regulators to force them to unwind suspect
Section 1 of that law (codified as 15 U.S.C. §1) transactions. For example, a hospital that gains
prohibits any “contract, combination . . . or con- too large a market share by acquiring competitors
spiracy in restraint of trade.” Such arrangements may be ordered to divest some of them. Courts
have been interpreted by the courts to include will generally consider factors such as the market
various forms of collusion among competitors, share, market concentration, and market power of
including price fixing, group boycotts, market the acquiring company in deciding whether a
allocation agreements, exclusive dealing, and tying transaction has violated this law.
arrangements. Section 2 (codified as 15 U.S.C §2) The final statute is the Federal Trade Commission
prohibits monopolization, attempted monopoliza- (FTC) Act, Section 5 of which (codified as 15
tion, and conspiracies to monopolize. Growth in U.S.C. §45) prohibits unfair and deceptive trade
the size of a company due to business success alone practices. Courts have interpreted such practices to
is not sufficient to violate this provision. Rather, include antitrust violations. This statute does not
monopoly power must be achieved or maintained extend the range of activities subject to antitrust
through willful anticompetitive conduct, such as the enforcement, but rather grants enforcement author-
use of threats, intimidation, coercion, or boycotts. ity concerning violations of other laws, including
However, monopolization of a market does not the Sherman and Clayton acts, to the FTC.
Antitrust Law 83
Antitrust Principles and Healthcare Markets Antitrust law has also presented a challenge for
hospitals and professional societies that discipline
Observers have noted a mismatch between the con- physicians for infractions of quality standards. For
ceptual foundations of antitrust law and the func- example, hospital credentials committees, which
tioning of healthcare markets. In healthcare, three decide who will be permitted to practice within the
underlying assumptions about traditional market institution, are composed of experienced physi-
structure are missing. These are the assumptions cians who often maintain practices of their own.
that buyers can make informed decisions, that they Therefore, they may be economic competitors of
respond to changes in price, and that they are aware those whose competence they must judge. In a
of the full costs of their purchases. Patients, as con- number of instances, physicians who have lost
sumers, lack the information and expertise to evalu- hospital privileges have sued the institution
ate purchasing decisions. They must rely for advice involved, alleging that its actual motives were to
on their physicians, who are the sellers of services, stifle competition rather than to maintain quality.
a situation that economists call asymmetry of infor Courts have generally ruled against the physicians
mation. Price fluctuations are unlikely to affect in these cases, and the U.S. Congress has further
patients’ purchasing decisions because the goods protected hospitals that engage in good faith peer
and services involved are essential to maintaining review of hospital staff members from antitrust
life and health, a situation that economists call price liability through a law known as the Health Care
inelasticity of demand. Finally, and perhaps most Quality Improvement Act of 1986. Nevertheless,
significantly, neither patients nor their physicians the threat of litigation persists as healthcare, unlike
are exposed to the full financial consequences of most other industries, must continue to rely on the
purchasing decisions because of the role of insur- expertise of market competitors to enforce quality
ance in covering the costs, a situation known as standards.
moral hazard. As a result of this mismatch, the role
of antitrust law in attempting to protect consumers
Regulatory Agencies
by maintaining a traditional economic market in
healthcare has been controversial. Two federal agencies have primary responsibility
The function of third-party insurance coverage for enforcing the antitrust laws. These are the U.S.
for healthcare costs has posed particular challenges Department of Justice (DOJ), through its antitrust
for antitrust enforcement. The Sherman Act was division, and the FTC. Either agency can bring a
passed to help buyers who were exploited by col- legal action against a violator for civil penalties,
lusive or monopolistic practices of sellers, and including fines or an injunction, although the FTC
courts have tended over the years to interpret it to is limited in its authority to act against nonprofit
favor buyers over sellers. It was enacted in an era organizations, such as nonprofit hospitals. Only
when many major American industries were con- the DOJ can act when criminal penalties are
trolled by single companies or by trusts composed sought. In addition to federal enforcement, states
of a few of them. In healthcare, however, the buyer attorneys general can proceed against violators
of services is usually an insurance company that under antitrust laws that have been enacted in
pays the bills, even though the actual consumer is most states.
an individual patient, and the seller is often a phy- Enforcement agencies have considerable dis-
sician practicing alone or in a small group. As a cretion in selecting the targets of their activities.
result, the act has at times had the effect in health- This latitude can play an especially important
care of protecting large corporate entities against role in the implementation of antitrust law in
the actions of individuals. For example, some healthcare because of the conceptual ambigui-
courts have characterized group negotiation by ties in applying legal principles that assume a
physicians with HMOs as a form of price fixing. traditional market structure to healthcare mar-
Some physicians have argued that the U.S. Congress kets. To reduce uncertainty and to guide private
should grant an exception to the antitrust laws for decision making, the DOJ and the FTC have
such joint bargaining similar to the one that applies jointly issued regulations that offer prospective
to labor unions. guidance on healthcare business practices that
84 Antitrust Law
they will consider to be legitimate under the Further Readings

Sherman Act and therefore exempt from prose- American Bar Association. Antitrust Health Care
cution. These are called Safety Zones, and they Handbook. 3d ed. Chicago: American Bar
devote particular attention to the integration of Association, 2005.
physician practices. Under these rules, factors Field, Robert I. Health Care Regulation in America:
such as market share, exclusivity rules for net- Complexity, Confrontation and Compromise. New
work members, and the extent of financial risk York: Oxford University Press, 2007.
sharing among members determine when physi- Greany, Thomas L. “Whither Antitrust? The Uncertain
cians may form networks without fear of anti- Future of Competition Law in Health Care,” Health
trust enforcement. Affairs, 21(2): 185–96, March–April 2002.
Haas-Wilson, Deborah. Managed Care and Monopoly
Power: The Antitrust Challenge. Cambridge, MA:
Future Implications
Harvard University Press, 2003.
Antitrust law seeks to improve the healthcare Hammer, Peter J., and William M. Sage. “Antitrust,
system by controlling certain kinds of abusive Health Care Quality, and the Courts,” Columbia Law
business practices that can inflate costs. These Review, 102(3): 545–649, April 2002.
practices include collusion between competing Kastor, John A. Mergers of Teaching Hospitals in
firms and growth in the market share of single Boston, New York, and Northern California. Ann
firms that is sufficient to create monopoly power. Arbor: University of Michigan Press, 2001.
However, the structure of healthcare creates Nichols, Len M., Paul B. Ginsburg, Robert A. Berenson,
challenges for antitrust enforcement because the et al. “Are Market Forces Strong Enough to Deliver
purchase and sale of healthcare goods and ser- Efficient Health Care Systems? Confidence Is
vices do not fit the characteristics of traditional Waning,” Health Affairs, 23(2): 8–21, March–April
markets. This is the result of several factors, most 2004.
Porter, Michael E., and Elizabeth O. Teisburg.
notably the role of insurance in buffering patients
“Redefining Competition in Health Care,” Harvard
from the full costs of the goods and services they
Business Review 82(6): 64–76, June 2004.
consume.
Robinson, James Claude. The Corporate Practice of
Long-standing judicial interpretations of the
Medicine: Competition and Innovation in Health
antitrust laws that generally favor buyers over sell-
Care. Berkeley: University of California Press,
ers have also created anomalies in enforcement 1999.
policy. In traditional markets, buyers tend to be Sage, William M., David A. Hyman, and Warren
individual consumers, and sellers to be large cor- Greenberg. “Why Competition Law Matters To
porate entities; however, in healthcare, the buyer is Health Care Quality,” Health Affairs 22(2): 31–44,
often not the actual patient but rather an insurance March–April 2003.
company, while the seller may be an individual Zelman, Walter A. The Changing Health Care
physician. The key antitrust regulatory agencies, Marketplace. San Francisco: Jossey-Bass, 1996.
the DOJ and the FTC, have tried to address this
incongruity with regulations that set forth special
enforcement policies regarding antitrust in health- Web Sites
care. Nevertheless, antitrust policy continues to
American Bar Association (ABA), Section of Antitrust
raise larger questions concerning the effectiveness
Law, Health Care and Pharmaceuticals Committee:
of applying market concepts to an industry whose
http://www.abanet.org/dch/committee.
functioning does not fit many traditional economic cfm?com=AT301000
assumptions. American Health Lawyers Association (AHLA):
Robert I. Field http://www.healthlawyers.org
Federal Trade Commission (FTC): http://www.ftc.gov/bc/
See also Competition in Healthcare; Healthcare Markets; healthindex.shtm
Health Economics; Hospitals; Managed Care; Public National Bureau of Economic Research (NBER):
Policy; Regulation; U.S. Government Accountability http://www.nber.org
Office (GAO) U.S. Code: http://www.gpoaccess.gov/uscode/browse.html
Arrow, Kenneth J. 85
U.S. Department of Justice (DOJ), Antitrust Division: Chicago. In 1949, he began teaching economics
http://www.usdoj.gov/atr and statistics at Stanford University, where he
U.S. Government Accountability Office (GAO): eventually achieved the rank of professor. In 1968,
http://www.gao.gov Arrow left Stanford to become a professor of eco-
nomics at Harvard University. He remained at
Harvard until 1979. That year, he returned to
Stanford University and remained there until 1991,
Arrow, Kenneth J. when he retired and became professor emeritus.
Arrow is the recipient of numerous awards and
Kenneth J. Arrow was one of the most prominent honors. He received the John Bates Clark Medal
economic theorists of the 20th century. Arrow’s of the American Economic Association. He is
classic 1963 article “Uncertainty and the Welfare an elected member of the National Academy of
Economics of Medical Care” launched the field of Sciences and the American Philosophical Society.
health economics. His landmark article addressed Arrow was also a fellow of the American Academy
the role of market competition in delivering of Arts and Sciences, the Economic Society, the
healthcare services, the implications of moral haz- Institute of Mathematical Statistics, and the
ard (the notion that health insurance increases American Statistical Association. He was the presi-
demand for healthcare services), the uncertainty dent of the Econometric Society, the Institute of
inherent in healthcare, the role of nonmarket Management Sciences, and the American Economic
social institutions, the existence of extreme infor- Association. He holds honorary degrees from the
mation asymmetry (the inequalities of informa- University of Chicago, the City University of New
tion between insurer, physician, and patient), and York, and the University of Vienna.
the importance of trust in the physician–patient Arrow’s broad research interests include the
relationship, given the existence of information economics of information and organization, collec-
asymmetry. tive decision making, general equilibrium theory,
Arrow is currently the Joan Kenney Professor of and environment and growth. His major contribu-
Economics and Professor of Operations Research, tion in the field of economics was his work in
Emeritus, at Stanford University, and senior fellow social choice theory, particularly his impossibility
at the Center for Health Policy at the Freeman theorem. Arrow also pioneered research in endog-
Spogli Institute for International Studies, the Center enous growth and information economics, which
for Outcomes Research, and the Institute for explained the source of technical change and why
Economic Policy Research, all at Stanford. In firms innovate. And his research on information
1972, Arrow won the Nobel Prize in Economics economics investigated the problems caused by
for his work on general equilibrium theory and asymmetric information in various markets.
welfare theory. In 2004, he also was awarded the
National Medal of Science, the nation’s highest Ross M. Mullner
scientific honor, for his contributions to under-
standing decision making under imperfect infor- See also Adverse Selection; Cost of Healthcare; Health
Economics; Health Insurance; Market Failure; Moral
mation and bearing risk.
Hazard; Public Policy
Arrow was born in 1921 in New York City. He
earned a bachelor’s degree in social science from
the City College of New York (1940) and a mas-
ter’s degree in mathematics (1941) and a doctorate Further Readings
degree in economics (1951) from Columbia Arrow, Kenneth J. “Uncertainty and the Welfare
University. During World War II, he served as a Economics of Medical Care,” American Economic
weather officer in the U.S. Army Air Corps, rising Review 53(5): 941–73, December 1963.
to the rank of captain. From 1946 through 1949, Hammer, Peter J., Deborah Haas-Wilson, Mark A.
he was a graduate student at Columbia University Peterson, et al., eds. Uncertain Times: Kenneth Arrow
and a research associate at the Cowles Commission and the Changing Economics of Health Care.
for Research in Economics at the University of Durham, NC: Duke University Press, 2003.
86 Association for the Accreditation of Human Research Protection Programs (AAHRPP)
Peterson, Mark A., ed. Kenneth Arrow and the Changing Experimental Biology (FASEB), National
Economics of Healthcare. Special issue, Journal of Association of State Universities and Land-Grant
Health Politics, Policy and Law 26(5): 823–1214, Colleges (NASULGC), National Health Council
October 2001. (NHC), and the Public Responsibility in Medicine
Savedoff, William D. “40th Anniversary: Kenneth Arrow and Research (PRIM&R).
and the Birth of Health Economics,” Bulletin of the In 2005, AAHRPP was awarded a federal
World Health Organization 82(2): 139–40, February 5-year contract by the U.S. Department of Veteran
2004. Affairs (VA) for the accreditation of all the VA’s
Human Research Protection Programs. During the
Web Sites course of the contract, AAHRPP will administer its
Duke University Libraries, Guide to the Kenneth J. accreditation program to all 120 VA facilities. In
Arrow Papers, 1939–2000: http://library.duke.edu/ 2006, AAHRPP accredited its first international
digitalcollections/rbmscl/arrow/inv medical center, the Samsung Medical Center, in
Nobel Prize Autobiography: http://nobelprize.org/nobel_ Seoul, Republic of Korea. In 2007, AAHRPP
prizes/economics/laureates/1972/arrow-autobio.html accredited a total of 47 organizations, which
Stanford University Economics Department Faculty Profile: included both major universities and VA facilities.
http://www-econ.stanford.edu/faculty/arrow.html
Mission
Responding to increased public concern for pro-
Association for the tecting human research participants, AAHRPP
Accreditation of Human seeks not only to ensure compliance with existing
regulations but also to raise the bar in human
Research Protection research protection by helping organizations reach
Programs (AAHRPP) performance standards that surpass the threshold
of federal requirements. Accreditation by AAHRPP
The Association for the Accreditation of Human signifies that an organization is committed to the
Research Protection Programs (AAHRPP) is a most comprehensive protections for research par-
nonprofit association, based in Washington, D.C., ticipants and the highest quality research. AAHRPP
that works with organizations that conduct human works to protect the rights and welfare of research
research to raise the level of protection for research participants and promote scientifically meritori-
participants. The association accredits organiza- ous and ethically sound research by fostering and
tions that can demonstrate that they provide par- advancing the professional and ethical conduct of
ticipant safeguards that surpass the threshold of persons and organizations that engage in research
federal requirements. Its accreditation program with human participants.
uses a voluntary, peer-driven, educational model
that includes site visits and a set of performance
Eligibility for Accreditation
standards and outcome measures.
AAHRPP accredits any eligible organization that
seeks accreditation. Most organizations that con-
History duct human research are also involved in other
The AAHRPP was founded in 2001 by seven non- activities that are not directly related to their
profit organizations with an interest in human research activities: Universities are involved in
research protection. The founding members were teaching and service, hospitals are involved in
the Association of American Medical Colleges patient care and community outreach, and com-
(AAMC), Association of American Universities panies are involved in marketing and distribution
(AAU), Consortium of Social Science Associations activities. AAHRPP only accredits an organiza-
(COSSA), Federation of American Societies for tion’s human research protection program.
Association for the Accreditation of Human Research Protection Programs (AAHRPP) 87
Accreditation Process mission; (4) the standards for protecting partici-

pants in human research will be clear, specific, and
AAHRPP’s accreditation process uses a set of
applicable to research across the full range of set-
objective standards to evaluate the quality and
tings (e.g., university-based biomedical, behavioral,
level of protection that an organization provides
and social science research, independent review
research participants. The accreditation process
boards, hospitals, government agencies, and oth-
consists of four steps: (1) application prepara-
ers); (5) the standards will identify outcome mea-
tion—the organization conducts a self-assessment
sures that organizations can use to assess and
to evaluate its program and makes improvements;
demonstrate quality improvement over time;
(2) on-site evaluation—a team of experts review
(6) the standards will be performance-based, using
materials and performs an on-site evaluation visit;
objective criteria and measurable outcomes to
(3) council review—the AAHRPP’s council on
evaluate whether a human research protection
accreditation reviews the report, deliberates on
program effectively implements the standards;
the team’s findings, and determines accreditation
(7) the accreditation process will provide a clear,
status; and (4) notification of accreditation
understandable pathway to accreditation, along
status—the organization receives a report detail-
with equally clear pathways for appeal and the
ing its accreditation status.
remediation of identified shortcomings; (8) the
accreditation process will be educational, involving
Standards and Principles collegial discussion and constructive feedback; and
The goal of AAHRPP’s accreditation is to improve (9) the accreditation process will be responsive to
the systems that protect the rights and welfare of changes in federal regulations and to standards that
individuals who participate in research. In addition, will evolve based on what AAHRPP learns from
accreditation can help communicate to the public the accrediting organizations from research settings.
strength of an organization’s commitment to the pro-
tection of human research participants. It will also
Domains and Standards
improve the overall quality of research by consistently
applying high standards and practices, raising the AAHRPP’s approach to voluntary accreditation
global benchmark for human research protection. incorporates five domains of a highly developed
To help promote all these goals, AAHRPP has human research protection program. The domains
adopted nine principles for accreditation of human refer to different areas of responsibility that must be
research protection program. These nine principles addressed. Meeting the requirements for all five
serve as the foundations for the content of the domains is the responsibility of the organization
AAHRPP accreditation standards. The standards seeking accreditation. Altogether, there are 20
themselves are designed to help organizations con- AAHRPP standards within the five domains. Each
sistently meet ethical principles and standards for standard is followed by one or more elements. The
protecting research participants, yet be flexible five domains are the following: (1) the organiza-
enough to account for the diverse institutional and tion—the entity that assumes responsibility for the
cultural contexts in which research is conducted human research protection program and applies for
and reviewed. The nine principles are as follows: accreditation (i.e., an academic institution, clinic,
(1) protecting the rights and welfare of research hospital, managed-care organization, contract
participants must be an organization’s first priority; research organization, or corporate entity, such as a
(2) protecting research participants is the responsi- pharmaceutical or biotechnology company, or inde-
bility of everyone within an organization and is not pendent review board); (2) research review unit—
limited to the institutional review board (IRB); the arrangements that the organization has made
(3) striving to exceed the federal requirements and for an independent review of ethical and scientific
continually seeking new safeguards for protecting aspects of each research protocol involving human
research participants while advancing scientific participants (such activities are generally carried
progress must be integrated into an organization’s out by an IRB); (3) investigator—the
88 Association of American Medical Colleges (AAMC)
various arrangements that the organization has Clinical Trials: http://clinicaltrials.gov

made for ensuring that individuals who plan to IRB Forum: http://www.irbforum.org
conduct research, whether as a principal investiga-
tor, coinvestigator, or other member of a research
team, understand and fulfill their responsibilities;
(4) sponsored research—the organization’s arrange- Association of American
ment for structuring its relationships with those
who fund or initiate research external to the organi Medical Colleges (AAMC)
zation, such as federal agencies, foundations, indi-
vidual donors, and corporations (e.g., pharmaceutical The Association of American Medical Colleges
or biotechnology companies); and (5) participant (AAMC) is a nonprofit organization that seeks to
outreach—the arrangements the organization has improve the nation’s health by enhancing the
made for understanding the social, psychological, effectiveness of academic medicine in three mis-
and physical needs and concerns of research par- sion areas: (1) medical education, (2) medical
ticipants and their communities. research, and (3) patient care. In the pursuit of its
mission, the AAMC serves the organizations that
Daniel J. O’Brien constitute the medical education system—medical
schools, teaching hospitals, and academic and
See also Academic Medical Centers; Association of
professional societies—and the individuals in this
American Medical Colleges (AAMC); Ethics;
system—medical school faculty, medical students,
Hospitals; Informed Consent; Randomized Controlled
Trials (RCTs); U.S. Department of Veterans Affairs and medical residents.
(VA); U.S. Food and Drug Administration (FDA)
History
Further Readings
The AAMC was initially formed in 1876 as the
Committee on Assessing the System for Protecting Human Provisional Association of Medical Colleges, and
Research Subjects, Board on Health Sciences Policy, its broad mission was to “consider all matters
Institute of Medicine. Preserving Public Trust: relating to reform in medical college work.” That
Accreditation and Human Research Protection Programs. it was formed in the late 1800s is a reflection of
Washington, DC: National Academies Press, 2001. the tremendous changes occurring at this time in
Federman, Daniel D., Kathi E. Hanna, and Laura Lyman higher education in general and medical education
Rodriguez, eds. Responsible Research: A Systems in particular. The nation’s leading medical schools
Approach to Protecting Research Participants. were advocating and implementing higher stan-
Washington, DC: National Academies Press, 2002. dards in medical education such as a longer aca-
“IRBs and Behavioral and Social Science Research: demic year, more years of training, more stringent
Finding the Middle Ground,” AAHRPP Advance
entry and graduation requirements, and more
5(1): 1, 6, Winter 2008.
intensive training in the biological sciences.
“The Need for Accreditation in an Increasingly Complex
As the nation’s medical education system has
Research Enterprise,” AAHRPP Advance 2(3): 1, 3,
evolved, so too has the AAMC. At its inception in
Fall 2005.
1876, the Provisional Association of Medical
“Research Enterprise Feeling Positive Impact of AAHRPP
Accredited Organizations: Academic and Medical
Colleges represented only 22 of the nation’s medi-
Institutions, IRBs, CROs Commit to Higher cal schools. Today, the AAMC represents not only
Standards,” AAHRPP Advance 4(1): 1, 3, Spring 2007. 125 U.S. and 17 Canadian medical schools but
also 400 teaching hospitals (including 98 related
health systems and 68 U.S. Department of Veterans
Web Sites Affairs’ [VA] medical centers), 94 professional
Association for the Accreditation of Human Research societies to which approximately 109,000 medical
Protection Programs (AAHRPP): faculty belong, and 171,000 medical students and
http://www.aahrpp.org residents.
Association of American Medical Colleges (AAMC) 89
Size and Structure representatives to the Executive Council, which is

the AAMC’s 30-member governing body.
The AAMC is located in Washington, D.C., and
employs nearly 400 individuals. Its mission and
service role are clearly reflected in its organization.
About half of the AAMC’s staff is concentrated Products and Activities
in five offices that support and service the organi- The AAMC administers and/or supports a wide
zation’s specific program areas, the public, and its range of programs and activities related to its mis-
members. The other half of the AAMC’s staff is sion areas of medical education, medical research,
concentrated in six divisions that reflect its mission and patient care. For example, the AAMC offers
or program areas. These divisions focus on diver- professional development programs, advocates
sity policy and programs, healthcare affairs, bio- for legislation critical to its mission, sponsors a
medical and health science research, medical loan program for medical students and residents,
education, medical school affairs, and medical and publishes more than 100 books, statistical
school services and studies. The medical education reports, documents, and periodicals. A common
division leads the AAMC’s efforts to improve the thread that runs through all the efforts of AAMCs
quality, content, and conduct of medical education is an emphasis on research, data collection, analy-
programs. The medical school affairs division sis, and reporting.
offers faculty and administrators professional Since a major focus of the AAMC is facilitating
development programs and services and supports and monitoring the medical education process,
medical schools in the areas of admissions, aca- many of its products involve some aspect of the pro-
demic progress and promotion, and financial aid. cess. The AAMC helps staff the Liaison Committee
The medical school services and studies division on Medical Education (LCME), which accredits
manages the AAMC’s medical school admission medical schools leading to the MD degree, and pub-
and application services and supports the residency lishes descriptions and the admission requirements
match process. of each medical school in the book Medical School
The AAMC also maintains three specialized Admission Requirements. The AAMC administers
units. Two units have recently been established to the test required for admission to medical school
highlight high-priority mission areas and stimulate called the Medical College Admission Test, or
development and support of innovations in these MCAT®. First-year applications to medical school
areas. One unit focuses on innovations with are funneled through a centralized application ser-
respect to improving clinical care, while the other vice called the American Medical College Application
focuses on innovations for improving medical edu- Service or AMCAS® that the AAMC helps adminis-
cation. The third unit is the Center for Workforce ter. As medical students graduate, the AAMC admin-
Studies, which develops data resources and col- isters the Medical School Graduation Questionnaire,
laborates on the research necessary to understand which asks students about their medical school
and inform decision making related to physician experiences; the data are compiled and made avail-
workforce issues. able to medical schools, researchers, and others. The
Member groups or councils represent the vari- AAMC provides services to the National Residency
ous groups served by the AAMC within its organi- Matching Program (NRMP), the organization that
zational structure. Each group meets regularly and matches medical school graduates to residency pro-
works with the AAMC to identify issues, develop grams. The AAMC manages the Electronic Residency
policies, and plan programs within its own area of Application Service, or ERAS®, that transmits docu-
expertise and interest. Three of these member ments such as applications and letters of recommen-
groups are governing councils: (1) the Council of dation to residency and fellowship programs. In
Deans, (2) the Council of Teaching Hospitals and cooperation with the American Medical Association
Health Systems, and (3) the Council of Academic (AMA), the AAMC conducts the National Graduate
Societies. These three councils, along with the Medical Education Census, which obtains informa-
Organization of Student Representatives and the tion on residency program characteristics and ros-
Organization of Resident Representatives, elect ters of residents.
90 Association of University Programs in Health Administration (AUPHA)
Future Implications Association of American Medical Colleges. Learn, Serve,

Lead: The Mission, Vision, and Strategic Priorities of
At its inception more than 130 years ago as the the AAMC. Washington, DC: Association of
Provisional Association of Medical Colleges, the American Medical Colleges, 2007.
AAMC focused simply on medical education. Association of American Medical Colleges. Medical
Today, the AAMC has broadened its focus to School Admission Requirements (MSAR), 2008–
address complex political, social, and economic 2009. Washington, DC: Association of American
issues that affect the ability of physicians to provide Medical Colleges, 2007.
quality medical care. Specifically, the AAMC has Starr, Paul. The Social Transformation of American
identified seven issues that have already spurred the Medicine: The Rise of a Sovereign Profession and the
development of several initiatives and will guide its Making of a Vast Industry. New York: Basic Books,
future programming. The issues are (a) improving 1982.
racial and ethnic diversity within the nation’s
medical schools, and ultimately within the physi-
Web Sites
cian workforce; (b) addressing and solving the issue
of Americans without health insurance, a burden Association of American Medical Colleges (AAMC):
shouldered disproportionately by academic medi- http://www.aamc.org
cal centers; (c) maximizing medicine’s readiness to Liaison Committee on Medical Education (LCME):
respond to large-scale disasters that threaten the http://www.lcme.org
health of the public through developing and incor- National Resident Matching Program (NRMP):
porating new curricula within the nation’s medical http://www.nrmp.org
schools; (d) ensuring patient-centered, quality
healthcare; (e) securing sufficient numbers and the
right types of physicians to meet the nation’s future Association of University
healthcare needs; (f) mitigating the impact of medi-
cal student debt on practice choices; and (g) assist-
Programs in Health
ing those medical schools, medical centers, and Administration (AUPHA)
students affected by Hurricane Katrina.
The Association of University Programs in Health
Penny L. Havlicek Administration (AUPHA) is a global network of
See also Academic Medical Centers; American Medical
colleges, universities, faculty, individuals, and
Association (AMA); Flexner, Abraham; Health organizations dedicated to improving health out-
Workforce; Hospitals; Physicians; Physician comes by promoting excellence in healthcare man-
Workforce Issues; Public Policy agement education. AUPHA fosters excellence
and innovation in healthcare management educa-
tion, research, and practice by providing opportu-
Further Readings nities for member programs to learn from each
other, by influencing practice, and by promoting
Association of American Medical Colleges. The
Handbook of Academic Medicine: How Medical
the value of healthcare management education. It
Schools and Teaching Hospitals Work. Washington, is the only nonprofit entity of its kind that works
DC: Association of American Medical Colleges, 2005. to improve the delivery of health services—and
Association of American Medical Colleges. AAMC Data thus the health of citizens—throughout the world
Book: Medical Schools and Teaching Hospitals by the by educating professional managers at the entry
Numbers. Washington, DC: Association of American level.
Medical Colleges, 2007. AUPHA’s membership includes baccalaureate
Association of American Medical Colleges. The and master’s degree programs in health administra-
Economic Impact of AAMC: Member Medical tion education in the United States and Canada. Its
Schools and Teaching Hospitals, 2005. Washington, faculty and individual members represent more
DC: Association of American Medical Colleges, 2007. than 500 colleges and universities. In addition, a
Association of University Programs in Health Administration (AUPHA) 91
large number of healthcare institutions, hospitals, Over the years, healthcare administration edu-
and other health services delivery organizations and cation has changed, and AUPHA has changed
associations worldwide participate in, and benefit along with it. From an original membership of
from, the network and services of the association. seven graduate programs in the United States and
Canada, it has grown to more than 160 graduate
History and undergraduate programs in North America
and hundreds of personal, corporate, and affiliated
AUPHA grew out of the efforts of the W. K.
program members all over the world. AUPHA is
Kellogg Foundation to professionalize the manage-
now an international consortium of graduate and
ment of hospitals following World War II. As the
undergraduate health administration programs
war wound down, the foundation identified the
and practitioners engaged in the development of
improvement of the hospitals in the United States
health management education.
and Canada as a priority for programming because
Yet many of the founding principles of the
the hospital sector had been neglected during the
AUPHA remain the same. The association continues
war years. The decision was influenced by the pres-
to provide forums for discussion where leaders from
ence on the staff of Andrew Pattullo, who had
the field can gather to share information on educa-
come to the Kellogg Foundation from the University
tional methods and research. And it continues to
of Chicago program in hospital administration,
serve as an effective advocate for the health admin-
and by the fact that Mr. Kellogg had been the
istration education community before various legis-
administrator of the Battle Creek Sanitarium, an
lative and executive bodies. Most important,
Adventist institution headed by his brother.
AUPHA continues to focus on providing its mem-
The founding programs in AUPHA were the
bers with the tools, research, venues, support, and
University of Chicago, Northwestern University,
forums that enable each program, as well as health-
Columbia University, University of Minnesota,
care administration education as a whole, to evolve
University of Toronto, Washington University, and
and thrive in a constantly changing industry.
Yale University. In 1950, AUPHA was incorpo-
rated in Illinois as a not-for-profit organization.
The Kellogg Foundation was the moving force Vision
behind the development of the field from an advi- AUPHA’s vision is to improve health outcomes
sory committee headed by Charles E. Prall in the by promoting excellence and innovation in health-
late 1940s through the founding of AUPHA. care management education.
Andrew Pattullo participated in all the early devel-
opments, including funding most of the programs.
And some small grants to the association sup- Mission
ported projects during the years 1949 to 1963. AUPHA fosters excellence and innovation in
From the outset, AUPHA set standards for healthcare management education, research, and
admission to the association. The first set of stan- practice by providing opportunities for member
dards included the requirement that programs programs to learn from each other, by influencing
granting master’s degrees require students to have practice, and by promoting the value of healthcare
at least one academic year of courses (of which a management education.
third must be directly concerned with hospital
administration) and a year of residency or equiva-
lent experience, have two professionally qualified Values
faculty members, and have a degree of autonomy AUPHA supports five values:
in operations. These standards were modified
many times over the years before the establishment 1. Excellence: The Association believes that excellence
of the quasi-independent Accrediting Commission in education (scholarship, teaching, and research)
on Graduate Education for Hospital Administration leads to excellence in healthcare practice and
in 1966. ultimately leads to improved healthcare outcomes.
92 Association of University Programs in Health Administration (AUPHA)
2. Innovation: The Association promotes Investigators, and the Filerman Prize for Innovation
innovation, encourages the adoption of new in Health Services Management Education.
strategies, and disseminates best practices in
healthcare management education.
Publications
3. Collaboration: The Association collaborates in AUPHA publishes every 2 years the Healthcare
the generation and translation of research and Management Education Directory of Programs.
the integration of theory and practice in This publication is a comprehensive listing of all
interprofessional work environments. AUPHA member healthcare management pro-
4. Diversity: The Association believes that grams. It features information on baccalaureate,
diversity—in people, in programs, and in master’s, doctoral, executive, and distance educa-
perspectives—is essential for an effective tion programs, including admissions procedures
interprofessional workforce. and costs including tuition, room and board, fees,
and books.
5. Learning: The Association pursues continual The AUPHA publishes quarterly the Journal of
learning to advance and share knowledge, to Health Administration Education. This peer-
foster the development of pedagogy, and to reviewed journal contains scholarly articles on
improve teaching and practice. various research topics, case studies, and essays by
leading healthcare management and administra-
tion educators and professions.
Programs and Services
The association also publishes the AUPHA
The Faculty Forums Exchange, an electronic quarterly newsletter on
The faculty forums foster communication and various issues in healthcare management educa-
support collaborative activities that are of special tion, with a brief monthly supplement containing
importance to their members, as well as to the field news from program members and a list of current
of practice. Only current members can participate employment opportunities.
in these unique and active groups.
Program Support
Web Site Resources AUPHA staff and faculty provide program con-
sultation regarding the membership process and
Program member faculty have access to a vari-
the undergraduate certification process. Specialized
ety of curricular materials geared toward the top-
consultation is also available on request. The
ics of the faculty. The materials include case
Commission on Accreditation of Healthcare
studies, class outlines, simulation programs, and
Management Education (CAHME) offers accredi-
class exercises and tests/assessments.
tation to qualified graduate academic programs.
Prizes, Awards, Scholarships, and Fellowships Surveys and Data Collection

AUPHA provides and administers several prizes, Members of AUPHA have access to various sur-
awards, scholarships, and fellowships each year vey reports and data gathered by the association,
for faculty and students from member programs, such as the Annual Survey of Health Administration
such as the William B. Graham Prize for Health Programs, the Faculty Salary Survey, current Trend
Services Research, the Triad Hospitals Corris Boyd Data for Health Administration Education, and
Scholars Program, the Bugbee-Falk Book Award, meeting presentations.
the David A. Winston Health Policy Fellow-
ship, the John D. Thompson Prize for Young Lydia M. Reed
Association of University Programs in Health Administration (AUPHA) 93
See also Academic Medical Centers; American College of Web Sites

Healthcare Executives (ACHE); Health Workforce;
Association of University Programs in Health
Hospitals; Kellogg Foundation
Administration (AUPHA): http://www.aupha.org
American College of Health Care Administrators
(ACHCA): http://www.achca.org
Further Readings
Haddock, Cynthia Carter, Robert A. McLean, and http://www.ache.org
Robert C. Chapman. Careers in Healthcare American College of Physician Executives (ACPE):
Management: How to Find Your Path and Follow It. http://www.acpe.org
Chicago: Health Administration Press, 2002. American Organization of Nurse Executives (AONE):
Kovner, Anthony R. Health Care Management in Mind: http://www.aone.org
Eight Careers. New York: Springer, 2000. Canadian College of Health Services Executives
Kovner, Anthony R., and Alan H. Channing. A Career (CCHSE): http://www.cchse.org
Guide for the Health Services Manager. 3d ed. Medical Group Management Association (MGMA):
Chicago: Health Administration Press, 2000. http://www.mgma.com
Snook, I. Donald. Opportunities in Hospital National Association of Health Services Executives
Administration Careers. New York: (NAHSE): http://www.nahse.org
McGraw-Hill, 2006. U.S. Department of Labor (BLS): http://www.bls.gov
B
the adoption of universal standards that the orga-
Benchmarking nization and industry strive toward. A central part
of benchmarking are the performance measures
Benchmarking in healthcare is an active process that establish the benchmark and the benchmark
of continuously evaluating critical processes partners, which can be allies or competitor orga-
and/or clinical outcomes and comparing those nizations against which comparisons are made.
results with similar organizations or populations. The core components of the benchmarking pro-
Benchmarking is a measure of best-practices cess include understanding one’s own organiza-
performance. Based on benchmarking results, tional performance, analyzing the performance
best practices can be identified and adopted, thus and outcomes of competitors or sister organiza-
achieving superior performance. Benchmarking is tions with superior performance, and implement-
useful in healthcare for both operational and ing the practices that improve performance and
clinical processes. This is particularly true in the outcomes. Benchmarking can instruct an organi-
clinical-practice environment, where providers zation about what can be achieved and how supe-
are increasingly being held accountable by regu- rior results can be attained.
lators and accreditation organizations for out- Benchmarking can be useful for healthcare
comes. Payers are also holding providers organizations to determine their core competencies
accountable for outcomes as part of pay-for- and how they compare against their competitors.
performance initiatives and value-based purchas- It can also be used to identify top performers rela-
ing decisions. tive to selected outcomes or care processes, deter-
mine where an organization is in relationship to
those outcomes, and position it to understand how
Background
to improve its own care processes through identi-
Benchmarking originated in industries outside of fication and implementation of best practices
healthcare to improve product quality, service, to achieve better outcomes. Through the use of
delivery, and practices. Benchmarking has its his- benchmarking, healthcare organizations can also
torical roots in kaizen, or the Japanese philosophy gain a better understanding of their business per-
of continuous improvement and competitive formance, including its strengths and weaknesses.
advantage. This technique can enable industries to This process allows an organization to develop
achieve superior performance and practices by strategies that facilitate better management and
investigating and comparing their practices and performance improvement on a continual basis.
outcomes with those of similar organizations. Benchmarking can be used as a management tool
Benchmarking provides the opportunity to iden- to overcome paradigm blindness, or thinking that
tify best practices for an industry and promotes the way processes are currently done is the best.
95
96 Benchmarking
Additionally, it can also lead to improved organi- concept, costs, and alternative designs by analyz-
zational effectiveness. ing the competitors’ product.
The concept of benchmarking has grown in
healthcare since costs have been escalating and
Benchmarking in Healthcare
payers have been demanding that healthcare
organizations deliver the highest quality of care Benchmarking in healthcare typically involves
for their money. In addition, the widespread use comparing an organization’s own data with a
of performance measures by accrediting bodies credible external source to facilitate decision mak-
such as the Joint Commission, the National ing and informing the quality improvement pro-
Committee for Quality Assurance (NCQA), and cess. Clinically, benchmarking is used to encourage
governmental agencies including the Centers for providers to achieve a higher level of performance
Medicare and Medicaid Services (CMS) to moni- by changing and, as appropriate, standardizing
tor healthcare organization performance has practice patterns and to reduce resource utiliza-
allowed benchmarking to become more prevalent tion by identifying cost-effective treatment strate-
by allowing individual organizations to compare gies. Additionally, managed-care organizations
their performance and outcomes with similar (MCOs) may use community health benchmarks
organizations. This permits an organization to to improve the overall care of a population. For
develop innovative strategies and techniques that example, MCOs may benchmark their perfor-
will enable it to improve its performance. mance of clinical population parameters, such
Benchmarking has become essential for health- as the performance indicators developed and
care organizations to survive in a competitive employed by the NCQA related to obesity, vacci-
marketplace where performance and outcomes nation status, and diabetes. Operationally, bench-
are measured. Thus, benchmarking allows organi- marking is used to look at cost and efficiency
zations to learn from their competitors or sister parameters, such as length of stay, referral rates
organizations how to address similar issues that per 1,000 patients, cost per member per month,
they are confronting. and costs of clinical ancillary departments.
Furthermore, benchmarking is used for contract-
ing purposes to help understand whether the
Types of Benchmarking
assumptions underlying proposed contract rates
There are several types of benchmarking that are valid (e.g., cost per member per month, utili-
organizations may use to meet their needs. Strategic zation data, cost data, severity scores). Regardless
benchmarking focuses on the strategies of compa- of the application, benchmarking has become an
nies and involves a comparative analysis of the important tool for improving performance and to
success and failures of these strategies. This can be inform decision making.
achieved through customer satisfaction surveys.
A limitation of strategic benchmarking is that it
The Benchmarking Process
may be difficult to obtain strategy information on
benchmarking partners. Central to a successful benchmarking initiative is
Functional benchmarking is a tool used by com- to clearly understand and articulate the goals of
panies to evaluate the success of core business func- the project. Once established, four relatively stan-
tions. Although in functional benchmarking there dard phases are followed to execute the bench-
does not need to be a focus on direct competition, marking project. The four phases are planning,
the benchmark partner should be in a similarly char- data collection and analysis, integration, and
acterized industry to allow for useful comparisons. action plan. The planning phase is the period that
Another type of benchmarking is best-practices organizations use to set goals, identify what will be
benchmarking. In this type of benchmarking, the benchmarked, select the benchmarking partners or
work processes of an organization and the man- data source to benchmark performance against,
agement processes behind them are examined. and determine data collection methods. There are
Last, product benchmarking, or competitive instances when an organization might choose
product analysis, examines competitors’ product to join a benchmarking initiative voluntarily or
Benchmarking 97
because of the need to meet accreditation stan- the patients in this study received appropriate
dards. An organization might belong to a group- therapy that would mitigate the risk of experienc-
purchasing organization, such as Premier, Inc. or ing a life-threatening event. Furthermore, even if
the University HealthSystem Consortium (UHS), patients received appropriate treatment for throm-
which have benchmarking databases and initia- boembolism, the drug dosing delivered was either
tives available to members. Alternatively, an orga- too low or too high, which increased the risk of
nization might be part of an integrated health experiencing a significant life-threatening event.
system that conducts benchmarking initiatives or The Steering Committee of the NABOR project,
participates in focused benchmarking initiatives, comprising leaders of national thought in the
such as the National Anticoagulation and United States, communicated the results back to
Benchmark Report (NABOR) initiative managed individual hospitals along with recommendations
by EPI-Q, Inc. and funded through a pharmaceuti- to be considered. The individual hospital project
cal sponsorship. The goal setting and identifica- groups evaluated the recommendations and cre-
tion of benchmark partners are the most important ated an action plan for their respective institutions.
components of this phase since the organization In response to the recommendations, several hos-
needs to establish what will be benchmarked and pitals in the NABOR project established anticoag-
choose an appropriate partner or data source to ulation clinics. And based on data from the
make a realistic comparison. NABOR benchmark database, those hospitals that
In the data collection and analysis stage, the did establish anticoagulation clinics were among
data are analyzed to identify competitive gaps the top performers.
or gaps between where practice should be and
where it currently is for the participating organi-
Challenges for Benchmarking
zation. Expected performance levels are based on
the top performers in the benchmark database. There are many challenges that remain for organi-
Future performance levels are then projected zations that use benchmarking. One of the chal-
based on these gaps, and areas for improvement lenges includes setting a benchmark that is both
are identified. In some instances, a benchmarking realistic and based on available and credible evi-
initiative can identify gaps in national treatment dence. The intended benchmark should be feasible
patterns. and practical, based on the organization’s current
During the integration phase, the results from performance in addition to the resources available
the analysis are communicated to the organization. for carrying out the action plan. Caution should
The findings are also used to integrate the actions also be used when evaluating data to ensure that
that will be taken as well as to compile objectives a benchmark is in fact representative of best prac-
and goals for the organization. tices. It is possible that a benchmark database
In the action plan phase, the organization exe- might have all the partners exhibiting average per-
cutes the action plan based on the recommenda- formance. If all organizations are striving toward
tions. As the action plan is implemented, the “average” performance, it will make the partici-
organization must continue to monitor its perfor- pating organization also attempt to achieve
mance, so that it is reaches its optimal potential, and only an average performance. Therefore, when an
recalibrate the benchmarking measures as needed. organization is evaluating whether to participate
An example of the benchmarking process is the with partners or a vendor in a benchmarking ini-
NABOR project, which identified a significant tiative, it is important that the data reports on
issue in the management of patients with throm- outcomes are at least in the upper quartile, if not
boembolic disease who were at increased risk of the top decile, of performance.
developing stroke and hemorrhage. The NABOR Organizations may also face a difficulty in arriv-
benchmark database included 4,000 patients from ing at a consensus benchmark as clinicians and
38 U.S. hospitals in which many practitioners administrators may have different views on what is
believed that their institution’s performance was at or is not an appropriate benchmark. Another chal-
least average. The results of the benchmarking lenge is to find a benchmarking partner that is appro-
initiative revealed, however, that less than half of priate and similar in nature for the organization to
98 Berwick, Donald M.
compare itself against. It may be difficult, however, Web Sites

to find information that is publicly available on a Agency for Healthcare Research and Quality (AHRQ):
competitor organization’s strategies. http://www.ahrq.gov
In conclusion, benchmarking has been used by Association for Benchmarking Health Care (ABHC):
organizations to outperform their competitors. http://www.abhc.org
This concept is starting to be routinely used by Centers for Medicare and Medicaid Services (CMS):
healthcare organizations to provide high-quality http://www.cms.hhs.gov
care under the increasing pressures of cost contain- National Committee for Quality Assurance (NCQA):
ment. In an increasingly competitive healthcare http://www.ncqa.org
marketplace, benchmarking is a technique that
will ensure the superior performance of healthcare
organizations.
Mark A. Jewell and Jared Lane K. Maeda Berwick, Donald M.
See also Agency for Healthcare Research and Quality Donald M. Berwick is a leading authority in the
(AHRQ); Centers for Medicare and Medicaid Services area of healthcare quality and quality improve-
(CMS); Health Report Cards; National Committee for ment. Berwick cofounded and is president and
Quality Assurance (NCQA); Outcomes Movement; chief executive officer of the Institute for Healthcare
Quality Management; Quality of Healthcare; Improvement (IHI), a not-for-profit organization
University HealthSystem Consortium (UHC)
based in Cambridge, Massachusetts, dedicated to
improving quality in healthcare that was formed
in 1991. Berwick is professor of health policy and
Further Readings
management at the Harvard School of Public
Camp, Robert C. Benchmarking: The Search for Health and clinical professor of pediatrics and
Industry Best Practices That Lead to Superior healthcare policy at the Harvard Medical School.
Performance. Milwaukee, WI: American Society for In addition, Berwick is an associate in pediatrics at
Quality Control Press, 1989. Children’s Hospital in Boston and a consultant in
Caprini, Joseph A., Victor F. Tapson, Thomas M. Hyers, pediatrics at the Massachusetts General Hospital.
et al. “Treatment of Venous Thromboembolism: Berwick has published numerous articles in
Adherence to Guidelines and Impact of Physician professional journals on the subjects of healthcare
Knowledge Attitudes and Beliefs,” Journal of policy, decision analysis, technology assessment,
Vascular Surgery 42(4): 726–32, October 2005. and healthcare quality management. He also has
Dattakumar, R., and R. Jagadeesh. “A Review of authored or coauthored several books, including
Literature on Benchmarking,” Benchmarking: An
Escape Fire: Designs for the Future of Health Care
International Journal 10(3): 176–209, 2003.
(2004), New Rules: Regulation, Markets and the
National Health Service Modernization Agency. The
Quality of American Health Care (1996), and
Essence of Care: Patient-Focused Benchmarking for
Curing Health Care: New Strategies for Quality
Clinical Governance. London: U.S. Department of
Health, National Health Service Modernization
Improvement (1990). And he is a member of sev-
Agency, 2003.
eral editorial boards, including the Journal of the
Tapson, Victor F., Thomas M. Hyers, Albert L. Waldo, American Medical Association.
et al. “Antithrombotic Therapy Practices in US Throughout his long and illustrious career, Berwick
Hospitals in an Era of Practice Guidelines,” Archives has served as the chair of various national commit-
of Internal Medicine 165(13): 1458–64, July 11, 2005. tees, including the Health Services Research Review
Waldo, Albert L., Richard C. Becker, Victor F. Tapson, Study Section of the Agency for Health Care Policy
et al. “Hospitalized Patients With Atrial Fibrillation and Research from 1995 to 1999 and the National
and a High Risk of Stroke Are Not Being Provided Advisory Council of the Agency for Healthcare
With Adequate Anticoagulation,” Journal of the Research and Quality (AHRQ) from 1999 through
American College of Cardiology 46(9): 1729–36, 2001. From 1990 to 1996, Berwick served as the vice
November 1, 2005. chair of the U.S. Preventive Services Task Force and
Bioterrorism 99
was the first “Independent Member” of the Board of Berwick, Donald M. Escape Fire: Designs for the Future
Trustees of the American Hospital Association (AHA) of Health Care. San Francisco: Jossey-Bass, 2004.
from 1996 through 1999. Berwick cofounded and Berwick, Donald M., A. Blanton Godfrey, and Jane
was a co–principal investigator for the National Roessner. Curing Health Care: New Strategies for
Demonstration Project on Quality Improvement in Quality Improvement. San Francisco: Jossey-Bass,
Health Care. Berwick is a past president of the 1990.
International Society for Medical Decision Making Brennan, Troyen A., and Donald M. Berwick. New
and is an elected member of the national Institute of Rules: Regulation, Markets and the Quality of
American Health Care. San Francisco: Jossey-Bass,
Medicine (IOM). He has served on the IOM’s gov-
1996.
erning council and has acted as a liaison to the IOM’s
Leape, Lucian L., and Donald M. Berwick. “Five Years
Global Health Board since 2002.
After “To Err Is Human”: What Have We Learned?”
In 1997, President Clinton appointed Berwick
to the Advisory Commission on Consumer 2384–90, May 18, 2005.
Protection and Quality in the Healthcare Industry.
This commission was cochaired by the Secretaries
of Health and Human Services and Labor and it Web Sites
was given the responsibility to gain a better under- Harvard School of Public Health Faculty Profile:
standing of the issues facing the changing health- http://www.hsph.harvard.edu/faculty/donald-berwick
care delivery system and build consensus on ways Institute for Healthcare Improvement (IHI):
to ensure and improve healthcare quality. http://www.ihi.org/ihi
Berwick is the recipient of numerous awards,
including the Earnest A. Codman Award, the first
Alfred I. DuPont award for excellence in children’s
healthcare from Nemours, the Award of Honor Bioterrorism
from the AHA for outstanding leadership for
improving healthcare quality, the Heinz Award for
Bioterrorism is the intentional release of biological
public policy, the Purpose Prize, and the William B.
agents used to cause casualties to a population.
Graham Prize for Health Services Research. In 2004,
Bioterrorism can also be directed to livestock,
Berwick was inducted as a fellow of the Royal
food, and the environment. The intrinsic features
College of Physicians in London. The following year,
necessary for a bioterror agent include infectivity,
he was appointed as honorary Knight Commander
virulence, toxicity, pathogenicity, incubation period,
of the Most Excellent Order of the British Empire.
transmissibility, stability, and lethality. As of
Berwick received his bachelor’s degree from
2008, nine nations in the world are believed to
Harvard College, a master of public policy degree
have the capability for biologic warfare agent pro-
from Harvard’s John F. Kennedy School of
duction: Iran, Israel, North Korea, China, Libya,
Government, and a doctor of medicine degree
Syria, Taiwan, Russia, and the United States.
from Harvard Medical School.
Jared Lane K. Maeda Classification of Diseases/Agents
See also Institute for Healthcare Improvement (IHI); The Centers for Disease Control and Prevention
Medical Errors; Outcomes Movement; Quality (CDC) classifies particular bioterrorism diseases/
Indicators; Quality Management; Quality of agents into one of three categories: A, B, and C.
Healthcare; Technology Assessment Category A diseases/agents are considered high
priority due to their ability to be transmitted easily
from person to person, which can result in high
Further Readings mortality rates. Public panic and social disruption
Berwick, Donald M. “Disseminating Innovations in may ensue, so special action for public health pre-
Health Care,” Journal of the American Medical paredness is necessary. This category includes
Association 289(15): 1969–75, April 16, 2003. anthrax (Bacillus anthracis), botulism (Clostridum
100 Bioterrorism
botulinum toxin), plague (Yersinia pestis), small- Medical Response System, and (4) Federal Emergency
pox (variola major), tularemia (Francisella tularen- Management Agency (FEMA).
sis), and the viral hemorrhagic fevers (filoviruses The HHS encompasses more than 300 pro-
and arena viruses). Except for botulism, these ill- grams, including the following: CDC; Food and
nesses usually present initially as a flu-like illness Drug Administration (FDA), Health Resources
with low-grade fever and fatigue. and Services Administration (HRSA), and the
Category B includes the second level of high- National Institutes of Health (NIH).
priority diseases/agents, with moderate dissemina- The DoD is the support agency for almost all
tion and morbidity rates and relatively low the emergency functions of the NRP, under the
mortality rates. These agents require specific CDC Military Support to Civil Authorities (MSCA) doc-
enhancements of diagnostic capability and disease trine. The MSCA is operationally directed through
surveillance. This category includes brucellosis the U.S. Northern Command in Colorado Springs,
(Brucella species); epsilon toxin (Clostridium per- Colorado.
fingens); and food and water safety threats such Last, the VA through its hospital and clinic net-
as Salmonella, Shigella, vitrio cholera, glanders work will also play a support role.
(Burkholderia mallei), meliodosis (Burkholderia The anthrax attacks in 2001 have demonstrated
pseudomallei), Q fever (Coxiella burnettii), ricin the need for a coordinated approach to identify
toxin from castor beans, staphyloccal enterotoxin and deliver antibiotics through the public health
B (as an incapacitating agent), typhus fever system. Subsequent to the attacks 33,000 individu-
(Rickettsia prowazekii), and viral encephalitis als were initially placed on antibiotics, with about
(alpha viruses). 10,000 individuals completing a 60-day course
Category C includes diseases/agents that are of antibiotics. The U.S. Army Medical Research
emerging pathogens that can be engineered for Institute for Infectious Diseases (USAMRIID) per-
mass dissemination in the future due to availabil- formed approximately 19,000 anthrax surveys
ity, ease of production, and potential for high mor- from clinical specimens. The cost to decontami-
bidity and mortality. Examples include the napah nate the Hart Senate Office Building was estimated
virus and hantavirus. to have exceeded $23 million. This was a second-
ary cost from attacks that involved only 22 cases.
Responsible Agencies
Response Approaches
The public health infrastructure is the central
component to monitor exposure to bioterrorism A comprehensive approach to biologic exposure
diseases/agents, identify the specific action required would include incident command if a point source
to prevent primary and secondary exposure, pro- is identified, decontamination, quarantine, per-
vide containment measures, and respond with sonal protection, diagnostic testing, vaccination,
necessary medical supplies. The basic premise of and antibiotic treatment.
the National Response Plan (NRP, Version 4.0)
developed by the U.S. Department of Homeland
Incident Command
Security is that such incidences are handled at the
lowest jurisdictional level possible. When a specific source is identified, the incident
Four federal agencies will likely be involved in command team is usually positioned uphill, upwind,
any response to bioterrorismin the country: or upriver from the site, and it should not be
(1) U.S. Department of Homeland Security (DHS), located near any building exhaust system. An isola-
(2) U.S. Department of Health and Human Services tion distance of at least 80 feet is recommended.
(HHS), (3) U.S. Department of Defense (DoD), First responders should handle the site of such an
and (4) U.S. Department of Veterans Affairs (VA). incident as a potential crime scene and should also
Founded in 2002, the DHS contains four impor be aware of explosive devices that could be used to
tant programs: (1) National Disaster Medical System, disseminate the substances. First responders should
(2) Strategic National Stockpile, (3) Metropolitan also avoid wet surfaces or puddles.
Bioterrorism 101
Decontamination include travel restrictions, public-gathering restric-

tions, and isolation of affected individuals. The
In general, a biological attack is less likely to
federal government has the authority to impose
occur than a radiological or chemical terrorist
these restrictions across state lines through the
attack. Because of the incubation period associated
CDC. The DoD and FEMA may also assist in this
with a biological attack, patients will likely seek
effort.
medical attention in waves from their primary-care
Using quarantine, especially with patient isola-
physicians, in clinics, or in hospital emergency
tion, must be considered for smallpox, plague, and
departments. Thus, decontamination procedures
viral hemorrhagic fever. With regard to quarantine
are less likely to be an issue.
for smallpox exposure, isolation of individual con-
Regarding specific decontamination issues, the
tacts, especially any person with a fever of more
focus is usually on contaminated environmental
than 38 °C (100.4 °F) for a 17-day period, should
surfaces. Following the aerosolization of biological
be considered. The decision to quarantine is based
agents, rapid-assay kits should be used to identify
on vaccination status, risk of exposure, and risk of
contaminated surfaces, although false-positive
disease.
results are common.
Quarantine should be considered for livestock
Plague is sensitive to heat and light and will not
with Q fever or glanders, but it would be unlikely
survive for a period of time outside the individual
to infecthumans. Quarantine is not necessary for
host. Botulinum toxin is destroyed by heating liquid
anthrax, botulism, tularemia, brucellosis, cholera,
or food to a temperature of 85 °C (185 °F.) for at
Cryptosporidium perfringens, Eshcherichia coli
least 5 minutes. Through aerosolization, botulinum
(0157:H7), meliodosis, psittacosis, ricin, samo-
toxin usually becomes detoxified in the atmosphere
nella, shigella, straphylococcus, enteroroxin B, and
within 2 days. Tularemia survives in cold, moist envi-
typhus.
ronments. Decontamination of environmental sur-
faces can be achieved by washing with a 10% bleach
solution, then using a 70% concentration of rubbing Personal Protection
alcohol after 10 minutes to wash away the bleach.
With regard to the hemorrhagic fever (yellow With the biological agents that do not exhibit
fever) virus, contamination linens should be placed human transmission (i.e., anthrax, botulism, tula-
in double bags and washed in hot water with remia, brucellosis), standard precautions are
bleach or autoclaved. Incineration is also an appropriate. In addition to standard precautions,
option. Equipment should be cleaned with a disin- healthcare workers should wear a surgical mask if
fectant or a 1:100 dilution of household bleach. within 4 feet of a patient with plague (treated for
It is not expected that the virus can persist for less than 2 days). Airborne and contact precau-
prolonged periods in the environment. tions should be used for smallpox and viral hemor-
Chlorination or boiling of contaminated water rhagic fever. Antibiotic contact prophylaxis should
is effective in eradicating cholera or tularemia. be considered for workers exposed to patients with
Smallpox does not survive for longer than 1 hour plague, glanders, and melioidosis.
in the environment. Standard bleach or quaternary Essentially, personal exposures should be inves-
ammonia compounds can be used to clean envi- tigated in case of unprotected contact within 4 feet
ronmental surfaces. of vital exposures, breaches in protection, or
febrile (more than 100.4 °F or 38 °C) illness in
individuals occurring within 3 weeks of exposure.
Smallpox and viral hemorrhagic fever patients
Quarantine
should be placed in private rooms with negative
The term quarantine refers to the compulsory air pressure (6–12 air exchanges per hour) and
physical separation of individuals. It may involve dedicated medical equipment. Personnel should
movement restriction and/or segregation of indi- wear N-95 respirators, double gloves, imperme-
viduals into specific geographical areas to halt the able gowns, goggles or face shields, and shoe
spread of a contagious disease. Such efforts may covers.
102 Bioterrorism
Diagnostic Testing Vaccination

Bacterial agents can usually be identified through Vaccines, in various stages of testing, have been
traditional culture techniques and colony identifi- developed for anthrax, plague, smallpox, tulare-
cation. Direct fluorescent antibody (DFA) tech- mia, hemorrhagic fever, cholera, Q fever, and
niques on capsule antigens are also a useful typhus. The FDA licenses the vaccines for anthrax,
modality, especially when identifying bacterium in hemorrhagic fever, Japanese B encephalitis, small-
tissues. Polymerase chain reaction (PCR) can be pox, and the plague.
used to detect and amplify genetic material from The anthrax vaccine is a series of six doses.
bacteria and is useful in identifying subtypes of Used since 1997 by the U.S. military, the anthrax
organisms. vaccine has been developed from a cell-free filtrate
The Laboratory Response Network (LRN) was of the nonencapsulated attenuated strain of the
organized in 1999 and involves more than 150 bacterium. Systemic events (headache, fever, vom-
clinical, military, veterinary, agricultural, and iting) occur in about 1% of individuals (women
water and food testing facilities; it is coordinated are at a greater risk than men), while the local
through the CDC. It also has laboratories in reaction rate is about 3.6%.
Canada, the United Kingdom, and Australia. The The smallpox vaccination was routinely given
purpose of the LRN is to rapidly identify threat to infants under the age of 1. It is estimated that
agents and to conduct definitive testing for these about 50% of the U.S. population has not received
agents. LRN laboratories are designated as senti- the vaccine. It is thought that the duration of
nel (hospital-based laboratories), reference (to immunity is about 10 years, although neutralizing
confirm the initial results), and national (designed antibodies can be detected for up to 30 years.
to handle highly infectious agents and identify Primary smallpox vaccination (preventive) that
specific strains). uses a bifurcated needle has been advocated for
Viral testing can be complicated. For example, military and healthcare personnel. The military
smallpox can be detected via dermatologic (vesi- experience noted a rate of 82 per million vacci-
cular) specimens obtained through barrier pre- nated for generalized vaccinia. There were also
cautions by scraping the base of a vesicle or by 37 cases of myopericarditis (of 450,000 vacci-
obtaining a 4-mm dermal punch biopsy. Viral nated), with recovery in all individuals. Encephalitis
detection can be achieved via electron microscopy occurs at a rate of 1 in 300,000. Severe adverse
or with PCR technology. Serum analysis can be reactions can be treated with vaccine immune
used to detect smallpox or viral hemorrhagic fever. globulin (VIG), with an intramuscular dose of
The latter agent should be referred to the CDC or 0.6 ml/kg.
the USAMRIID. Postexposure vaccination for smallpox may
Biological toxin identification also presents its offer some protection if given within 4 days of
own unique challenges. The mouse bioassay, using exposure. Persons identified as being at risk (face-
30 ml of serum or gastrointestinal contents from to-face contact with a household member or
the patient, is the primary modality to identify within 6.5 feet of a suspected case) should be con-
botulism toxin. Disease is usually evident within sidered for vaccination. The CDC is the sole dis-
24 hours. Electromyography (EMG) is the primary tributor for the vaccine and VIG.
clinical modality in diagnosing botulism with its For hemorrhagic fever virus, the yellow fever
characteristic findings (repetitive nerve stimula- live attenuated vaccine has limited usefulness due
tion) at 20 to 30 Hz: short duration of motor unit to the long period before an immune response
potentials, polyphasic motor unit potentials, develops (which can take up to 10 days), limited
decreased amplitude of compound muscle action supplies, and an adverse-effect profile.
potentials of proximal muscle groups following a A live attenuated vaccine for tularemia is being
single nerve stimulus, and normal sensory and developed, but as in the yellow fever vaccine, the
nerve conduction velocity. The CDC is currently long period for neutralizing antibody development
developing a urinary ricin assay to be used with the (2 weeks) makes this vaccine less useful for postex-
LRN. posure prophylaxis.
Blue Cross and Blue Shield 103
The vaccines for Q fever, cholera, and botulism Kman, Nicholas E., and Richard N. Nelson.
(using pentavalent antitoxin) are in various stages “Infectious Agents of Bioterrorism: A Review
of development, as are the vaccines for viral for Emergency Physicians,” Emergency Medicine
encephalitis, Rift Valley fever, chikungunya fever, Clinics of North America 26(2): 517–47,
and Junin virus. May 2008.
Leikin, Jerrod B., and Robin B. McFee, eds. Handbook
of Nuclear, Biological, and Chemical Agent
Antibiotic Treatment Exposures. Boca Raton, FL: CRC Press, 2007.
Antibiotics are the mainstay of therapy for bio-

logical agents that are related to bacterial infec- Web Sites
tion. For most of these agents (i.e., anthrax,
Association for Professionals in Infection Control and
plague, psittarosis, tularemia, cholera), a combi-
Epidemiology (APIC): http://www.apic.org
nation of a fluoroquinolone and doxycycline is the
Association of State and Territorial Health Officials
medical treatment of choice. Antibiotics are not
(ASTHO): http://www.astho.org
useful therapy for botulism, ricin, or any viral
Centers for Disease Control and Prevention (CDC):
agent. http://www.bt.cdc.gov/bioterrorism
U.S. Department of Homeland Security:
Future Implications http://www.dhs.gov
In the event of a bioterrorism attack, patients

exposed to the agents are likely to have subtle
symptoms presenting in outpatient clinics. These
patients, however, are likely to occur in large Blue Cross and Blue Shield
numbers, and thus healthcare facilities will need
to follow the basics of emergency preparedness in The Blue Cross and Blue Shield brands are the
order to deal with the entity. most recognized health insurance brands in the
country. The Blue Cross plans provide health
Jerrold B. Leikin insurance coverage for hospital services, while
the Blue Shield plans provide coverage for physi-
See also Access to Healthcare; Emergency and Disaster cian services. There are currently 39 Blue Cross
Preparedness; Emergency Medical Services (EMS); and Blue Shield companies in the United States,
Epidemiology; Health Communication; Hospital which collectively employ more that 150,000
Emergency Departments; Hospitals; Public Health
individuals nationwide. Nearly 65.8 million mem-
bers are enrolled in preferred provider organiza-
tions (PPOs), 12.9 million in fee-for-service plans,
Further Readings 15.8 million in health maintenance organizations
(HMOs), and 4.8 million in point-of-service
Antosia, Robert E., and John D. Cahill, eds. Handbook
(POS) products. The Blue Cross and Blue Shield
of Bioterrorism and Disaster Medicine. New York:
Springer Science, 2006.
companies boast that they collectively insure one
Clark, William R. Bracing for Armageddon?: The out of every three Americans. If all the Blue Cross
Science and Politics of Bioterrorism in America. New and Blue Shield plans were one company rather
York: Oxford University Press, 2008. than 39 confederated companies, it would be one
Henderson, Donald A., Thomas V. Inglesby, and Tara of the top 20 employers in the nation. The plans
O’Toole. Bioterrorism: Guidelines for Medical and have contracts with 90% of all U.S. hospitals and
Public Health Management. Chicago: American 80% of physicians. In recent years, the compa-
Medical Association, 2002. nies have been in the spotlight as they pursue
Khardori, Nancy, ed. Bioterrorism Preparedness: business interests that some say contradict their
Medicine, Public Health, Policy. Weinheim, Germany: history as nonprofit firms with a community-
Wiley-VCH, 2006. benefits tradition.
104 Blue Cross and Blue Shield
History HMO sponsorship. McNerney was instrumental

in moving the Blue Cross plans away from the
The original Blue Cross company was an out- control of the AHA, an early sponsor of the hos-
growth of the Baylor Plan, a nonprofit health pital insurance concept, and the AMA, which
insurance plan established in Houston, Texas, in managed the BSA. In 1972, the Blue Cross and
1929 by Francis Ford Kimball to provide coverage Blue Shield companies formally separated from
for teachers through a prepayment plan of the AHA, which ushered in the tensions between
50 cents a month. The Houston plan was the fore- the organizations.
runner of the Blue Cross plans that provided hospi- McNerney was intent on merging the Blue
tal services. The Blue Cross name and symbol were Cross and the Blue Shield plans and ultimately
created in 1934 by E. A. van Steenwyk from undertook an extensive strategic planning initia-
St. Paul, Minnesota’s group health plan. Blue Cross’s tive to examine the plans and seek cooperation of
former Chicago headquarters was housed in the the plans across the nation. His stated goal was to
American Hospital Association (AHA) building. limit the number of plans operating in the states.
Blue Cross plans later developed in New York, The plans were developed under three different
New Jersey, and California. By 1935, there were organization types—stock, mutual, and nonprofit.
15 plans in 11 states. The number of Blue Cross These organization models continue to exist in
plans had grown from 56 to 80 between 1940 and 2008. The nonprofit plans were established with
1945, and enrollment increased from 6 million to no individual or organizational entity with an
19 million. ownership interest, and control rested with the
During this period, a comparable plan to cover board of directors. The stock companies are those
physician services was also established in the states in which the financial ownership consists of capital
of Washington and California. From these physi- stock, which is divided into shares, and control
cian plans, the medical societies around the nation rests with stockholders. Mutual companies are
began to develop prepaid insurance programs that corporations without capital stock; ultimate con-
covered physician services. In 1946, a number of trol is with policyholders. Although there has been
plans banded into a national group called the considerable debate in recent years about the own-
Associated Medical Care Plans, overseen by the ership type of the company, the ownership of the
American Medical Association (AMA), and infor- plans is transparent to its members.
mally adopted the Blue Shield as its symbol. This During the 1980s, hospital cost escalation was
organization eventually became the Blue Shield considerable. As a result, President Jimmy Carter
Association (BSA). The Blue Shield plans that pro- attempted to introduce cost controls by legislating
vided physician services had an early enrollment of caps on health spending. The Carter administra-
3 million. In the 1960s, there were 148 Blue Cross tion desired to limit annual hospital cost increases
and Blue Shield plans in the United States; some and capital spending as well as physician reim-
providing hospital insurance under the Blue Cross bursement under Medicare and Medicaid. The
plans and others providing physician coverage reception to these proposals was lukewarm. While
under the Blue Shield plans. the voluntary effort to control healthcare costs was
In 1961, Walter J. McNerney (1925–2005), introduced, there was little done to implement
who was recruited by the Michigan Blue Cross healthcare change. When Ronald Reagan was
plan from the University of Michigan to examine elected president in 1982, a procompetitive, anti-
the hospital and medical care costs and insurance regulatory strategy toward controlling healthcare
coverage in that state, became the president of the costs was introduced. The HMO model took hold,
Blue Cross Association. The McNerney era was with its prospective payment that rewarded pro-
marked by numerous changes in the nation’s viders for minimizing costs. Alain Enthoven, a
healthcare system, including the development of Stanford economist and consultant to the Reagan
the federal Medicare and Medicaid programs in administration, introduced the consumer choice
1965, utilization and case management initia- philosophy, which advocated cost-efficient benefit
tives, the collaboration of plans to offer national programs. With the consolidation of the Blue
products, preadmission testing programs, and Cross and Blue Shield plans, the development of
Blue Cross and Blue Shield 105
the Blue Cross Blue Shield Association (BCBSA), conversions increased to include California,
and the move to interplan collaboration for the Colorado, Connecticut, Georgia, Indiana,
benefit of the plan members, new HMO products Kentucky, Maine, Missouri, Nevada, New
were introduced with the stated benefit of control- Hampshire, New York City, Ohio, Virginia, and
ling healthcare utilization and costs. Wisconsin, the public is raising questions about
Blue Cross and Blue Shield continued to col- the consequences of such conversions. From 1990
laborate with federal and state governments in to 1993, Blue Cross and Blue Shield plans in
providing healthcare benefits. The BCBSA was Maryland, New Jersey, New York, West Virginia,
instrumental in advocating for the benefit manage- and Washington, D.C., encountered a series of
ment of the federal Medicare and state Medicaid U.S. Senate investigations into their financial
products along with HMO and indemnity prod- management practices. In response to these inves-
ucts. It became a major benefits manager for the tigations, the BCBSA developed a code of conduct
federal government when the Federal Employee to guide plan entrepreneurism.
Health Benefits Plan was introduced in 1960 to As the U.S. economy changed, large multistate
provide coverage for 9 million federal employees clients wanted an extensive network of providers,
and their dependents, including members of the affordable products, efficient customer service,
U.S. Congress. and limited intrusion by the insurer into medical
management. Blue Cross Blue Shield’s competitors
provided such an alternative with their products
Conversion From
and services. Blue Cross responded in kind to these
Nonprofit to For-Profit Status
competitor threats by investing extensively in
In 1994, BCBSA voted to change its charter to information and billing systems, cultivating excel-
allow for-profit conversions of plans if the plans lent provider relations, and introducing preferred
met specific guidelines. These included safeguards provider product offerings with limited medical
such as control of branded subsidiaries by the management. The BCBSA’s introduction of the
parent plans, accreditation for managed-care com Blue Card benefit in 1994 that allowed interplan
panies, codes of conduct for officers, rules for use of services by members was an initiative to
disclosure of records, agreement to mandatory provide a rational system of services as members
dispute resolution, and financial standards and moved between states and traveled outside the
guarantees. Blue Cross Blue Shield of California continental United States.
was the first conversion, and it changed its name
to Wellpoint. Since 1994, 14 of the 42 state BCBS
Health Insurance Consolidations
plans in the United States have changed their tax
status from nonprofit to for-profit. The stated The U.S. healthcare environment changed dra-
rationale for conversion of tax status is to raise matically between 1980 and 2002 for health
capital to better compete with commercial insur- insurance companies and hospitals. Large multi-
ance companies, such as Aetna, Cigna, and the state insurance companies providing health insur-
UnitedHealth Group. ance coverage in conjunction with financial,
In 1994, as the first plan to convert, Blue Cross casualty, and life insurance had become the norm.
of California received minimal public scrutiny. It quickly became apparent that healthcare
The denial of Blue Cross and Blue Shield of required a different type of insurance, leading
Maryland’s for-profit conversion by the State companies to divest or expand into health insur-
Insurance Commissioner in March 2003, fol- ance. For example, MetraHealth was formed in
lowed by the Kansas Supreme Court blocking the 1995 through the combination of the group
acquisition of the Blue Cross plan by the for- healthcare business of Metropolitan Life Insurance
profit Anthem and the subsequent retractions of Company and the Travelers Insurance Company.
the New Jersey and North Carolina Blue Cross MetraHealth served millions of Americans with
and Blue Shield plans of their proposed conver- its healthcare plans, and it operated in all 50
sion initiatives have raised the visibility of the states. The company’s managed-care networks
conversion phenomenon. As the numbers of plan included 29 HMO licenses, 72 point-of-service
106 Blue Cross and Blue Shield
networks, and PPOs managed in more than mergers in the health insurance industry, HMO
90 markets nationwide. In addition to its full capitation, and failure of insurers to adhere to
range of both managed care and indemnity plans, prompt payment laws.
the company offered managed behavioral health, With the consolidation in the hospital and com-
managed pharmacy, data analysis, demand man- mercial insurance industries, the nonprofit Blue
agement, managed workers’ compensation, and Cross plans began to respond to the competition
third-party administrator services. In 1995, presented by large national and regional insurance
UnitedHealth Group purchased MetraHealth, plans. The conversion phenomenon and BCBSA’s
bringing the services of MetLife and Travelers development of a division to handle national
under its umbrella. accounts, The Blue Card, that crosses the jurisdic-
In 1990, the Associated Insurance Companies tional boundaries of state Blue Cross plans repre-
of Indianapolis (the forerunner to Anthem Blue sented an internal management decision to respond
Cross and Blue Shield located in Indiana, which to the changes in the hospital and insurance indus-
has grown to incorporate more Blue Cross plans tries. The Blue Card initiative was an acknowledg-
under its umbrella) purchased the Dallas-based ment that multistate employers wanted to deal
American General Insurance Company. This acqui- with a corporate entity that could resolve inter-
sition of a diversified insurance company that state insurance issues and did not want to negoti-
would compete with other Blue Cross and Blue ate between multiple Blue Cross plans. It also
Shield plans outside Indiana introduced plan com- recognized that the Blue Cross and Blue Shield
petition and diversity in the Blue Cross and Blue organization, regardless of its ownership or state
Shield organization. boundaries, needed to provide a seamless system
Between 1996 and 1998, Aetna Insurance of care for its member companies and their
Company acquired U.S. Healthcare, and then the employees. When the public viewed the Blue Cross
healthcare divisions of The New York Life Insur plans, they saw one company, not 39 independent
ance Company (NYLIC) and Prudential Insurance licensees of the BCBSA. Its commercial competi-
Company, making it the largest health insurance tion was investing tremendous resources into pro-
company in the nation, covering 21 million lives. viding national services, and The Blue Card
Aetna, as the largest health insurer, expanded into introduced a national product for the companies.
healthcare and eliminated unprofitable lines of In addition, the Blue Healthcare Bank was estab-
business. Aetna’s management decided that it lished in 2007 to provide healthcare-related bank-
could no longer be the “department store of insuring in all 50 states of the nation. The bank services
ance.” Smaller specialty firms that possessed customers with high deductible health savings
greater levels of management focus and were accounts (HSAs). The Blue Cross bank was a
quicker to adapt to market changes were under- direct result of the commercial insurance giant
mining its role as a traditional multiline insurer UnitedHealth Group’s Exante Bank acquisition.
trying to compete in all insurance markets. Aetna’s The internecine warfare between the various
decision in 1991 to exit individual health lines Blue Cross plans appears to have settled down in
ended a 91-year-old coverage. In 1991, it exited 2008. Scott Serota, the president and CEO of the
the automobile and homeowners insurance mar- BCBSA, has quietly introduced new products with
kets, and in 1996, it left the property casualty The Blue Card, pursued the collaboration with
market, based on market profitability and com- America’s Health Insurance Plans (AHIP) to pro-
pany expertise and resources. mote portability standards for patient information
As the largest health insurance company between through the electronic health record, promoted the
1998 and 2000, Aetna became the market leader. Patient-Centered Primary-Care Collaborative to
With its acquisitions U.S. Healthcare, Prudential, secure primary-care medical homes for enrollees,
and NYLIC, providers were finding that the major and promoted Medicare E-prescribing. Once again,
part of their business was being dictated by one Blue Cross and Blue Shield is increasing its mem-
company that had previously been four separate bership, innovating with new products and pro-
companies. In 1999, the provider community grams, and collaborating with other insurers to
started to revolt against the consolidation and advance the insurance industry.
Brook, Robert H. 107
Future Implications
Brook, Robert H.
The Blue Cross and Blue Shield companies have
undergone a dramatic change since the early
Robert H. Brook is an internationally recognized
founding of the company in 1929. The company
expert on quality assessment and quality assur-
has endured because of its early association with
ance. Brook and his colleagues at the University of
the hospital industry. The cost control movement,
California, Los Angeles (UCLA) and the RAND
the organization’s strategic plan, internal com-
Corporation are widely credited with developing
pany reorganization, the procompetition move-
pioneering methods for studying the appropriate-
ment, new product offerings, and the growth of
ness of medical care and measuring quality.
the uninsured has fundamentally changed Blue
Brook’s seminal work on healthcare quality and
Cross as it was originally envisioned. Nonetheless,
health status measurement has led to the develop-
the Blue Cross and Blue Shield companies remain
ment of policies for improved health and quality.
a formidable brand and continue to dominate
His research has also created the scientific basis
other insurers in their local markets.
for deciding if many different medical and surgical
Diane M. Howard procedures are used appropriately.
Brook is professor of medicine and health ser-
See also Committee on the Costs of Medical Care vices at the UCLA, where he directs the Robert
(CCMC); For-Profit Versus Not-for-Profit Healthcare;
Wood Johnson/UCLA Clinical Scholars Program.
Health Insurance; Health Maintenance Organizations
(HMOs); Health Savings Accounts (HSAs); Kimball,
He is also vice president and director of the RAND
Justin Ford; McNerney, Walter J.; Preferred Provider Corporation’s Health Sciences Program.
Organizations (PPOs) Brook received his bachelor of science degree
from the University of Arizona. He went on to
receive a medical degree from Johns Hopkins
Further Readings Medical School and a doctorate of science degree
from Johns Hopkins School of Hygiene and Public
Cunningham, Robert, III, and Robert M. Cunningham
Health.
Jr. The Blues: A History of the Blue Cross and Blue
Since 1974, Brook has served on the faculty of
Shield System. DeKalb: Northern Illinois University
Press, 1997.
the UCLA. Over the course of more than 30 years
Friedman, Emily. “What Price Survival? The Future of
at that university, he has trained many healthcare
Blue Cross and Blue Shield,” Journal of the American industry leaders. As the director of the Robert
Medical Association 279(23): 1863–68, June 17, 1998. Wood Johnson Clinical Scholars Program, he has
Hall, Mark A., and Christopher J. Conover. “For-Profit been pivotally involved in training physicians to
Conversion of Blue Cross Plans: Public Benefit or take an active role in policy and to focus on health-
Public Harm?” Annual Review of Public Health 27: care at the community level
443–63, 2006. Brook’s contributions have been recognized with
Miller, Irwin. American Health Care Blues: Blue Cross, a number of awards and honors, including the
HMOs, and Pragmatic Reform Since 1960. New Baxter Foundation Prize for excellence in health
Brunswick, NJ: Transaction, 1996. services research, the Institute of Medicine’s Lienhard
Morrisey, Michael A. Health Insurance. Chicago: Health Award, the Rosenthal Foundation Award of the
Administration Press, 2007. American Association of Physicians, the Peter
Reizenstein Prize, the Distinguished Health Services
Research Award of the Association of Health
Web Sites Services Research, the Robert J. Glaser Award of
America’s Health Insurance Plans (AHIP): the Society of General Internal Medicine, the
http://www.hiaa.org National Committee for Quality Assurance (NCQA)
American Hospital Association (AHA): Health Quality Award for the pursuit of healthcare
http://www.aha.org quality at all levels of the health system and
Blue Cross Blue Shield Association (BCBSA): research, and America’s 2000 Advocacy Award for
http://www.bcbs.com Sustained Leadership at the National Level. Brook
108 Brookings Institution
also was selected as one of the 75 Heroes of Public Death Rates: Randomness, Severity of Illness, Quality
Health by Johns Hopkins University in 1991. He is of Care,” Journal of the American Medical
a member of the National Academy of Sciences, Association 264(4): 484–90, July 25, 1990.
Institute of Medicine (IOM); the American Society Schuster, Mark A., Elizabeth A. McGlynn, and Robert
for Clinical Investigation; the American Association H. Brook. “How Good Is the Quality of Care in the
of Physicians; and the Board of Overseers at the United States,” Millbank Quarterly 76(4): 517–63,
University of California Davis Medical School. 1998.
Brook has published nearly 300 medical articles
throughout his career. As a board-certified inter-
nist, he has conducted revolutionary work in the Web Sites
field of quality measurement that has led to RAND Expert Profile: http://www.rand.org/media/
the development of measurement tools used by the experts/bios/brook_robert_h.html
government, physicians, and other groups. Brook University of California, Los Angeles, School of Public
has focused specific attention on developing health Health, Faculty Profile: http://www.ph.ucla.edu/hs/
status and quality measures for vulnerable popula- bio_brook.asp
tions, including the elderly, HIV-positive individu-
als, and special-needs children.
Recently, Brook was appointed the chair of a
panel on coronary artery bypass graft surgical Brookings Institution
outcomes that will advise California’s Office of
Statewide Health Planning. Brook has dedicated The Brookings Institution is one of the nation’s
his career to improving the effectiveness and effi- oldest research and policy organizations dedicated
ciency of the healthcare delivery system, and his to questions of governance and the economy.
work has transformed the way in which healthcare Although the Brookings Institution is now only
quality is evaluated. Because of Brook’s substantial one of the many Washington think tanks, its long
contributions in this field, policymakers have history of influence and volume of research output
incorporated his research findings into national ensure that it remains a prominent one. While
healthcare policy standards. healthcare issues have not historically been its
chief focus, the relationship of health to econom-
Jared Lane K. Maeda
ics is an emerging research interest, and the
See also Clinical Practice Guidelines; Public Policy; Brookings Institution has immersed itself in the
Quality Indicators; Quality of Healthcare; RAND debates surrounding healthcare and national
Corporation; Robert Wood Johnson Foundation spending priorities.
(RWJF); Vulnerable Populations
History
Further Readings The Brookings Institution was formed in 1927 by
the merger of the Institute for Governmental
Brook, Robert H. “Measuring Quality—Part 2 of Six,”
Research and the Carnegie Corporation’s Institute
New England Journal of Medicine 335(13): 966–70,
September 26, 1996.
of Economics, two small research and policy orga-
Brook, Robert H., and Francis A. Appel. “Quality of nizations. These two predecessor organizations
Care Assessment: Choosing a Method for Peer were formed to provide the federal government
Review,” New England Journal of Medicine 288(25): with statistics and research aimed at meeting
1323–29, June 21, 1973. administrative and budget policy needs arising
Grudzen, Corita, and Robert H. Brook. “High- from the growth of government in the early 20th
Deductible Health Plans and Emergency Department century and U.S. involvement in World War I.
Use,” Journal of the American Medical Association A third institution, the Brookings Graduate
297(10): 1126–27, March 14, 2007. School, was also involved in the merger. The
Park, Rolla Edward, Robert H. Brook, Jacqueline school was founded in 1922 as an independent
Kosecoff, et al. “Explaining Variations in Hospital institution by Robert S. Brookings (1850–1932), a
Brookings Institution 109
businessman, philanthropist, and governmental at the time that Armacost’s appointment repre-
reformer. Brookings was a friend of the American sented an official recognition by the institute
industrialist Andrew Carnegie (1835–1919) and of the new prevalence of conservative ideas in
played a leading role in improving Washington Washington.
University’s School of Medicine, which, as a result, The current president of the Brookings
was described in positive terms in Abraham Institution is Strobe Talbott, a former journalist
Flexner’s 1910 report on the state of medical edu- and U.S. secretary of state in the Clinton adminis-
cation in the United States. Brookings shared tration. Talbott became president of the institute
Carnegie’s interest in questions of public policy in 2002.
and governance and had founded his school to
contribute to the education of students interested
Current Activities
in serving in the government.
The new institute, headquartered in Washington, While the Brookings Institution has not histori-
D.C., and, in its original location, close to the cally emphasized healthcare issues in its research,
White House, was to serve as a source of profes- in July 2007 it created the Engelberg Center for
sional and nonpartisan research and advice to the Health Care Reform. The founding director of
federal government. The Institution’s first presi- the new center is Mark B. McClellan, former
dent was the economist Harold G. Moulton. commissioner of the U.S. Food and Drug
The Great Depression and President Franklin Administration and administrator of the Centers
D. Roosevelt’s attempts to deal with it provided for Medicare and Medicaid Services (CMS). The
the Brookings Institution with an enormous chal- center will serve as the hub of Brookings activities
lenge. Despite the institute’s later reputation as an related to health policy. Its mission is to effect
advocate of liberal policies, Brookings researchers lasting change by providing practical solutions
were critical of Roosevelt’s New Deal policies and that result in high-quality, innovative, and afford-
their curbs on what they considered to be the pre- able healthcare. The center plans to focus on four
rogative of the free market. The institute was simi- key areas: improving the quality of medical care,
larly critical of aspects of the policies of the increasing access to affordable health insurance
Truman administration. coverage, reducing the costs of public and private
Despite its criticisms, however, the Brookings programs, and encouraging rapid and effective
Institution grew in prominence, becoming espe- innovation for the development of more personal-
cially influential during the period of its second ized medicines.
president, Robert Calkins (1952–1967). During Other areas of the institute also focus on
this time, the John F. Kennedy and Lyndon B. healthcare. The Health Policy Initiative sponsors
Johnson administrations frequently consulted the events, coordinates research, and publishes papers
Institution. In addition, the Institution added for- on healthcare spending and resource allocation.
eign policy research to its traditional focus on The Global Health Financing Initiative, orga-
domestic policy issues. nized in 2006 with funding from the Bill and
Over the years, the Institution evolved into the Melinda Gates Foundation, focuses on similar
archetype of the powerful Washington think tank. issues in the countries of the developing world.
During the tenure of its third president, Kermit The Wolfensohn Center for Development (initi-
Gordon (1967–1977), Brookings also became the ated in 2006 and named after James Wolfensohn,
target of rhetorical hostility from the executive the former head of the World Bank), the Hamilton
branch. Members of the Nixon administration Project (named after Alexander Hamilton), and
openly criticized the institute because of its influ- the Center on Children and Families also deal, at
ence and the perceived opposition of its staff to the least peripherally, with health issues. An under-
President’s policies. taking launched in 1998 with the American
Bruce MacLaury became Brookings’s fourth Enterprise Institute (AEI), another prominent
president in 1977, followed by Michael think tank, is called the Joint Center for Regulatory
Armacost, a former staffer for President Ronald Studies and deals with topics including health
Reagan, in 1995. Some commentators remarked policy and economics.
110 Brookings Institution
Publications Further Readings
The Brookings Institution has a large number of Aaron, Henry J. “Budget Crisis, Entitlement Crisis,
outlets for the dissemination of its research efforts. Health Care Financing Problem: Which Is It?” Health
The Brookings Bulletin, a quarterly launched in Affairs 26(6): 1622–33, November–December 2007.
1962, served as its house organ until 1982, when it Aaron, Henry J., and Joseph P. Newhouse. “Meeting the
was succeeded by the quarterly Brookings Review. Dilemma of Health Care Access: Extend Insurance
The Brookings Review was retired in 2003, but the Coverage While Controlling Costs,” Opportunity 08:
Institution currently publishes an array of periodi- Independent Ideas for Our Next President.
Washington, DC: Brookings Institution, 2007.
cal titles on an annual or semiannual basis. Among
Aaron, Henry J., William B. Schwartz, and Melissa Cox.
these journals, articles on medicine, public health,
Can We Say No? The Challenge of Rationing Health
medical insurance, and other health-related topics
Care. Washington, DC: Brookings Institution Press,
appear in the Brookings Papers on Economic
2005.
Activity and The Future of Children, copublished Anderson, Gerard F., and Hugh R. Waters. “Achieving
with Princeton University’s Woodrow Wilson Universal Coverage through Medicare Part
School of Public and International Affairs. E(veryone),” Hamilton Project Discussion Paper
The Brookings Institution Press also publishes a 2007–10. Washington, DC: Brookings Institution,
wide variety of books dealing with aspects of medi- 2007.
cine, medical education, medical insurance, economic Critchlow, Donald T. The Brookings Institution,
and social health policy, and biomedical technology. 1916–1952. DeKalb: Northern Illinois University
In addition to its publishing efforts, Brookings Press, 1985.
researchers also submit items to newspaper opinion Ezekiel, J. Emanuel, and Victor R. Fuchs. “Health Care
and editorial pages, appear before U.S. congressio- Reconsidered: Options for Change,” Hamilton
nal panels, and make themselves available for speak- Project Discussion Paper 2007–11. Washington, DC:
ing engagements and broadcast media appearances. Brookings Institution, 2007.
Smith, James Allen. Brookings at Seventy-Five.
Kevin O’Brien Washington, DC: Brookings Institution Press, 1991.
See also American Enterprise Institute for Public Policy

Research (AEI); Cato Institute; Flexner, Abraham;
Web Sites
Gates Foundation; Health Economics; Public Policy;
RAND Corporation; Urban Institute Brookings Institution: http://www.brookings.edu
C
of health services and policy research. The pro-
Canadian Association for posed new organization was formally introduced
Health Services and Policy at the Institute of Health Services and Policy
Research symposium that was held in November
Research (CAHSPR) 2003. And the CHERA transitioned into the
CAHSPR.
The Canadian Association for Health Services and
Policy Research (CAHSPR) is Canada’s largest
and most diverse health services and policy Key Features
research association. Incorporated in 2004, the
The key features of the CAHSPR are as follows: It
CAHSPR evolved from the Canadian Health
is multidisciplinary; it is committed to improving
Economics Research Association (CHERA), in
the quality, relevance, and application of health
response to changes in Canada’s health services
services and policy research; its membership
research landscape. The CHERA, which began in
includes both health services and policy research-
1985, primarily focused on health economics and
ers from a wide range of disciplines and consumers
policy. Over the years, it evolved into a broader
of research from government and nongovernment
organization with diverse members, including not
organizations and industry.
only health economists but also health services
These features allow the CAHSPR to be in a
researchers, policy analysts, and other profession-
unique position to foster and support linkages
als. Over time, there was a belief by many outside
between researchers and decision makers; to pro-
individuals and organizations that because of its
mote knowledge transfer, exchange, and integra-
name and official objectives, the CHERA was nar-
tion; to encourage education and training; and to
rowly focused on health economists. The associa-
advocate for research and its more effective use in
tion’s members saw this as a significant barrier to
planning, practice, and policy making.
the organization’s continued growth.
In 2002, the leadership of the CHERA decided
to survey its members as well as external stake-
Member Services
holders to determine if there was interest in
broadening the mandate and membership of the The CAHSPR provides a number of services to its
organization. The response was overwhelmingly members and others, including organizing an
supportive of making changes to the organization annual conference, publishing a peer-reviewed
and having it become a national, broad-based, journal, distributing information through a weekly
interdisciplinary health services and policy research listserv, and supporting interdisciplinary research
association for practitioners, users, and students and knowledge transfer.
111
112 Canadian Association for Health Services and Policy Research (CAHSPR)
One of the most important activities of the Foundation, the Institute of Health Services and
CAHSPR is its annual conference. The associa- Policy Research (within the Canadian Institutes of
tion’s inaugural conference was held in Montreal Health Research), the Canadian Institute for Health
in May 2004. The themes of this conference were Information, the Canadian Coordinating Office
“Learning From International Comparisons” and for Health Technology Assessment, the Advisory
“Knowledge Exchange Between Researchers and Committee on Governance and Accountability of
Decision-Makers.” In September 2005, the associ- the Federal-Provincial-Territorial Conference of
ation’s second annual conference was again held in Deputy Ministers of Health, and the Health
Montreal, this time in conjunction with the Statistics Division of Statistics Canada. The consul-
Jean-Yves Rivard Conference and the International tation was intended to establish both a primary
Conference on the Scientific Basis of Health research agenda and a research synthesis agenda to
Services. The theme was “Canada’s Health recognize the immediate needs of policymakers,
Priorities: Building and Maintaining Research managers, and the public for accessible summaries
Capacity.” The third annual conference, which of research evidence. The research themes that
took place in September 2006, had the theme were identified and drive the content of Healthcare
“Insight, Interaction and Innovation: New Policy include workforce planning, training, and
Approaches to Health Services, Research, Policy regulation; management of the healthcare work-
and Management.” It was held in conjunction with place; timely access to quality care for all; manag-
the National Healthcare Leadership Conference in ing for quality and safety; understanding and
Vancouver, British Columbia. In June 2007, the responding to public expectations; sustainable
association’s fourth annual conference, “Leading, funding and ethical resource allocation; gover-
Linking and Listening: Knowledge Exchange at the nance and accountability; managing and adapting
Frontiers of Health Services and Policy Research,” to change; linking care across place, time, and set-
was once again held in conjunction with the tings; and linking public health to health services.
National Healthcare Leadership Conference in The CAHSPR distributes an informational e-mail
Toronto. The association’s fifth annual conference to all members on a weekly basis. The e-mail
was held in May 2008 at Gatineau, Quebec. Its includes information on a variety of topics of
theme was “Bridging Silos.” Whenever possible, importance to members, including career opportu-
the association holds its conferences consecutively nities, CAHSPR activities and upcoming events,
or concurrently with other organizations to maxi- links to course materials for student members, and
mize the opportunity for collaboration between current research and policy items of interest to
other researchers and decision makers. members.
The CAHSPR publishes Healthcare Policy. This These services allow the association to provide
quarterly journal includes original scholarly and support for interdisciplinary research and knowl-
research articles that support health policy devel- edge transfer. It provides a home for decision mak-
opment and decision making. The articles address ers from the healthcare sector who are interested in
diverse topics such as governance, organization, research outcomes and participating in research
and service delivery to funding and resource allo- collaborations. In addition, the association works
cation. The journal’s diverse readership includes closely with the Canadian College of Health Services
health system managers, practitioners, policymak- Executives (CCHSE), the Canadian Institute for
ers, educators, and academics. In line with the Health Research (CIHR), the Canadian Health
interdisciplinary nature of the CAHSPR, the jour- Services Research Foundation (CHSRF), and other
nal is open to researchers from a broad range of organizations to strengthen the connection between
disciplines. The submission of articles from deci- researchers and research users within Canada’s
sion makers and researcher–decision maker col- healthcare system.
laborations that address knowledge exchange and
application are strongly encouraged.
Organization
Healthcare Policy has adopted the themes iden-
tified in 2004 through a national consultation initi- The CAHSPR is governed by a board of directors,
ated by the Canadian Health Services Research which is composed of a president, president-designate,
Canadian Health Services Research Foundation (CHSRF) 113
past president, secretary (appointee), treasurer Its immediate objective was to bring together
(appointee), a minimum of six and a maximum of provincial governments, health institutions, and
nine directors, a student representative (nonvoting), the private sector as partners to engage in practi-
representatives from each study group (nonvoting), cal research that would identify what works in
current conference convener (nonvoting), upcoming Canada’s healthcare system, what does not work,
conference convener (nonvoting), the Emmett Hall and what procedures and interventions require
Foundation president (ex officio), and an executive further evaluation. The original commitment
director (nonvoting). The president, president-desig- through the federal budget was CAN$65 million.
nate, past president, secretary, and treasurer are the While it was originally envisioned that the
officers of the association. The day-to-day operation Medical Research Council of Canada would
of the association is the responsibility of an executive administer the fund, the Canadian College of
director. Health Services Executives (CCHSE) allowed its
own foundation to be transformed into the
Gregory S. Finlayson Canadian Health Services Research Foundation.
See also Canadian Health Services Research Foundation
In November 1996, the CCHSE’s board of direc-
(CHSRF); Canadian Institute of Health Services and tors changed the name and objectives of the
Policy Research (IHSPR); Health Services Research in foundation—those changes were subsequently
Canada approved by Industry Canada.
Purpose
Further Readings
According to the supplementary letters patent, the
CAHSPR Annual General Meeting Report. Ottawa,
CHSRF was established for the purpose of identi-
Ontario: Canadian Association of Health Services and
fying research gaps and needs in the field of health
Policy Research, 2006.
services research and defining priorities; the fund-
CAHSPR President’s Report. Ottawa, Ontario:
ing of peer-adjudicated research into the manage-
Canadian Association of Health Services and Policy
ment, organization, and effectiveness of health
Research, 2004.
services, including research into the outcomes of
health-affecting interventions as well as into the
Web Sites
organization and management of institutional
and noninstitutional models of health services
Canadian Association of Health Services and Policy delivery; and the promotion of best practices of
Research (CAHSPR): http://www.cahspr.ca health services delivery and the communication of
Canadian College of Health Services Executives research outcomes.
(CCHSE): http://www.cchse.org As an endowment, the CHSRF was designed
Canadian Health Services Research Foundation to work at arm’s length from government, with
(CHSRF): http://www.chsrf.ca stable funding at a sufficient level to have an
Canadian Institutes of Health Research (CIHR):
impact on health services in Canada. At the
http://www.cihr-irsc.gc.ca
time of its formation, the CHSRF received
CAN$66.5 million. Since then, it has received a
total of CAN$151.5 million in endowment contri-
Canadian Health Services butions. During its history, the foundation has
used its endowed funds to support applied research
Research Foundation (CHSRF) projects, open grants competitions focusing on
priority themes identified by managers and policy-
The Canadian Health Services Research Founda makers, the development of the Canadian Institutes
tion (CHSRF) was created through the Canadian of Health Research (CIHR), education and men-
federal budget in March 1996. It was established toring Chairs, regional training centers, nursing
in response to federal and provincial government research, and knowledge transfer. The most recent
interest in renewing Canada’s healthcare system. contribution of CAN$25 million was specifically
114 Canadian Health Services Research Foundation (CHSRF)
directed at developing the capacity of health ser- foundation has also established strategic objec-
vice executives and their organizations to use tives to create high-quality new research that is
research. useful for health service managers and policy-
makers (especially in the foundation’s priority
theme areas); to increase the number and nature
Mission and Vision of applied health services and nursing researchers;
Between 1997 and 2002, the mission of the to get needed research into the hands of health
CHSRF was to improve the health of Canadians system managers and policymakers in the right
by promoting and funding health services research format, at the right time, and through the right
and increasing its quality, relevance, and useful- channels; and to help health system managers,
ness for policymakers and managers by encourag- policymakers and their organizations to routinely
ing in its peer-reviewed funding a focus on issues acquire, appraise, adapt, and apply relevant
of importance for decision makers, the regular research in their work.
sharing of results and issues between decision
makers and researchers, the persuasive communi-
Priorities and Programs
cation of research results and the training and
support of health services and nursing research- The CHSRF supports management and policy
ers; funding syntheses of research and experience research in health services and nursing, and the
and encouraging user-friendly communication of dissemination of research results through research
research results and their implications for deci- funding for both researchers and decision makers,
sion makers; working with health service orga- training opportunities for senior decision makers,
nizations to increase their ability to acquire, training and personnel development for new and
appraise, adapt, and apply research to policy established researchers from within the field as
making and management; and developing rela- well as those who are prepared to apply skills
tionships with partners and cosponsors who from other fields to health systems, services and
uphold the foundation’s goals of generating and resources to support communication and research
promoting the use of health services and nursing dissemination, and recognizing excellence
research that is relevant to decision makers’ and achievement in doing, supporting, communi-
needs. cating, and using research results. In 2005,
As the result of a 2002 external review, the CAN$13.6 million was allocated for these purposes.
CHSRF worked with the Canadian Institutes of The CHSRF groups its priorities into various
Health Research (CIHR) and transferred research themes. While these change over time, in 2008,
project funding to the CIHR in favor of supporting they included the following: managing for quality
four to six programs of research, capacity develop- and safety, management of the healthcare work-
ment, and knowledge transfer. place, primary healthcare, nursing leadership,
The current vision of the CHSRF is “a strong organization, and policy. Past themes have included
Canadian healthcare system driven by solid, centralization and aggregation of health services,
research-informed management and policy deci- informed public participation in decision making,
sions,” and the mission of the foundation is “to health and human resources, and managing conti-
support evidence-informed decision making in the nuity. Current priorities are posted on the CHSRF’s
organization, management, and delivery of health Web site.
services through research, building capacity and Specific activities of the CHSRF include research,
transferring knowledge.” The strategy adopted by exchange, and impact for system support; commis-
the CHSRF to work toward this vision and missioned research; nursing research fund; an execu-
sion is “to bring researchers and decision makers tive training for research application program;
together regularly to understand each other’s building capacity for applied and developmental
goals and professional culture, influence each research and evaluation in health services and
other’s work, and forge new partnerships.” The nursing; the Harkness Associates program; the
Canadian Institute of Health Services and Policy Research (IHSPR) 115
health services research advancement award; and

bringing out publications designed to translate Canadian Institute of
research into information that is accessible to deci- Health Services and
sion makers.
Policy Research (IHSPR)
Organization The Canadian Institute of Health Services and
Located in Ottawa, the CHSRF is governed by Policy Research (IHSPR) is 1 of 13 institutes of the
a board of trustees of up to 14 people, many of Canadian Institutes of Health Research (CIHR).
whom are researchers and decision makers. The CIHR were created in June 2000, when an act
Trustees are elected for 3-year renewable terms. of the Canadian Parliament came into force. This
The CHSRF employees a staff of approximately act states that the CHIR will achieve their objec-
50 individuals, and it is led by a chief executive tives through “encouraging interdisciplinary, inte-
officer who is responsible for the day-to-day grative health research through the creation of
operations of the foundation. health research institutes” and established a gov-
erning council, which is responsible for the cre-
Gregory S. Finlayson ation of health research institutes. The purpose of
the institutes is to support individuals, groups, and
See also Canadian Association for Health Services and communities of researchers for the purpose of
Policy Research (CAHSPR); Health Services Research
achieving the objectives of CIHR. In July 2000,
in Canada; Lomas, Jonathan; Quality of Healthcare
the governing council of CIHR established the
IHSPR, and in December 2000, Morris Barer of
the University of British Columbia was appointed
Further Readings its first scientific director.
“Bridging the Research Knowledge Gap,” Links: The The CIHR are considered “virtual” institutes
Newsletter of the Canadian Health Services Research in that they are not housed in a central location
Foundation 10(3): 1–2, Fall 2007. and can be considered a focal point for networks
“Engaging Front-Line Staff: How a Long-Term Care of researchers with common interests. The loca-
Home Is Using Evidence to Build a Quality- tion of each institute’s office is determined by its
Improvement Culture,” Promising Practices in respective scientific director. For the first 5 years
Research Use, 15: 1–2, November–December 2007. of its operation, the IHSPR was located in
“The Extent and Organizational Determinants of Vancouver, British Columbia. In September
Research Utilization in Canadian Health Services 2006, Colleen M. Flood was appointed the sci-
Organizations,” Insight and Action, 17: 1–2, August entific director of IHSPR, and with this appoint-
2007. ment, the institute’s office was relocated to
“Incorporate Lay Health Workers to Promote Health Toronto.
and Prevent Disease,” Evidence Boost for Quality,
1–2, September 2007.
“Myth: Direct-to-Consumer Advertising Is Educational Vision, Goals, and Objectives
for Patients,” Myth Busters, 1–2, September 2007.
Like all the institutes, the IHSPR’s “objective is to
excel, according to internationally accepted stan-
Web Sites dards of scientific excellence, in the creation of
Canadian College of Health Services Executives new knowledge and its translation into improved
(CCHSE): http://www.cchse.org health for Canadians, more effective health ser-
Canadian Health Services Research Foundation vices and products, and a strengthened Canadian
(CHSRF): http://www.chsrf.ca healthcare system.”
Canadian Institutes of Health Research (CIHR): The IHSPR’s vision, mandate, values, and guid-
http://www.cihr-irsc.gc.ca ing principles are discussed below.
116 Canadian Institute of Health Services and Policy Research (IHSPR)
Vision and tomorrow; (c) encourage productive collabo-

ration among researchers who use diverse methods
The vision of the institute is to strengthen
and offer varied types of expertise; (d) uphold the
Canada’s healthcare system through health services
principles of academic freedom, independence,
and policy research. Specifically, its vision is of a
and the right to publish; (e) address, wherever pos-
vibrant community of excellent researchers who
sible and practical, regional and other disparities
conduct outstanding health services and policy
in Canada’s capacity to undertake outstanding
research that informs Canadians about their health-
research in the domain of the institute’s mandate;
care system, is used by decision makers to strengthen
(f) facilitate access to data that can be used to con-
Canada’s healthcare system, and influences health
duct health services and policy research, at the
and social policy in Canada and abroad.
same time working with partners to ensure that
access protocols respect the privacy of information
Mandate on individual patients, providers, and organiza-
tions; (g) support initiatives that will result in the
The mandate of the institute is to support health
timely translation of relevant research knowledge;
services and policy research and its timely transla-
(h) provide timely responses to all those who com-
tion. Specifically, it is to support outstanding
municate with staff of the institute; and (i) interact
research, capacity building, and knowledge trans-
with all individuals and organizations with integ-
lation initiatives designed to improve the way
rity and respect.
healthcare services are organized, regulated, man-
As a dynamic organization, the specific goals
aged, financed, paid for, used, and delivered, in the
and objectives of the IHSPR are expected to evolve
interest of improving the health and quality of life
as changes occur in the environment in which the
of all Canadians.
institute operates. However, strategic planning is
guided by five key areas, corresponding to the
Values institute’s planning, reporting, and accountability
structure: (1) creation and synthesis of outstand-
The institute’s fundamental and core values that ing research; (2) building a community of out-
influence its decision making, strategic activities, standing researchers in innovative environments;
and operations are (a) international excellence; (3) translating health research into action; (4) dev
(b) ethically responsible research; (c) scientific eloping and nurturing effective partnerships and
rigor; (d) diversity in theoretical and methodologi- public engagement; and (5) promoting and facili-
cal approaches; (e) innovation; (f) impartial, arms- tating organizational excellence in all institute
length, peer, and merit adjudication; (g) involve- activities, and with the CIHR generally. The insti-
ment and recognition of, and respect for, a wide tute’s current goals and objectives are listed in its
range of partners from all relevant sectors, prov- Web site.
inces, and other countries; and (h) a transparent
approach that facilitates accountability to all
Canadians. Activities and Funding
To achieve its mandate, the IHSPR initiates and
administers funding programs, supports knowl-
Guiding Principles
edge transfer between researchers and decision
The institute is guided in its strategic and opera- makers, initiates the establishment of strategic
tional activities by the following principles: (a) partnerships, and develops and disseminates pub-
provide leadership through working collabora- lications and other resources.
tively with key partners in identifying, coordinat- Between FY1999–2000 and April 2007, the insti-
ing, focusing, and integrating health services and tute awarded CAN$135 million. During FY2006–
policy research and knowledge translation priori- 2007, it awarded CAN$24.2 million to 371 projects.
ties for Canada; (b) support superb research and The institute’s funding opportunities announced
researchers involved in addressing the problems during 2006 included fellowship awards, grants for
confronting healthcare decision makers of today pandemic flu preparedness, partnerships for health
Canadian Institute of Health Services and Policy Research (IHSPR) 117
system improvement, knowledge translation, access synthesis is the process of using systematic meth-
to care, and the development of wait-time bench- ods to aggregate data from multiple studies on a
marks. particular topic. Syntheses can make an important
Knowledge translation is another important contribution to the process that decision makers
function of the IHSPR. Knowledge translation is and healthcare administrators use when establish-
the exchange, synthesis, and application of knowl- ing policy. Syntheses translate a body of knowl-
edge within a complex set of interactions among edge into information useable by those who can
researchers and users, which accelerates the cap- use it to inform their decisions.
ture of the benefits of research through improved The development of national benchmarks on
health, more effective services and products, and a wait times is an important contribution to the
strengthened healthcare system. Knowledge trans- Canadian healthcare system. Within a single-
lation is required as an integral part of all institute- payer healthcare system such as the one operating
funded initiatives. In addition, the institute supports in Canada, it is necessary to have research evi-
knowledge translation through the journal Health dence that identifies wait times that do not exceed
care Policy, through the development of knowl- lengths that have been shown to have negative
edge translation casebooks, and through other effects on people’s health. The institute has
direct-funding programs. funded research teams to contribute to develop-
Healthcare Policy is the first Canadian journal ing this evidence that was subsequently used as
dealing with a wide range of policy-related health part of the process of developing national bench-
issues from a multidisciplinary perspective. The marks. The institute-funded research on wait
institute was instrumental in establishing the jour- times continues.
nal, in partnership with the Canadian Association
for Health Services and Policy Research (CAHSPR).
The journal is published quarterly and is available Organization
in electronic and print formats. As part of the CIHR, the IHSPR is ultimately
Casebooks are an approach to knowledge accountable to the Canadian parliament. A govern-
translation that showcases creative initiatives taken ing council is responsible for the management of
to share knowledge between researchers and deci- the property, business, and affairs of all the insti-
sion makers. The first knowledge translation case- tutes. Each of the institutes is led by a scientific
book developed by the institute was Evidence in director who has responsibility for building the
Action, Acting on Evidence. This publication institute and research capacity; establishing and
draws from the experiences of individuals, teams, nurturing partnerships; fostering networking,
and organizations from across Canada, and it knowledge dissemination, and communications;
describes a broad range of knowledge translation and conducting research. An institute advisory
activities, including what worked, what did not board provides advice to each scientific director on
work, and lessons learned. A second casebook strategic directions for the institute. This is a key
titled Moving Population and Public Health link between institute and stakeholder communities
Knowledge Into Action: A Casebook of Knowledge and is a source of broad community engagement.
Translation Stories was developed in partnership
with the Canadian Population Health Initiative. Gregory S. Finlayson
This casebook focuses on population and public
See also Access to Healthcare; Benchmarking; Canadian
health research. Topics include aboriginal health, Association for Health Services and Policy Research
child and youth health, women’s health, occupa- (CAHSPR); Canadian Health Services Research
tional and workplace health, and infectious and Foundation (CHSRF); Health Services Research in
chronic diseases. Canada
The IHSPR has initiated special knowledge
translation activities in recent years, including
Further Readings
funding research syntheses, and contributing to the
establishment of national benchmarks for wait Barer, Morris. “Wait Times,” Research Spotlight, 1–2,
times for selected healthcare services. Research January 2006.
118 Cancer Care
Fooks, Cathy. The Taming of the Queue: Wait Time of smell, and his or her ability to consume enough
Measurement, Monitoring and Management— food, this may result in various side effects. Cancer
Colloquium Report. Ottawa, Ontario: patients may also be confronted with emotional
Canadian Policy Research Networks, 2004. problems, such as giving up hope that they will
Institute of Health Services and Policy Research. survive treatment. Therefore, trained social work-
Strategic Plan April 1, 2005–March 31, 2008: Health ers and pastoral counselors, working together with
Services and Policy Research, Making the Best of the oncologist and nutritionist, can help patients
Canadian Health Care. Vancouver, British Columbia, during this difficult time. Getting patients to focus
Canada: Institute of Health Services and Policy
on recovery and convincing them to consume the
Research, 2005.
right kinds of food during and after treatment
McIntosh, Tom. The Taming of the Queue II: Wait
helps them stay strong.
Times Measurement, Monitoring and Management—
Colloquium Report. Ottawa, Ontario: Canadian
Policy Research Networks, 2005. Diet and Nutrition Therapy
Torgerson, Renee, and Tom McIntosh. The Taming of
the Queue III: Wait Time Measurement, Monitoring Research has shown that cancerous tumors may
and Management: Where the Rubber Meets the Road. produce chemicals that change the way the body
Ottawa, Ontario: Canadian Policy Research uses nutrients. The human body’s use of proteins,
Networks, 2006. carbohydrates, and fats may be affected, espe-
cially by stomach and intestinal tumors. To ensure
proper nutrition, a cancer patient has to consume
Web Sites enough foods that contain the essential nutrients
of vitamins, minerals, protein, and carbohydrates.
Canadian Institute of Health Services and Policy Research Malnutrition can cause cancer patients to be
(IHSPR): http://www.cihr-irsc.gc.ca/e/13733.html
weak, tired, and unable to resist infections or
Canadian Institutes of Health Research (CIHR):
withstand needed cancer therapies. Not consum-
http:// www.cihr-irsc.gc.ca
ing enough protein and calories is a common
nutrition problem faced by many cancer patients
as these are important for healing, fighting infec-
tion, and providing enough energy for daily
Cancer Care activities. Sometimes a patient may appear to be
eating enough, but the body may not be able to
Cancer care involves an entire team of medical absorb all the nutrients. Thus, diets high in pro-
specialists who care for patients with this chronic tein and calories can help prevent the onset of
condition. Although the diagnosis of cancer gener- cachexia, a disease common among cancer patients
ally begins with an oncologist or other physician, who appear to be physically wasting away.
a healthcare team comprising nutritionists, social Nutrition therapy can help maintain body
workers, and even pastoral counselors may work weight and strength, prevent body tissue from
with the patient. Depending on the stage and type breaking down, rebuild tissue, and fight infec-
of cancer, a patient may undergo surgery, chemo- tion. Nutritional guidelines for cancer patients
therapy, radiation therapy, or immunotherapy. can be very different from the usual suggestions
Additionally, patients may seek out complemen- for healthful eating. People who eat as sug-
tary and alternative treatments, such as nutritional gested during cancer treatment may be able to
therapy, that may be essential to healing and trans- handle higher dosages of certain anticancer
forming cancer patients into cancer survivors. treatments.
Each of the various cancer treatments can affect Another treatment that may help relieve cancer
recovery in a different way. Cancer and its associ- symptoms and side effects that cause weight loss is
ated therapies can often cause nutrition-related through natural drug supplements. These are natu-
side effects, which may impede the recovery of ral drugs that can relieve the symptoms of nausea,
patients. Furthermore, because cancer treatments vomiting, diarrhea, and constipation and increase
can interfere with a patient’s appetite, taste, sense the production of pancreatic enzymes.
Cancer Care 119
Surgery oatmeal and bran—beans, vegetables, fruit, and

whole-grain breads; (c) select high-protein and
More than half of all patients who have cancer, high-calorie foods to help surgical wounds heal—
including head, neck, stomach, and intestinal can- excellent food choices include eggs, cheese, whole
cer, elect to have surgery. The surgical procedure milk, ice cream, nuts, peanut butter, meat, poul-
may involve the removal of all or part of the try, and fish; and (d) increase calories by frying
affected organ. Surgery increases the body’s need foods and using gravies, mayonnaise, and salad
for nutrients and energy to heal the wounds. This dressings.
can also result in complications that affect a
patient’s ability to eat and metabolize food.
Chemotherapy
Surgery to the neck and head often cause chew-
ing and swallowing problems. In addition, stress Chemotherapy is a cancer treatment that uses
due to the amount of tissue removed during sur- drugs to stop the proliferation of cancer cells,
gery may also affect the appetite. Surgery for can- either by killing the cells outright or by stopping
cer in the digestive tract may reduce the ability of those cells from dividing. Because chemotherapy
the gastrointestinal system to work properly and targets rapidly dividing cells, healthy cells that
may inhibit the digestion of food. Furthermore, usually grow and divide rapidly may also be
removal of a part of the stomach may cause the affected by the cancer treatments. These include
feeling of fullness for the patient before enough cells in the mouth as well as in the digestive tract.
food has been eaten. Stomach surgery can also There are a number of nutrition-related side
cause dumping syndrome or the emptying of the effects that often occur during chemotherapy that
stomach into the intestines before food is digested. affect a person’s ability to eat and digest food
Because the organs of the digestive system nor- properly. Some of the most common side effects
mally produce important chemicals and hormones, include anorexia, nausea, vomiting, diarrhea, con-
which are needed for digestion, surgery on these stipation, inflammation, and infections.
organs may affect the body’s ability to absorb The side effects of chemotherapy may also make
nutrients and vitamins. Additionally, levels of it difficult for a patient to obtain the nutrients
sugar, salt, and fluids in the body may become needed to regain healthy blood cell counts between
unbalanced. successive chemotherapy treatments. Thus, nutri-
Nutrition therapy may be able to treat these tion therapy can help patients get the appropriate
complications and allow cancer patients receive nutrients to tolerate and recover from chemother-
the nutrients they need. Some of the nutrition apy as well as prevent weight loss and maintain
therapy for cancer surgery patients may include overall general health. Nutrition therapy for
enteral nutrition or feeding liquid through a tube patients undergoing chemotherapy may include
into the stomach or intestine; parenteral nutrition supplements high in calories and protein and
or feeding through a catheter into a vein; medi- enteral nutrition or tube feedings.
cines to increase appetite; and nutritional supple-
ment drinks.
Radiation Therapy
It is common for patients to experience pain,
tiredness, and loss of appetite after surgery. Some Radiation therapy is a cancer treatment that uses
patients may not be able to consume their regular high-energy X rays and other forms of radiation
diet because of these symptoms. Thus, the follow- to kill cancerous cells. There are two basic types
ing eating tips are commonly recommended by of radiation therapy: external radiation therapy,
physicians: (a) Avoid carbonated drinks—such as which uses a machine outside the body to send
soda pop—and gas-producing foods, including radiation to the cancer, and internal radiation
beans, peas, broccoli, cabbage, Brussels sprouts, therapy, which uses a radioactive substance sealed
green peppers, radishes, and cucumber; (b) in needles, seeds, wires, or catheters that are
increase fiber by small amounts and drink lots of placed directly into or near the cancer site.
water, if regularity is a problem, and good sources Radiation therapy can often harm healthy cells in
of fiber include whole-grain cereals—including the treatment area. Side effects can occur when
120 Cancer Care
healthy cells that are near the cancerous cells are Psychosocial Interventions
affected by the radiation treatments. These side
effects depend mostly on the dose of radiation and There are also psychosocial interventions avail-
the part of the body that is treated. able for cancer care, such as counseling, that are a
Radiation therapy that is performed near the part of the offerings at major hospitals. These
digestive tract is likely to cause nutrition-related interventions may include education, behavioral
side effects. Radiation therapy to the head and training, individual psychotherapy, and group
neck may cause anorexia, taste changes, dry interventions.
mouth, inflammation of the mouth and gums, According to researchers at the University of
swallowing problems, jaw spasms, cavities, or California at Los Angeles School of Medicine, there
infection, while radiation therapy to the chest may is a need for a wide variety of psychosocial inter-
cause swallowing problems, esophageal reflux or a ventions for cancer patients as these types of inter-
backward flow to the stomach. In addition, radia- ventions positively affect the survival of cancer
tion therapy to the pelvis or abdomen may cause patients. Furthermore, the need for a variety of psy-
diarrhea, nausea and vomiting, inflammation of chosocial interventions is enhanced, as increasing
the rectum or intestine, and fistula in the stomach numbers of patients with cancer survive longer.
or intestines. Some long-term effects can include Excellent communications skills in the oncolo-
narrowing of the intestine and poor absorption or gist can also help patients understand that comple-
blockage in the stomach or intestine. Radiation mentary therapies are available to them. A study
therapy may also cause exhaustion, which can reported that communication within the field of
lead to a decrease in appetite and a reduced desire oncology is a core clinical skill but one in which
to eat. few oncologists or cancer nurse specialists have
Nutrition therapy may be able to treat some of received much formal training. Additionally, com-
these side effects associated with radiation therapy, munication difficulties may interfere with the
and it can provide the patient with enough calories recruitment of patients into clinical trials, which
and protein to tolerate the treatment, prevent may result in delaying the introduction of effica-
weight loss, and maintain general health. The cious new treatments. Oncologists have acknowl-
therapeutic regimen may include nutritional sup- edged that insufficient training in communication
plement drinks between meals, tube feedings, or and management skills is a major factor contribut-
other changes, including eating small meals ing to their own stress, lack of job satisfaction, and
throughout the day and choosing certain kinds emotional burnout. As a result, there have been
of food. various initiatives targeted at improving basic
communication skills and training for healthcare
professionals in the cancer field.
Immunotherapy Researchers have also noted that there is a
Immunotherapy or biological therapy is a form of growing acknowledgment about the role that faith
cancer treatment that uses a patient’s own immune plays in patients seeking out cancer therapy as well
system to fight cancer. Substances that are made as in healing. Thus, many cancer hospitals have
by the body or made in a laboratory can be used increased the role of chaplains and pastoral care
to boost or restore the body’s natural defenses personnel in cancer care units. One study noted
against cancer. Some of the most common side that decisions regarding cancer treatment choices
effects associated with immunotherapy include can be difficult and that many factors may influ-
fever, nausea, vomiting, diarrhea, anorexia, and ence the patient’s decision to undergo treatment. A
exhaustion. poorly understood factor is the role of a patient’s
Nutrition therapy can be used to treat the faith in how he or she makes medical decisions. In
nutrition-related side effects of immunotherapy. If this study, researchers interviewed more than 100
these side effects are not addressed, weight loss patients with advanced lung cancer, their caregiv-
and malnutrition may occur and lead to complica- ers, and 257 medical oncologists. The study par-
tions during recovery, such as poor healing or ticipants were asked to rank the importance of
infection. their cancer physician’s recommendation, faith in
Cancer Care 121
God, ability of the treatment to cure disease, connect with their spiritual side by the mind-body
side effects, family physician’s recommendation, therapies there during the cancer care treatment.
spouse’s recommendation, and children’s recom- Patients can be instructed in spiritual practices
mendation as factors that might influence their such as yoga, Tai Chi, or other techniques from the
treatment decisions. The findings revealed that all Far East that can be used to concentrate the mind
three groups ranked the oncologist’s recommenda- and body and help facilitate the healing process
tion as the most important, and patients and care- from cancer therapy.
givers ranked their faith in God second. The
researchers concluded that patients and caregivers
agree on the factors that are important in deciding Future Implications
treatment for advanced lung cancer; however, their With the aging of the nation’s population, the
decision differed from physicians. All the groups number and rate of cancer patients will continue
agreed that the oncologist’s recommendation was to increase. To meet their needs, cancer care will
the most important. The results indicated that this involve many different facets in the healing pro-
was the first study to demonstrate that faith is an cess, including traditional as well as complemen-
important factor in medical decision making. tary and alternative treatments. A medical team
Another study also found a positive role for must work in synchrony to effectively care for
religious faith in cancer care for breast cancer cancer patients. Additionally, oncologists and
patients. The study identified and examined the other healthcare team members must be cognizant
religious and spiritual coping strategies of elderly and attentive to cancer patients’ unique needs to
women newly diagnosed with breast cancer. For better facilitate cancer care and achieve the best
this study, 33 women, aged 65 and older, of vari- possible outcome.
ous religious denominations were recruited, within
6 months of diagnosis. The findings from this Gene J. Koprowski
study showed that religious faith either stayed the
same or increased during the cancer crisis. Three See also Acute and Chronic Diseases; Chronic Care
themes also emerged from the analysis: Religious Model; Complementary and Alternative Medicine;
faith provided the respondents with the emotional Mortality, Major Causes in the United States; Quality
support necessary to cope with breast cancer; faith of Healthcare; Quality of Life, Health-Related;
communities provided social support for patients; Randomized Controlled Trials (RCTs)
and faith provided patients with the ability to
make sense of their lives during cancer.
In another study, it was found that cancer Further Readings
patients have a range of psychosocial needs that
Adler, Nancy E., Ann E. K. Page, and the Committee on
require particular support interventions. Although
Psychosocial Services to Cancer Patients/Families in a
patients may have strong needs that relate to iden-
Community Setting, eds. Cancer Care for the Whole
tity, emotional, spiritual, and practical issues, they
Patient: Meeting Psychosocial Health Needs.
are less commonly expressed. Furthermore, patients
may have particular needs based on their tumor Cohen, Lorenzo, and Maurie Markman, eds. Integrative
type, severity of illness, age, gender, health status, Oncology: Incorporating Complementary Medicine
and socioeconomic and other social factors. Into Conventional Cancer Care. Totowa, NJ:
Many cancer treatment centers seek to provide Humana Press, 2008.
patients with the necessary tools to cope with their Corner, Jessica, and Christopher Bailey, eds. Cancer
illness when treating their patients. One center, for Nursing: Care in Context. Malden, MA: Blackwell,
example, offers daily spiritual gatherings for can- 2008.
cer patients and holds classes in praying the rosary Jacobs, Lea K., ed. Coping With Cancer. New York:
for Roman Catholic, Orthodox, and Anglican Nova Science, 2008.
patients, as well as Bible study for evangelical Lyman, Gary H., and Jeffrey Crawford, eds. Cancer
Protestants. Even patients who do not come from Supportive Care: Advances in Therapeutic Strategies.
a strong religious background are encouraged to New York: Informa Healthcare, 2008.
122 Capitation
Silvestri, Gerard A., Sommer Knittig, James S. Zoller, et It is recorded that under the rule of Henry I of
al. “Importance of Faith on Medical Decisions England and Normandy that John of Essex
Regarding Cancer Care,” Journal of Clinical received an honorarium of 1 penny per day for
Oncology 21(7): 1379–82, April 1, 2003. serving in a physician’s role, a sum equal to that
Sparks, Lisa, Dan O’Hair, and Gary L. Kreps, eds. paid for a foot soldier or blind person of the
Cancer, Communication, and Aging. Cresskill, NJ: time.
Hampton Press, 2008. Some early American physicians were also paid
Tovey, Philip, John Chatwin, and Alex Broom. on a capitated basis. The author Samuel Clemens,
Traditional, Complementary, and Alternative
better known as Mark Twain, noted that while he
Medicine and Cancer Care: An International
was growing up in Hannibal, Missouri, his parents
Analysis of Grassroots Integration. New York:
paid a local physician $25 annually to care for his
Routledge, 2007.
family when they were ill.
At the height of the managed-care movement, in
the 1980s and 1990s, many physicians were paid a
Web Sites lump sum each month to deliver primary and/or
American Cancer Society (ACS): http://www.cancer.org specialty services for patients. Patients were
National Cancer Institute (NCI): http://www.cancer.gov required through insurance arrangements to desig-
National Comprehensive Cancer Network (NCCN): nate a primary-care physician through whom all
http://www.nccn.org their primary services would be provided. The
physician then would have a panel of patients they
could see on a walk-in or appointment basis.
Primary care, internal medicine, and pediatrics
were the clinical areas that were customarily desig-
Capitation nated for capitation payment.
In the late 1990s, physician capitation expanded
Capitation is the prepayment for patient health- from individual physicians to encompass physician
care services. Generally, capitation payments are group practices. Insurers used enhanced capitation
based on a per-member per-month (PMPM) basis. schedules to recruit large physician networks and
While all types of physicians can be compensated then introduced the global capitation philosophy,
on a capitated basis, primary-care physicians in which incorporated multiple primary physicians
family practice, internal medicine, and pediatrics and ancillary services. As the capitation phenome-
are often paid on a capitated basis. The capitation non grew, some practices realized that they were
rate includes services provided by the physicians, poorly managing the PMPM rate that they were
and it usually also includes diagnostic tests per- being paid. Patients started demanding more ser-
formed in their offices. The capitation rates vary vices, and the physicians were demanding enhanced
with the age and gender of the patients. For payment. Thus, insurers introduced enhanced
example, the capitation rate for a child under 1 quality payments and bonus payments for meeting
year of age is higher than the rate for a 2- to performance standards.
5-year-old child because the number of physician The clinical changes in the specialties of cardiol-
visits is expected to be greater. Similarly, the capi- ogy and orthopedics that incorporated diagnostic
tation rates for women between the ages of 18 and technological advancements were revolution-
and 40 are higher because the utilization of ser- izing those disciplines. As a result, insurance com-
vices is expected to increase due to their child- panies wanted to expand capitation payment into
bearing years. those clinical specialties; however, this did not
catch on as a payment method. Incorporating the
broad array of procedures and equipment into
Overview
specialty capitation transferred too much risk to
Capitation in the United States is often associ- the physician. Providers who tried to manage
ated with managed-care organizations; however, patients under a capitation arrangement found it
the concept dates as far back as the Middle Ages. difficult to meet their financial expectations.
Capitation 123
Calculation of Capitation advantage is that there is a relationship with a

primary-care physician and minimal out-of-pocket
Every physician office has a bill collection and
expenditure for services.
utilization profile. An insurance or managed-care
In terms of disadvantages, physicians may
company will use an actuary to develop a profile
assume too much risk by having many capitated
of the physician. For example, the average prima-
patients who are severely ill and need medical ser-
ry-care physician may charge $100 per visit.
vices. Furthermore, some payers, particularly
Based on the age of the patient, the physician may
Medicaid, may not adequately pay, or not pay in a
expect to see the patient 2.5 times a year.
timely manner, for their capitated patients.
Therefore, in a year, the billed rate would be
$100 × 2.5 visits = $250/12 months per year =
$20.83 per member per month. For every patient Future Implications
with the same gender and age, the physician
would receive $20.83 per month. Although this Today, capitation remains an important physi-
amount is high, it can be used for illustration pur- cian payment method, especially in areas domi-
poses. Moreover, the case-mix of the patients in nated by managed-care organizations. This is the
an office may affect the physician compensation. case in some of the western parts of the nation,
For example, a physician with a large HIV/AIDS where large health maintenance organizations
patient population may receive a higher capita- (HMOs) are the dominant providers of care.
tion rate because of the complexity of the care the However, for the most part, capitation is no lon-
patients need to receive. In other cases, the loca- ger the preferred payment source of physicians
tion of the physician’s office may also affect the because many prefer to unbundle their services
capitation rate because the cost of living in certain and be paid on a fee schedule. This may change as
areas may dictate a higher capitation rate. A par- healthcare expenditures continue to increase and
ticular primary-care specialty may also dictate federal and state governments along with employ-
that a physician be paid more than another such ers move to reduce costs through the capitated
as in the case of an internist being paid more than model of care.
a family practitioner. Diane M. Howard
See also Cost of Healthcare; Employee Health Benefits;

Advantages and Disadvantages of Capitation Fee-for-Service; Health Insurance; Health Maintenance
Organizations (HMOs); Managed Care; Payment
The advantage of capitation for the physician is Mechanisms; Physicians
that he or she can negotiate a contractual relation-
ship with an insurance company for a payment.
Through the insurance company relationship, the Further Readings
insurer will have members who require a physi-
Bloom, Joan R., Teh-wei Hu, Neal Wallace, et al.
cian relationship. The patient-member is required
“Mental Health Costs and Access Under Alternative
to designate a primary-care physician who is
Capitation Systems in Colorado,” Health Services
responsible for his or her care. The patient can
Research 37(2): 315–40, April 2002.
then presumably visit the physician on an unlim- Grieve, Richard, Jasjeet S. Sekhon, Teh-wei Hu, et al.
ited basis under the capitation arrangement. In “Evaluating Health Care Programs by Combining
this example, the physician assumes the risk of Cost With Quality of Life Measures: A Case Study
managing the patients in a manner that allows his Comparing Capitation and Fee for Service,” Health
or her practice to make a profit. Services Research 43(4): 1204–22, August 2008.
The advantage of capitation for an insurer is Super, Nora. “From Capitation to Fee-for-Service in
that there is predictable budgeting and the delega- Cincinnati: A Physician Group Responds to a
tion of medical management to the provider. For Changing Marketplace,” Health Affairs 25(1):
the provider’s part, there is also a predictable 219–25, January–February 2006.
income and steady payment on a biweekly or Terry, Ken. “Capitation: Still a Factor for Some,” Medical
monthly basis from the insurer. For the patient, the Economics 84(23): 38, 40–41, December 7, 2007.
124 Carve-Outs
Web Sites In the 1980s, insurance companies developed

America’s Health Insurance Plans (AHIP): large utilization review programs with elaborate
http://www.ahip.org referral systems that quickly frustrated enrollees and
American College of Physicians (ACP): primary-care physicians because of the paperwork
http://www.acponline.org involved in getting a referral. Behavioral health, den-
Employee Benefit Research Institute (EBRI): tal care, and worker’s compensation services were
http://www.ebri.org unique and required specialized oversight. For the
most part, the staffs employed by the insurance com-
panies had general medical/surgical backgrounds,
and therefore they found it difficult to approve spe-
cialty referrals to services for which they had limited
Carve-Outs formal training. In response to these knowledge
gaps, insurance and managed-care companies
The term carve-outs in the health insurance indus- recruited nurses and physicians who had expertise in
try relates to the unique healthcare services that are behavioral health, dental care, and worker’s com-
removed or carved out from a given set of insur- pensation to fill this void and develop carve-outs.
ance benefits. The carved-out services are provided
by a separate vendor or company that offers exper-
tise to a given membership base, and provision of Advantages and Disadvantages of Carve-Outs
these services involves a contract that is separate
The intent of carve-outs is to deliver efficient and
from any made with a managed-care organization.
cost-effective services by a central source that has
The concept of carve-outs was popularized in the
expertise in a particular service. Some examples
late 1980s, when managed care accelerated in the
of carve-outs include dental care, mental health,
United States due to rising healthcare costs. Carve-
workers compensation, and pharmacy benefits.
outs have advantages as well as disadvantages for
The advantages of carve-outs include the follow-
healthcare providers and consumers.
ing: economies of specialization, enhancement in
access to care, the knowledge and expertise that
Overview comes with specialization, better coordinating of
services with medical and surgical services, con-
Carve-outs represent a model of contracting for
trol of utilization, and using market power to
specialty care with providers as a way of control-
affect quality. In contrast, the disadvantages of
ling rising healthcare costs. Carve-out contracts
carve-outs include the lack of coordination
can include care for patients with certain condi-
between various providers and the time needed to
tions, particular services, or care for an entire
perform the coordination. Oftentimes, patients
subpopulation of patients. Carve-outs are distinct
are caught in the middle, and they do not have
because they involve a set of providers or manage-
anyone to serve as their advocate. In some cases,
ment organizations different from those that are
companies have in-sourced their carve-outs to
otherwise available for patients within a health
limit the confusion. Some of the coordination dif-
plan. They permit a unique set of managed-care
ficulties have occurred prominently in the mental
techniques to be applied to an area of care that is
health area.
costly or involves complex benefits. Carve-out
arrangements can occur at different levels of the
healthcare system, including the payer, health
Carve-Out Examples
plans, or group practices to manage a portion of
the insurance risk. Carve-outs appear to lower the The number of specialty service companies in den-
associated costs of healthcare for employers and tal care, mental health, workers’ compensation,
health plans, although whether or not they improve and pharmacy benefits has greatly increased. For
patient outcomes is unclear. In addition, carve- example, several states have developed contrac-
outs may change the competition dynamics among tual relationships with trade unions for carve-out
health plans. dental services.
Case Management 125
Behavioral or mental health services are another Future Implications

example of frequent carve-outs. The types of ser-
The future of carve-outs is unclear. The U.S.
vices under the behavioral health umbrella include
healthcare system is dynamic, and the nature of
the following: hospital inpatient services, residen-
services will continue to change as economic
tial treatment, partial hospitalization, intensive
incentives shift. There are many opportunities to
outpatient programs, outpatient treatment, and
change the nation’s healthcare system so that it
employment assistance programs. In the early
meets better the expectations of federal and state
1990s, many state governments were trying to
governments, employers, insurers, and individu-
move their Medicaid recipients into more cost-
als. As long as carve-outs add efficiencies, limit
efficient services. State governments anticipated
healthcare expenditures, offer enhanced access to
that they could take advantage of the cost savings
services, and coordinate care, they will likely con-
offered in managed care, and they began to pro-
tinue to play a role in the nation’s healthcare
mote Medicaid managed-care programs; Medicaid
system.
recipients were moved into plans with defined ben-
efits with an associated per-member per-month Diane M. Howard
(PMPM) rate. Often, the state’s Medicaid recipi-
ents were given a choice of two managed-care See also Acute and Chronic Diseases; Competition in
programs to join. The very nature of Medicaid Healthcare; Cost of Healthcare; Disease Management;
recipients with their socioeconomic problems and Health Insurance; Health Maintenance Organizations
their associated mental health issues moved states (HMOs); Managed Care; Mental Health
to carve out mental health services from medical
and surgical services.
Many state workers’ compensation programs Further Readings
were established in the United States at the begin- Davidoff, Amy, Ian Hill, Brigette Courtot, et al. “Effects
ning of the 20th century. These programs provide of Managed Care on Service Use and Access for
medical care and disability income to workers who Publicly Insured Children With Chronic Health
are injured in the course of their employment. Conditions,” Pediatrics 119(5): 956–64, May 2007.
Under the programs, the injured worker is prohib- Feinberg, David T. “Are ‘Carve-Outs’ In or Out?”
ited from bringing a lawsuit against the employer, Journal of Child and Adolescent Psychopharmacology
and the employer is obligated to pay the mandated 14(2): 161–63, June 2004.
benefits. Since workers’ compensation programs Frank, Richard G., and Rachel L. Garfield. “Managed
are mandated by the states, the programs are Behavioral Health Care Carve-Outs: Past
funded primarily through private insurance com- Performance and Future Prospects,” Annual Review
panies, state funds, or self-insurance provided by of Public Health 28: 303–20, 2007.
employers. Employers that want to protect them- Morrisey, Michael A. Health Insurance. Chicago: Health
selves from the specialized legal and regulatory Administration Press, 2007.
nature of the workers’ compensation program
often carve out these services to companies with
this clinical and legal expertise. Web Sites
Pharmacy benefits have also been carved out to America’s Health Insurance Plans (AHIP):
pharmacy benefit managers (PBMs). Pharmacy http://www.hiaa.org
benefits are currently the third largest healthcare Employee Benefit Research Institute (EBRI):
benefit expenditure of insurance plans after hospi- http://www.ebri.org
tal and outpatient medical benefits. The percent-
age increase in pharmacy benefits has increased to
the double digits to 10.1% of healthcare expendi-
tures in 2006. And because of the aging and Case Management
increasing longevity of the nation’s population,
pharmacy services will likely continue increasing Case management is a clinical tool that is used
in the near and distant future. to increase the efficiency and effectiveness of
126 Case Management
client health and social services and control the modern case management model was estab-
costs at the same time. The Case Management lished in the 1970s through the Medicare and
Society of America (CMSA) defines case man Medicaid programs, which used social workers as
agement as a collaborative approach to assess, caseworkers to facilitate care provided by multiple
plan, facilitate, and advocate for services that health and social service providers for identified
meet the health needs of individuals and to special-needs populations, such as the elderly and
increase the quality and cost-effectiveness of those with mental illness.
client outcomes. More generally, case manage- As the healthcare system and the management
ment helps coordinate resources and services; of disease and disability have grown increasingly
advocates for client’s/patient’s rights; monitors complex and fragmented, the need for case man-
and manages clients/patients throughout epi- agement has increased substantially. The applica-
sodes of illness across all care settings and sys- tion of case management, however, varies based on
tems; and addresses clients’/patients’ physical, three criteria—the profession of the individual
emotional, social, mental, and economic needs. providing the case management services (i.e., regis-
Case managers often help clients navigate tered nurse or social worker), the population
between the different stages of care and provid- receiving the services (i.e., the elderly or individu-
ers as well as to help facilitate payment by pri- als with mental illness), and the type of organiza-
vate or government payers. The broad goals of tion providing the case management (i.e., hospital
case management seeks to prevent rehospitaliza- or insurance company).
tion, prevent inappropriate hospital emergency A social service/public health model focuses on
department use, and reduce the number of lost patient advocacy and access to services in a frag-
days of work the client experiences to arrange mented healthcare system. The case management
for care. Case management also acknowledges model that has emerged from the managed-care
the role of other systems, such as the labor, sector, however, has been motivated by cost con-
financial, and legal systems, in implementing tainment and encourages the utilization of cost-
healthcare. effective community care.
In the current environment of escalating health-
care costs, case management has become a popu-
Overview
lar method to control costs and eliminate the
Case management has its origins in the commu- duplication of services and prioritize less costly
nity mental health movement following the dein- services that may be equally effective. The man-
stitutionalization of the mentally ill that began in aged-care model of case management that has
the 1950s. Client-centered community support been increasingly used, however, is primarily
systems for the deinstitutionalized mentally ill driven by cost containment as opposed to the
were created under the Community Support client-centered approach of the public health
Program at the National Institute of Mental model. As a result, appropriate care may be com-
Health (NIMH). Due to the lack of sufficient pub- promised by denying treatments that may be
lic funding for care, individual case managers, clinically necessary or by discharging patients
who were mostly in the field of social work, earlier than recommended.
assumed the responsibility for linking mentally ill Case management can be of great value when
clients to needed community mental health ser- dealing with the complex needs of clients who
vices and support. The case manager identified the have multiple health and social issues, such as indi-
resources and support systems in the communities, viduals with mental illness, HIV/AIDS, or sub-
provided counseling, and assisted with the tasks of stance abuse problems. Case managers typically
daily living while providing linkages to needed use a client-centered approach to assess clients in a
services. The private-sector interest in case man- holistic manner, prioritize and advocate for their
agement grew following World War II as a method needs, and navigate them through the continuum
to control the healthcare costs of returning veter- of care.
ans with complicated injuries who needed treat- Case managers can be internal to an organiza-
ment from multiple providers. The foundation for tion by working within a program or facility.
Case Management 127
On the other hand, external or independent case care. Hospitals often treat patients with compli-
managers are often employed by insurance compa- cated healthcare needs and therefore use case
nies and are hired to provide case management managers to help facilitate access to and coordina-
services. External case managers try to facilitate tion of services to ensure a smooth transition
coordination of care among various providers, across the continuum of care. Case management is
programs, systems, and facilities. also used in long-term care to help clients attain
Although case management may be imple- needed services such as rehabilitation, nursing
mented differently across various settings, the five home facility placement, and home health care.
common goals of case management are (1) enhanc- In addition, the context of service delivery
ing continuity of care; (2) providing access to must be taken into account when considering the
cross-sectional service delivery that is comprehen- range of services provided under case manage-
sive, coordinated, and ongoing; (3) enhancing ment. To receive and effectively use healthcare
accessibility by overcoming administrative barri- services, the client who is living in the community
ers; (4) enhancing accountability by designating a will need stable and safe housing, adequate nutri-
case manager as the point of contact for the tional intake, and a source of income or financial
responsibility of ensuring the effectiveness of the assistance. The client is involved in the process of
system; and (5) enhancing efficiency by increasing service linkages; his or her background and pref-
the likelihood of clients receiving timely delivery of erences are taken into account when identifying
appropriate services. Some of the key functions of a service delivery system, including ethnic
case management include assessment, planning, group affiliation, cultural practices, language,
linking, monitoring, and advocacy. Outreach is and neighborhood.
also sometimes identified as another function of
case management.
Models of Case Management
Case management is also a key component of
systems of care. When case management is a part Numerous models of case management exist;
of the system of care, it has the fiscal authority to however, they can generally be categorized into
procure needed services for clients. For example, a four groups: the broker model, the rehabilitation
community agency can develop a memoranda of model, the full support model, and the strengths
understanding with other agencies to provide care model. The broker case management model is the
to their clients. This approach helps enhance a least intensive and case managers in this model
seamless continuity of services. Systems of care can generally have high caseloads. Under the broker
be located in a single multiservice center acting as model, the case manager links the client with a
a one-stop shop for clients. On the other hand, the service provider. The rehabilitation and full sup-
systems of care can use a saturation approach, port models, however, are more intensive. Under
mobilizing the entire spectrum of services from these models, case managers identify the client’s
medical to social services, and financial and legal strengths and weaknesses and work to address the
services. Additionally, treatment services, rehabili- barriers that prevent them from functioning inde-
tation, housing, employment, and other supports pendently in the community. The full support
can be included. model also includes an in-house team of service
providers to treat clients who have complex and
long-term needs. Last, the strengths model focuses
Case Management Settings
entirely on the client’s strengths. The case man-
and Service Delivery
ager works with the client to develop client-cen-
Case management has been used across a variety tered goals and relies heavily on the client-case
of settings to improve service provision, service manager relationship. This model requires thor-
coordination, and health outcomes. Some of the ough outreach and follow-up services.
individual needs that case managers address Case management is used mostly on a short-
include healthcare and social issues, acute and term basis for hospital discharge planning, reha-
chronic illnesses, substance abuse, homelessness, bilitation, or end-of-life planning. Longer-term
mental illness, domestic violence, and long-term case management may be used for chronic or
128 Case Management
complex diseases such as cancer, diabetes, and case management with increasing frequency,
asthma. Case management has also been used in including rehabilitation counselors and occupa-
communities to coordinate care for low-income tional therapists.
pregnant women to reduce low-birth-weight or
premature babies to reduce infant mortality.
Effectiveness of Case Management
Clients who use case management may also
include the mentally ill, children with mental The effectiveness of case management has been
health and behavior problems, the elderly, and seriously debated, and there are no clear answers.
those with developmental or physical disabilities. Although some studies have found case manage-
Case managers generally receive referrals from ment to be not effective in attaining improved
client identification and outreach in the medical patient health status and cost-effective outcomes,
community; case managers may also identify cli- other studies have found the opposite result.
ents through their outreach. Case managers develop Because case management is integrated with
a therapeutic relationship with their clients to help other client support services in various settings
facilitate care. After client identification, case man- and has broad goals, this concept is very difficult
agers assess the clients’ needs for obtaining care. to evaluate and measure. The effectiveness of a
The case manager identifies those barriers that the program depends on a variety of factors, includ-
client confronts in accessing, obtaining, and receiving the program design, how well it was imple-
ing needed healthcare services. This may include mented, and how well it conforms to
identifying the financing for care, locating trans- evidence-based practices. Measuring the effec-
portation to care, and identifying the appropriate tiveness of case management interventions can
treatment and geographic location for that treat- prove challenging. However, researchers can use
ment. The case manager facilitates the timely treat- scales, client interviews, and questionnaires to
ment and receipt of services by linking the client gain further insight.
with the service provider. Monitoring is a core
component of case management since clients’
Future Implications
needs change over time, especially with complex
and multiple disabilities or medical problems. Case Case management could potentially have an
management is particularly important when medi- impact on reducing the costs for healthcare ser-
cal services are difficult to understand or when vices. Nonetheless, health services research on
navigating healthcare services is uncoordinated. If case management has to include the variations in
a client needs ongoing healthcare services over case management models. Investigators, therefore,
time and continuity of care is critical, case manag- continue to explore the outcomes in access to ser-
ers can link and monitor service use. Case manage- vices, systems performance, cost-effectiveness,
ment is also helpful when a patient has multiple and service patterns. Although some studies point
comorbidities and has a need for multiple services. out that case management has been ineffective in
The case manager coordinates care when there is a meeting its intended goals of coordinating patient
need for attention to provide multiple services at care and reducing costs, other research studies
any one point in time. have pointed out that it can increase access to care
The case manager functions as the patient’s and subsequently improve health outcomes. When
navigator, and the caseload can vary, depending patients are provided with case management,
on the client’s severity of need, type of medical there is a decreased chance of duplicating unneces-
care needed, and the duration of medical service sary medical services and an increased chance of
utilization. The case manager is typically a social providing appropriate and necessary care. Case
worker, registered nurse, or paraprofessional. management remains a promising tool to help
The training and supervision of case managers certain populations obtain needed and essential
includes training in service coordination and ser- social and health services. It is likely that case
vice evaluation. With the increased use of case management will continue to be used by hospitals,
management by insurance companies, profession- insurance companies, and others to control rising
als in various disciplines have also started to use healthcare expenditures and adequately manage
Case-Mix Adjustment 129
the health of special-needs populations and the of the characteristics of those receiving services.
chronically ill. Case-mix adjustment is crucial in reimbursement
for health services, especially in any prospective
Sharon Telleen reimbursement model. For example, the services
See also Acute and Chronic Diseases; Continuum of
needed by an 80-year-old diabetic with arterio-
Care; Cost Containment Strategies; Disease sclerotic heart disease who is admitted to a hospi-
Management; Managed Care; Medicaid; Patient- tal for an acute exacerbation of congestive heart
Centered Care; Primary-Care Case Management failure will differ dramatically from those required
(PCCM) by a 25-year-old athlete admitted for repair of a
torn knee ligament. Equitable and effective reim-
bursement models must take such differences into
Further Readings account. The first widely used case-mix adjust-
ment system was the Diagnosis Related Groups
Daniels, Stefani, and Marianne McHale Ramey. The
(DRGs) used by Medicare since 1983, which paid
Leader’s Guide to Hospital Case Management.
a specific amount for acute care depending on a
Sudbury, MA: Jones and Bartlett, 2004.
Hall, James A., Christopher Carswell, Elizabeth Walsh,
hospital patient’s discharge diagnosis, gender, age,
et al. “Iowa Case Management: Innovative Social
procedures, and comorbidities.
Casework,” Social Work 47(2): 132–41, April 2002. Any attempt to analyze individual health out-
Laramee, Ann S., Susan K. Levinsky, Jesse Sargent, et al. comes also requires researchers to include in their
“Case Management in a Heterogeneous Congestive models those individual characteristics that affect
Heart Failure Population,” Archives of Internal a patient’s likelihood of a better or worse out-
Medicine 163(7): 809–817, April 14, 2003. come. The likelihood of in-hospital mortality will
Myers, Janet, Barry Zack, Katie Kramer, et al. “Get differ dramatically between a patient who has
Connected: An HIV Prevention Case Management fallen and sustained a serious closed health trauma
Program for Men and Women Leaving California and a similar patient whose fall resulted in a hip
Prisons,” American Journal of Public Health 95(10): fracture. These types of adjustments are also nec-
1682–84, October 2005. essary when one analyzes some measures of pro-
Weissert, William G., Richard A. Hirth, Michael E. cess quality. The presence or absence of specific
Chernew, et al. “Case Management: Effects of care practices may depend on the severity of one’s
Improved Risk and Value Information,” illness.
Gerontologist 43(6): 797–805, December 2003. Finally, case-mix adjustment is crucial when
one attempts to measure provider performance,
either for quality assurance or some pay-for-per-
Web Sites formance model. Mortality rates in tertiary care
American Case Management Association (ACMA): hospitals may be higher than mortality rates in
http://www.acmaweb.org community hospitals due to the differing nature of
Case Management Society of America (CMSA): their patient populations. Failing to adjust for
http://www.cmsa.org those differences may significantly distort one’s
Commission for Case Manager Certification (CCMC): judgment concerning differences in the quality of
http://www.ccmcertification.org care provided by those two types of acute care
National Association of Social Workers (NASW): settings.
http://www.socialworkers.org
Nursing Home Example

The Medicare resource utilization group (RUG)
Case-Mix Adjustment models used in nursing homes are examples of
case-mix classification systems used for reim-
A variety of situations in health services research bursement. The steps in the development of the
demand the use of some type of case-mix or acuity RUG models are the same as those that might be
adjustment, that is, adjustment made on the basis used in any healthcare setting. First, a sample of
130 Case-Mix Adjustment
nursing homes (i.e., healthcare providers) is as not receiving appropriate reimbursement for the
selected for participation in the development of care they give. The implementation of these models
the classification model. The sample must meet creates both winners and losers in terms of reim-
minimum quality criteria. Second, researchers bursement levels. For this reason, the models are
conduct a time study in the chosen nursing homes, often implemented in a “soft” manner with wide
in which each staff member or caregiver records corridors around presumptive reimbursement lev-
how they spend all their time over a 1- to 3-day els for nursing homes. Over time, however, these
period. The care time provided by each type of corridors narrow as the providers adjust to this
staff member (e.g., registered nurse, nurse aide) new reimbursement model.
will eventually be weighted by his or her relative Among advocates and academics, the most
salary level. Third, at roughly the same time, each common criticism is that these models only repli-
resident in the selected nursing homes is assessed cate the care provided. Case-mix classification
using a multidimensional assessment tool that models do not identify ideal patterns of care or
evaluates his or her need for care. Fourth, statisti- recognize and reimburse best practices. The
cal analyses are performed on the data concerning resource use estimates that form the core of these
roughly half to two thirds of the residents. These models, whether they are weighted hours of care in
analyses result in the identification of groups of a nursing home or days of care in a hospital, rest
residents who received roughly the same amount on current care patterns. These patterns can be
of wage-weighted care time and had relatively excellent, adequate, or inadequate. Those involved
similar health problems or levels of impairment. in nursing home resident classification have a stan-
The degree to which these groups explain the sta- dard response to this argument. They believe that
tistical variation in weighted care time is an the relative differences reflected by case-mix
important criterion for choosing among potential indexes reflect real differences among residents.
classification models. In nursing homes, for exam- They admit, however, that the specific hours of
ple, these models usually explained between 50% care provided to the index group may not be ideal.
and 70% of the statistical variance in weighted As reassuring as this argument seems, it currently
care time. Fifth, the chosen patient classification lacks a strong base of empirical evidence.
model is validated on data from the remaining Also, for long-term care, such models pay a
residents. Sixth, one group of residents is chosen provider more if it allows someone to decline or
to serve as the index group and given a case-mix become more seriously ill. In essence, these models
index of 1.0. Every other group of residents is can arguably be said to offer incentives exactly the
assigned a case-mix index that reflects the relative opposite of pay-for-performance models. Pro
average weighted care time provided to that fessional ethics, state inspections, the availability of
group compared with the average weighted care ombudsmen and consumer advocates, and reports
time provided to the index group. Seventh, in to consumers of provider performance would all
some instances (RUG-III), case-mix indexes are seem to counterbalance such perverse financial
adjusted, based on clinical judgments. Finally, the incentives. At times, it seems that these “counterin-
case-mix index for the group into which a patient centives” may not function as well as one would
falls can then be used to adjust all, or a portion hope. In acute care, one must only remember con-
of, the payment for that provider’s services to that cerns about “quicker and sicker” hospital dis-
patient. charges as a result of the implementation of the
Medicare DRG system to realize such concerns are
unwarranted. In long-term care, one simply needs
Common Criticisms
to remember the state residential care reimburse-
One of the most common criticisms of all case-mix ment model that paid for the care of residents in
classification systems comes from healthcare pro- wheelchairs and those residential care homes that
viders. Some providers invariably believe that these allegedly put all their residents in wheelchairs,
models fail to capture the true level of need exhib- needed or not, to maximize reimbursement.
ited by their clients, patients, or residents. This In performance-measurement or consumer-
means, of course, that these providers see themselves reporting models, one of the most common
Case-Mix Adjustment 131
objectives of case-mix adjustments comes again of care provided by that nursing home during the
from healthcare providers. Most provider organi- first 9 months of his or her stay. Thus, the idea of
zations that find themselves identified as giving adjusting for “baseline status” unrelated to the pro-
poorer care in a performance measurement or vider’s performance (as in hospitals) is quite diffi-
consumer reporting system argue that their per- cult to achieve. Surprisingly, however, this difficulty
formance is unfairly reflected in that system. has not driven nursing home researchers to move
They often blame any case-mix adjustment model more heavily toward the use of process quality
for this error. If appropriate adjustments for the measures that often require less acuity adjustment.
acuity or consumer needs were made, these pro-
viders argue, their organization would fare much
better. Future Implications
Across the entire spectrum of health services, the
Case-Mix Adjustment in Various Settings eventual success of the growing movement toward
pay-for-performance will depend heavily on the
In adjusting quality measures, usually outcomes, quality of the case-mix adjustment used in these
acute care in many ways provides the simplest set- reimbursement models. Paying more to healthcare
ting. The patient’s stay is generally very short, the providers that perform better is an eminently rea-
admission often involves a single presenting prob- sonable idea. However, to the degree that indica-
lem, and the patient’s status at admission is clearly tors of clinical outcomes are used as part of such a
unrelated to the hospital’s performance (assuming process, it is important that one understands, for
this is not a readmission). All these things make such indicators, just how much of the variation
for somewhat less complicated risk adjustment. among providers is a function of random fluctua-
The nature of the primary complaint, the severity tion, consumer characteristics, or provider action.
of that complaint, and the number and severity of In essence, when the variation in a quality indica-
comorbidities, along with the patient’s demo- tor is broken down, a sizeable proportion of that
graphic characteristics, constitute the basics for variation should be attributable to provider perfor-
good risk, acuity, or case-mix adjustment in an mance. At this time, it is unclear how attentive those
acute care setting. pursing the development of pay-for-performance
However, this same process is more complicated models are to this issue.
in other settings. In nursing homes, for example,
the average length of stay for long-stay residents Charles D. Phillips
amounts to years, not days. Evaluating quality
over such longer time periods when the residents See also Diagnosis Related Groups (DRGs); Long-Term
are exposed to the nursing home’s performance Care; Nursing Homes; Pay-for-Performance; Payment
Mechanisms; Prospective Payment; Quality of
becomes difficult. A nursing home resident’s health
Healthcare; Severity Adjustment
may decline between the 9th and 12th months of
their stay. This decline will probably be reflected in
the diminution in their ability to independently Further Readings
perform certain activities of daily living (ADLs). It
Blumenthal, David, Joel S. Weissman, Mellissa
is difficult to determine whether that decline was Wachterman, et al. “The Who, What, and Why of
an unavoidable result of their disease burden or Risk Adjustment: A Technology on the Cusp of
whether it might have been avoided if the nursing Adoption,” Journal of Health Politics, Policy, and
home had provided additional or different care in Law 30(3): 453–73, June 2005.
the first 9 months of their stay. Bottle, Alex, and Paul Aylin. “Intelligent Information: A
Attempting, under such circumstances, to deter- National System for Monitoring Clinical
mine how much of the change in outcomes can be Performance,” Health Services Research 43(1):
attributed to the care provided by a nursing home 10–31, February 2008.
and the “natural” process of decline is exceedingly Greenfield, Sheldon, Sherrie H. Kaplan, Richard Kahn,
difficult. The condition of the resident in that 12th et al. “Profiling Care Provided by Different Groups of
month is inextricably intertwined with the quality Physician: Effects of Patient Case-Mix (Bias) and
132 Cato Institute
Physician-Level Clustering on Quality Assessment Publications Program

Results,” Annals of Internal Medicine 136(2):
111–21, January 2002. The Cato Institute undertakes an extensive publica-
Iezzonni, Lisa I., ed. Risk Adjustment for Measuring tions program dealing with the complete spectrum
Health Care Outcomes. 3d ed. Chicago: of public policy issues. Books, monographs, brief-
AcademyHealth/HAP, 2003. ing papers, and shorter studies are commissioned
to examine issues in nearly every corner of the pub-
lic policy debate. Policy forums and book forums
Web Sites are held regularly, as are major policy conferences,
which Cato hosts throughout the year and from
Centers for Medicare and Medicaid Services (CMS): which papers are published thrice yearly in the
http://www.cms.hhs.gov
Cato Journal. All these events are recorded and
InterRAI: http://www.interrai.org
archived on Cato’s Web site. Additionally, Cato
Johns Hopkins University ACG Case-Mix System:
has held major conferences in London, Moscow,
http://www.acq.jhsph.edu
Shanghai, and Mexico City. The institute also pub-
National Association of Children’s Hospitals and
Related Institutions (NACHI):
lished the quarterly magazine, Regulation, and a
http://www.childrenshospitals.net
bimonthly newsletter, Cato Policy Report. The
institute recently launched the Cato@Liberty blog,
where its scholars provide timely commentary on
public affairs, and Cato Unbound, a monthly
Cato Institute online magazine that engages the world’s leading
thinkers in the exchange of big-picture ideas.
The Cato Institute seeks to broaden the parame-
ters of public policy debate—including debates
over health and medicine—to allow consideration Health Policy Studies
of the traditional American principles of limited
Cato scholars argue that individuals should be
government, individual liberty, free markets, and
free to own and control their earnings, to engage
peace. Toward that goal, the Cato Institute strives
in whatever exchanges of health-related goods
to achieve greater involvement of the intelligent,
and services they choose, and to engage in what-
concerned lay public in questions of policy and
ever behaviors they choose—provided they respect
the proper role of government.
the equal rights of others. Cato scholars maintain
that in a free and open society, the government
should play no special role in health or medicine:
Background
In the absence of violence, theft, tortious injury,
The Cato Institute was founded in 1977 by fraud, or breach of contract, introducing the gov-
Edward H. Crane. It is a nonprofit public policy ernment’s power to coerce is unwarranted,
research foundation headquartered in Washington, immoral, and counterproductive.
D.C. The institute is named for Cato’s Letters, a For example, Cato scholars assert that federal
series of libertarian pamphlets that helped lay the and state governments deny individuals the freedom
philosophical foundation for the American to choose whether to purchase health insurance and
Revolution. what type; deny the freedom to choose whether and
To maintain its independence, the Cato Institute how to provide charitable care; restrict patients’
accepts no government funding. Cato receives ability to choose their course of medical treatment;
approximately 75% of its funding from individuals, restrict free entry into the medical professions; pro-
with smaller amounts coming from foundations, hibit the sale of human organs; and refuse to honor
corporations, and the sale of publications. Cato’s contracts limiting providers’ liability for malprac-
2005 revenues were more than $22.4 million, and tice. These scholars argue that individuals have a
it has approximately 95 full-time employees, 70 fundamental right to self-determination in each of
adjunct scholars, and 20 fellows, plus interns. these areas, free from any coercive restraints.
Cato Institute 133
Where advocates of government regulation of Cato scholars argue that the government likely
drugs and medical devices claim that such regula- does the greatest damage in the area of financing
tion protects the public from unsafe products, medical care. Government programs such as
Cato scholars maintain that government has no Medicare and Medicaid finance nearly half of all
constitutional or moral authority to prohibit a medical expenditures in the United States, displace
patient from using a medical treatment that private markets, deny adults the freedom to choose
imposes costs on no one but herself or himself. how to fund their health needs in retirement and
Moreover, the economic literature suggest that the how to assist the needy, and waste scores of bil-
U.S. Food and Drug Administration (FDA) causes lions of dollars each year on services that make
more morbidity and mortality than it prevents. patients no healthier or happier. Cato scholars
Likewise, proponents of medical licensing, argue that targeted tax breaks, principally for
which restricts entry into the professions and employer-sponsored insurance, have much the
dictates what services each profession may offer, same effects: They deny workers control over their
claim that it enhances the quality of care. Cato earnings and health insurance decisions, encourage
scholars say that licensure denies patients the wasteful spending, strip workers of their coverage
right to be treated by the practitioner of their when they leave a job, and hamper the pursuit of
choice; that low-quality care is widespread high-quality, affordable healthcare.
despite licensing; that licensing does not improve Cato scholars seek to eliminate these restric-
overall quality because it reduces access to care tions on the freedom of individuals to control their
(primarily among the poor); and the chief propo- earnings and on the decisions that affect their
nents of licensing are incumbent practitioners health. Moreover, Cato scholars reject government
who profit by restricting entry; and that licensing intervention to remedy private health problems,
has enabled the medical profession to resist evi- such as obesity, diabetes, or addiction.
dence-based efforts to improve quality such as
electronic medical records. Cato scholars further Health Policy Impact
argue that markets—backed up by the tort
system—develop voluntary means of ensuring The Cato Institute has played an influential role
quality, such as hospital-admitting privileges and in U.S. health policy for more than a decade. In
board certification. 1992, the institute published the book Patient
Cato scholars argue that laws prohibiting the Power: Solving America’s Health Care Crisis,
sale of human organs (to transplant patients or which laid the intellectual foundation for the
organ brokers) restrict the freedom of individuals consumer-directed healthcare movement. Two
to control their own bodies, cause an artificial years later, Cato published a companion book,
shortage of transplantable organs that leads to titled Patient Power: The Free-Enterprise
thousands of unnecessary deaths each year, and Alternative to Clinton’s Health Plan, for a wider
ominously allow the government to assert a prop- audience. The book made medical savings
erty right in the body of every citizen. accounts a household term, helped defeat President
Cato scholars also object to the refusal of courts Bill Clinton’s Health Security Act, and set the
to uphold contracts limiting a provider’s liability stage for the creation of health savings accounts
for malpractice in exchange for reduced-price or in 2003.
free medical care. Opponents of such contracts Cato scholars continue to advocate the restora-
argue that patients harmed by negligent providers tion of liberties that have been eroded by political
might not be able to recover. Cato scholars counter intervention in health and medicine.
that such a rule limits the right of consenting
Michael F. Cannon
adults to engage in mutually beneficial exchanges
that harm no one else, reduces access to care See also American Medical Association (AMA);
among those least able to pay, and reduces experi- Consumer-Directed Health Plans (CDHPs);
mentation with malpractice rules that ensure both Credentialing; Public Policy; U.S. Food and Drug
quality and access. Administration (FDA)
134 Causal Analysis
Further Readings Why is causal inference so difficult? Even in

Cannon, Michael F., and Michael D. Tanner. Healthy cases where RCTs are possible, the results are
Competition: What’s Holding Back Health Care and often open to challenge. In cases where random-
How to Free It. 2d ed. Washington, DC: Cato ized studies are not possible, due to ethical or other
Institute, 2007. reasons, establishing causality is far more difficult.
Goodman, John C., and Gerald L. Musgrave. Patient The concept of cause itself is famously elusive.
Power: Solving America’s Health Care Crisis. Apart from definitional problems, attempts to elu-
Washington, DC: Cato Institute, 1992. cidate sets of causal criteria, from David Hume to
Goodman, John C., and Gerald L. Musgrave. Patient John Stuart Mill to Austin Bradford Hill, have not
Power: The Free-Enterprise Alternative to Clinton’s provided necessary and sufficient conditions for
Health Plan. Washington, DC: Cato Institute, 1994. concluding that an observed association between
Hyman, David A. Medicare Meets Mephistopheles. two variables results from the causal impact of one
Washington, DC: Cato Institute, 2006. on the other. From the standpoint of social science
Kling, Arnold. Crisis of Abundance: Rethinking How research, at least three issues are problematic.
We Pay for Health Care. Washington, DC: Cato First, many philosophical discussions of cause
Institute, 2006. begin with a deterministic relationship. If X
changes, Y changes, by the same amount and for
Web Sites all cases under study. But in health services research
relationships are usually probabilistic and hetero-
Cato Institute: http://www.cato.org
geneous. A change in X may or may not result in
Cato@Liberty (blog): http://www.cato-at-liberty.org
a change in Y, the amount of change may vary
Cato Unbound (monthly magazine):
across units of the population, and changes in X
http://www.cato-unbound.org
may not be the only source of variation in Y. While
statistical models are designed to cope with proba-
bilistic outcomes, they are often based on assump-
Causal Analysis tions that are difficult to defend (e.g., that the
source of random noise in the data is uncorrelated
Does smoking cause lung cancer? It is hard to with systematic sources of variation). A second
believe that this was once a question in some dis- problem, related to the first, is that variation in
pute. Yet despite the fact that there has been no many outcomes is multicausal. For example, a
randomized controlled trial (RCT) in which teenager’s proclivity to commit violent acts may
research subjects were randomly assigned to have its origins in a variety of genetic and environ-
smoking or nonsmoking conditions with subse- mental factors, any one of which may be sufficient
quent long-term follow-up to ascertain differences to cause violent behavior in some but not all per-
in health outcomes, there has long been a consen- sons exposed to the risk. Finally, in health services
sus that smoking does indeed cause lung cancer, research, researchers are often interested in a
although it is certainly not the only cause. However, causal sequence such that at a particular attribute,
although smoking-and-health is certainly not the say race, puts an individual at varying levels of risk
only case where a consensus has been reached for some outcome, say discrimination, which in
about causality, asbestos exposure being another, turn is reflected in a subsequent outcome such as
the research literature and the popular press are access to healthcare. Demonstrating the validity of
full of cases where causal impacts are in hot dis- the mediational assumption is often difficult.
pute. For example, currently bisphenol A, a An important source of confusion is a failure to
chemical found in baby bottles and many other distinguish between research that seeks to find the
plastic products, has been tentatively associated causes of an effect and that which examines the
with various health conditions. However, the effects of causes. In the former case, researchers
extent to which the association is causal and the seek to elucidate a set of variables that explain
strength of the effect, if any, remain in dispute, variance in some outcome, say the probability of
and a long series of investigations will need to be preterm birth. The result may be a series of regres-
conducted to resolve the matter. sion models in which various candidate variables
Causal Analysis 135
are considered as possible causes (risk factors) of there is potentially Yit, person i in the treatment
the outcome. Not uncommonly, the variables are a condition, and Yic, the same person in the control
mixture of demographic, biological, and psychoso- condition. An obvious measure of effect then is
cial measures, and the researcher seeks to deter- Yit − Yic. But researchers do not see persons in both
mine which of them are “important.” Studies of conditions; one of them is counterfactual and thus
this kind are essentially descriptive, however a form of missing data, a fact that has been called
sophisticated the statistical analysis, and open to the fundamental problem of causal inference. This
the charge that this or that variable has been point is a bit subtle; typically researchers talk
ignored or badly measured or that a particular about “changes in X causing changes in Y.” The
population has been excluded. While it is true that potential outcome approach asks researchers to
work of this kind has a degree of cumulativeness think about changing the conditions under which
as researchers come to agree on a set of relevant a particular subject is observed, which leads to the
variables and then explore those variables in counterfactual. These ideas easily generalize to
increasingly diverse populations, the process is multiple group designs.
slow and difficult to focus. Results are often pre- Randomized designs assume that the potential
sented with very little serious comparison to other effect of treatment is the same for subjects in
studies in terms of effect sizes, samples, and other both groups (i.e., that had subjects in the control
details. Given the usual constraints of journal pub- condition been in the treatment group, the treat-
lication, this is understandable but nonetheless ment effect for them would have been, on aver-
lamentable. age, the same as it was for the subjects who were
actually there). But when subjects self-select, it is
possible that the treatment effect among the
Effects of Causes and Potential Outcomes
treated group would be quite different from the
In contrast are studies that seek to determine the potential treatment effect among those who were
effects of some cause, say the effect of a particular not treated. Thus one can think about the treat-
health promotion intervention for expectant ment effect among the treated as opposed to the
mothers on the probability of a preterm birth. (potential) treatment effect among the non-
Here, the focus is on a particular variable, which, treated. Even in crossover research designs, where
at least potentially, can be manipulated. Indeed, subjects are observed in both conditions, they
one point of view is that of “no cause without experience the conditions in a particular order
manipulation,” ruling out causal effects of fixed (e.g., the control condition first, and for a given
attributes of individuals such as gender and race. subject, the opposite order is counterfactual). For
While many argue with this point of view, at least the sample two-group case, an obvious “solu-
potentially, the definition of cause can be lodged tion”
– –is to compute the difference in the means,
in the difference or change that comes about in an Y E − Y C as a measure of effect, realizing that the
outcome variable as a result of exposure to differ- two means are computed on different groups of
ent conditions. Other variables may be impor- subjects, and the question then becomes whether
tant, particularly if the study is not randomized, that is justified.
but by focusing on a particular well-defined
potential cause, at least some difficulties are
Randomized Studies
avoided.
Donald Rubin has formalized this idea in what A controlled experiment, in which subjects are
has become known as the potential outcomes assigned at random to two or more treatment con-
approach. The basic idea is quite simple. In a ditions, is the bedrock of causal inference. This
simple two-group study in which some subjects are design, known in the medical literature as a ran-
exposed to some “treatment”—a drug, an educa- domized controlled trial (RCT), allows a researcher
tional program, a particular environment—and to rule out alternative explanations of observed
others are not, researchers can think of an indi- postintervention differences between groups on
vidual as having a score on an outcome variable Y the basis of long-run equivalence of the two
under both circumstances. For every individual i, groups, that is, the expected value of the group
136 Causal Analysis
means prior to the intervention being the same. imagine a randomized study of the effects of
Although investigators sometimes worry about breast-feeding but assigning mothers at random to
randomization failure (i.e., the persistence of conditions would encounter strong resistance both
group differences on one or more variables after from ethics review boards and from the potential
properly executed randomization), standard meth- research subjects themselves. Finally, even when
ods of statistical inference evaluate the probability randomization is possible, it may only be feasible
of observed postintervention differences relative at the group level, as when particular hospital
to the variability introduced by randomization. It units and all patients in them are assigned to an
is easy to show that if the assumptions are met, intervention and other units are the controls. This
simple mean comparisons in a randomized study design, known as a group randomized trial, brings
result in unbiased estimates of causal effect. with it other issues of analysis and generalization.
Despite its obvious strengths, the randomized In particular, the statistical power of such trials is
design is not without problems. Randomization is notoriously low.
sometimes more easily designed than done.
Elaborate randomization schemes may not work
Observational Studies
in practice, research subjects may not comply with
and Quasi-Experiments
the treatment, and measurement may be biased in
particular treatment groups. Generalization to the In many cases then, randomized studies are simply
intended population (referred to as selection bias) impossible. In some cases, researchers might con-
is often a major source of difficulty. It may be dif- clude that the trade-off between using data from a
ficult to recruit and retain subjects in RCTs, par- true probability sample that does not permit ran-
ticularly those in which some risk is involved or in domization versus a randomized study on a non-
which a potentially effective treatment for some probability sample is worth it. An example in the
disease is withheld from members of the control United States is the Health and Retirement Study,
group. In many cases, potential subjects for a study in which a representative cross-sectional sample of
are relatively rare, and as a result the study is con- the population 51 to 61 years of age was sampled
ducted at a number of different institutions that at baseline and has been followed longitudinally
draw on populations that vary in numerous ways. for many years. Various life course events and
Although a formal requirement for generalization transitions such as retirements and major illnesses
(i.e., to support the computation of p-values in occur over the course of the study. With observa-
standard statistical analysis) is that the sample be tions at fixed intervals, these events occur more or
drawn such that each member of a well-defined less at random with respect to observation points,
population has a known probability of inclusion, and investigators have varying amounts of pre-
this is often not feasible. Instead, subjects are and postevent data. The determinants of such
recruited from available sources, such as patients events can be studied (causes of effects), or their
in medical practices or self-selected volunteers sequelae (effects of causes) can be studied. Thus
recruited in various ways. Thus, the experimental the study is strong on one form of generalization
result may be generalized to an ill-defined local at the expense of being weak on another. A study
population, and the degree to which the interven- of this kind is usually referred to as observational,
tion will be effective to the population at large is a word that highlights the passive nature of the
unknown. design.
When it can be conducted, the RCT remains the Although some researchers refer to any nonran-
gold standard for causal inference. Unfortunately, domized study as observational, quasiexperiments
in many areas of investigation, that standard is usually involve some comparison or manipulation
unreachable. In some cases, randomization is liter- of experimental conditions but without random-
ally impossible. The effects of natural disasters on ization and other aspects of control associated
healthcare delivery are of intense interest, but hur- with true experiments. Sometimes the intervention
ricanes cannot be delivered at random. In other is under the control of the researcher, such as pro-
cases, randomization might, in principle, be feasi- viding an “exercise and healthy eating program”
ble, but strong ethical barriers exist. One can in a workplace to self-selected participants. In
Causal Analysis 137
other cases, the investigator takes advantage of a in quartiles on some composite of education and
so-called natural experiment as might be the case income. Noting that race (measured simply as
when a health facility introduces an electronic White/non-White in this example) is strongly cor-
clinical records system or when a change in regu- related with the outcome, the researchers control
lation requires healthcare suppliers to deal sud- on it. But the association of race and SES is such
denly with new clients. There are many variants that the lowest SES quartile consists almost
on the quasiexperimental theme. Over the years, entirely of non-Whites and the reverse is true in
an elaborate classification of such designs, each the highest quartile. In such a case, what does it
assessed with respect to its various strengths and mean to look at the effects of SES, “holding race
weaknesses, has emerged. constant?”
Faced with nonrandom assignment, the instinc-
tive thing to do is to statistically adjust group
Matching and Propensity Scores
comparisons for preexisting differences. A simple
way to do this is via blocking or stratification of One way to avoid the unbalanced comparison
the sample on one or more variables that are asso- problem is by matching. Some decades ago,
ciated with the outcome and that are differentially matching fell into some disrepute, largely as a
distributed across comparison groups. For exam- result of the difficulty of matching on multiple
ple, if women were more likely to choose an exer- variables. In fact, one can see the “blocking on
cise program than were men and it was suspected gender” example above as a primitive form of
that gender was related to the outcome variable, matching. Recent work has led to a variety of
gender could be treated as a design factor, sophisticated approaches to matching on multiple
although the result is frequently “unbalanced” variables along with a set of weights indicating
because members of one gender self-select into a the quality of the match. A very popular approach
particular condition. This approach not only is to create a set of propensity scores in which the
allows researchers to explore the effects of the researcher regresses a 0/1 indicator for group
intervention conditional on gender but also may membership on a set of covariates and estimates
substantially increase the statistical power of the the probability of being in one group or another
analysis. It is relatively rare, of course, to have to based on them. The estimated probability sum-
deal with only one potentially contaminating marizes all the available information in the cova-
variable. More commonly, there are many such riates and allows the researcher to stratify the
variables, and researchers deal with them by sample on propensity scores, assess the balance
treating them as linear covariates in regression- across groups on those scores, and carry out
type models. This approach to analysis has been analyses within strata. Many other approaches
the backbone of many research areas for many are possible, including using the propensity scores
years. directly in the analysis or as weights. These meth-
There are several difficulties with this approach, ods require the researcher to assume that all
however. First, researchers never can know if the potential sources of bias are directly observed.
right covariates are in the model. In many cases, More sophisticated methods, particularly when
there are relatively few of the potentially impor- longitudinal data are available, permit research-
tant covariates actually observed. Second, most ers to control on unobserved sources of bias as
models treat the effect of covariates in simply lin- well.
ear and additive terms. In principle, this is not
necessary; any functional form is admissible, and
Statistical Approaches
covariates can interact. However, relatively large
sample sizes are required to deal with such com- Whether or not researchers match in some fash-
plexities, and in any case, researchers often do not ion, in recent years, several statistical approaches
make the effort. A third issue is “balance.” to dealing with nonequivalent comparison groups
Suppose researchers want to assess the effects of have emerged. The space available does not
socioeconomic status (SES) on healthcare utiliza- permit a lengthy discussion here, but two
tion. For simplicity, assume that SES is measured approaches bear mentioning. The first is to model
138 Causal Analysis
the selection process itself. Ideally, researchers studies, close replication is essential. Somehow,
look for one or more variables that determine regardless of statistical niceties, researchers are
selection but that are correlated with the outcome generally more confident of independent replica-
only via the effects on treatment. That is, the vari- tions that reach the same conclusions. With regard
ables in the selection equation cannot have a to observational studies, the conclusions of which
direct effect on the outcome. Finding such vari- tend to be assumption-dependent, supportable
ables is not easy, although not impossible. A conclusions tend to be achieved when researchers
famous example is the random selection of birth have conducted a series of studies that reach simi-
dates to determine eligibility for the Vietnam era lar conclusions in the face of a substantial varia-
military draft. Researchers interested in the effects tion in design and analysis rather than from exact
of military service on later income were able to replications. Usually, that variation occurs in an
use birth date as an instrument for military service unplanned way, and thus the time to reach a con-
in income estimation equations. Causal estimates sensus is longer than it might be in the face of a
from models of this kind are strongly dependent more systematic approach. This is unfortunate
on assumptions and require careful sensitivity because the public finds itself buffeted by each
analyses. Recent statistical work has focused on sequence of studies that contradict previous well-
establishing upper and lower bounds for effects in publicized results, and public confidence in the
these kinds of models and others. research enterprise often suffers as a result. Still, a
A second approach is known as the regression great deal of significant work in causal inference
discontinuity design. Suppose that selection for has been accomplished in recent decades, the
treatment is based on some cutoff on a continuous result of which has at least been increased clarity
measure, for example access to subsidized medical in what needs to be done. Two things head the list:
care. All subjects below an income cutoff get the rapid and wide diffusion of techniques more
treatment, while those above it do not. Obviously, appropriate than simple regression models for the
the cutoff is somewhat arbitrary, and those just analysis of observational data; and greater insis-
above the cutoff are probably not a great deal tence from journal editors that authors take prior
unlike those just below it. As a result, a regression work seriously, carefully specifying how the
of the outcome variable on the selection variable is research design and results of their own analyses
likely to show a jump (a change in the intercept) differ from the best prior work.
and perhaps a change in the slope of the regression
line at the cutoff. Richard T. Campbell
See also Cohort Studies; Cross-Sectional Studies;

Future Implications Epidemiology; Measurement in Health Services
Research; Meta-Analysis; Public Health; Randomized
It is comparatively rare for a single randomized Controlled Trials (RCTs); Risk
study to definitively resolve a causal question and
even rarer for an observational study to do so.
Studies which seek to isolate causes of effects Further Readings
rather than effects of causes are unlikely to ever Aickin, Mikel. Causal Analysis in Biomedicine and
do so. Still, as the history of research on smoking Epidemiology: Based on Minimal Sufficient
and health demonstrates, resolutions are achiev- Causation. Boca Raton, FL: Chapman and Hall/CRC,
able. Technical approaches to summarizing avail- 2002.
able information, such as meta-analysis, continue Campbell, Joseph Keim, Michael O’Rourke, and Harry
to grow in sophistication. So also do institutional- S. Silverstein, eds. Causation and Explanation.
ized means of reconciling controversial and con- Cambridge: MIT Press, 2007.
flicting evidence such as the U.S. Preventative Cartwright, Nancy. Hunting Causes and Using Them:
Agencies Task Force and formal National Institutes Approaches in Philosophy and Economics. New
of Health (NIH) consensus conferences. The pro- York: Cambridge University Press, 2007.
cess is slow and sometimes discouraging. In most Morgan, Stephen L., and Christopher Winship.
cases, even for most well-designed randomized Counterfactuals and Causal Inference: Methods and
Center for Studying Health System Change 139
Principles for Social Research. New York: Cambridge Wood Johnson Foundation (RWJF) but also
University Press, 2007. conducts research consistent with its mission for
Pearl, Judea. Causality: Models, Reasoning, and Inference. others, including foundations and government
New York: Cambridge University Press, 2007. agencies. The HSC is affiliated with Mathematica
Rubin, Donald B. “Causal Models Using Potential Policy Research, a leader in evaluating the effec-
Outcomes: Designs, Models, Decisions,” Journal of tiveness of local, state, and federal, health, human
the American Statistical Association 100(469): services, and educational programs.
322–31, March 2005. To preserve the HSC’s reputation for high-
Salmon, Wesley C. Causality and Explanation. New
quality, independent, and nonpartisan research,
York: Oxford University Press, 1998.
nurtured and sustained during the long period
Shadish, William R., Thomas D. Cook, and Donald T.
when the RWJF was the sole source of support, the
Campbell. Experimental and Quasi-Experimental
HSC only accepts funding when it retains the right
Designs for Generalized Causal Inference. New York:
Houghton Mifflin, 2002.
to publish all research results. Final research topic
Sloman, Steven. Causal Models: How People Think
selection, methodological, and editorial decisions
About the World and Its Alternatives. New York: ultimately reside with the HSC. Guided by these
Oxford University Press, 2005. principles, the HSC seeks research support from
many different types of sources: government enti-
ties, foundations, and private nonprofit and for-
Web Sites profit organizations.
http://www.ahrq.gov Healthcare in Communities
American Statistical Association (ASA):
Ultimately, all healthcare is organized and deliv-
http://www.amstat.org
National Institutes of Health (NIH): http://www.nih.gov
ered in local communities—where the HSC col-
lects information about the changing health system.
The HSC’s main research tool is the Community
Tracking Study (CTS), which consists of national
Center for Studying surveys of consumer households and physicians.
The HSC also conducts intensive site visits at 12
Health System Change metropolitan communities selected randomly to
be representative of the nation. Led by Paul B.
Founded in 1995, the Center for Studying Health Ginsburg, a nationally known health economist
System Change (HSC) is a nonpartisan policy and health policy expert, the HSC researchers
research organization based at Washington, DC, combine quantitative and qualitative research
focused on changes in the financing, delivery, and from the surveys and site visits to provide policy-
quality of healthcare in the United States, with a makers with a vibrant picture of changing health-
particular emphasis on the policy implications of care market dynamics and the implications
these changes. The HSC strives to provide high- for healthcare policy. The HSC researchers—
quality, timely, and objective research and analysis economists, physicians, sociologists, and public
that lead to sound policy decisions, with the ultimate policy experts—are knowledgeable about a wide
goal of improving the health of the American public. range of healthcare policy topics. Their areas of
Instead of advocating for particular policies, the expertise include private health insurance cover-
HSC serves as an honest broker of information for age, access to healthcare by the uninsured, health-
policymakers, the news media, employers, healthcare quality, and healthcare markets. The HSC
care providers, health insurers, and the public. researchers regularly publish in peer-reviewed
All research undertaken by the HSC is consistent journals, including Health Affairs, The New
with the organization’s mission to inform health- England Journal of Medicine, The Journal of the
care decision and policymakers about changes in American Medical Association, Archives of
the healthcare system at both the local and national Internal Medicine, Inquiry, and Health Services
levels. The HSC is funded principally by the Robert Research.
140 Center for Studying Health System Change
Key Policy Research Areas with its mission. Recent and current funders
include the Agency for Healthcare Research and
The HSC’s focus on local market dynamics allows
Quality (AHRQ), the California HealthCare Foun
it to provide targeted research that can contribute
dation, the Commonwealth Fund, the Henry J.
to better health policy. To assist policymakers, the
Kaiser Family Foundation, the National Institute
HSC focuses on four key policy research areas:
on Aging, the National Cancer Institute, the
health insurance coverage and costs, access to
Health Care Financing and Organization Program
healthcare, quality and healthcare delivery, and
of the RWJF, and the U.S. Department of Health
healthcare markets.
and Human Services, Assistant Secretary for
Planning and Evaluation.
National Household and Physician Surveys
Since 1996, the HSC has conducted four national Timely Access to
surveys of American households and physicians Publications and Related Data Files
and is in the process of conducting the fifth survey.
Approximately 46,600 people in 25,400 families The HSC is committed to providing policymakers,
take part in the household survey, which focuses on the news media, the public, and researchers with
assessing whether consumers’ access to healthcare convenient and timely access to its survey data
is improving or declining over time. The household files and related publications. The HSC’s publica-
survey also explores patients’ satisfaction with the tion series includes Issue Briefs, Data Bulletins,
healthcare they receive and with their health insur- Tracking Reports, and Research Briefs—all of
ance coverage. Approximately 6,600 practicing which combine to provide detailed information on
physicians across the nation provide survey infor- survey and site-visit findings. All the HSC’s publi-
mation about how the practice of medicine is cations and public-use and restricted-use data files
changing. In the physician survey, they respond to are available on its Web site. The HSC also offers
questions about their ability to provide needed ser- a convenient e-mail notification service to alert
vices for patients, how much charity care they pro- interested parties to its new publications and
vide, how they are compensated, and other topics. research that is available on its Web site.
Site Visits to Nationally CTSonline

Representative Communities CTSonline is an easy-to-use, Web-based tool pro-
In 2007, the HSC completed its sixth round of vided by the HSC to allow policymakers and the
intensive site visits to Boston, Massachusetts; public to quickly access and interpret data from
Cleveland, Ohio; Greenville, South Carolina; its surveys.
Indianapolis, Indiana; Lansing, Michigan; Little Alwyn Cassil
Rock, Arkansas; Miami, Florida; northern New
Jersey; Orange County, California; Phoenix, See also Access to Healthcare; Forces Changing
Arizona; Seattle, Washington; and Syracuse, New Healthcare; Ginsburg, Paul B.; Healthcare Financial
York. In each community, the HSC researchers Management; Health Insurance; Mathematica Policy
interviewed between 50 and 100 local healthcare Research (MPR); Quality of Healthcare; Robert Wood
leaders, including employers, physicians, hospital Johnson Foundation (RWJF)
executives, policymakers, safety net providers,
and health insurers.
Further Readings
Berenson, Robert A., and Paul B. Ginsburg. “Hospital-
Additional Research Projects
Physician Relations: Cooperation, Competition or
Although principally funded by the RWJF, the Separation?” Health Affairs Web Exclusive 26(1):
HSC also conducts research for others consistent W31–W43, 2007.
Centers for Disease Control and Prevention (CDC) 141
Correy, Catherine, and Joy M. Grossman. “Clinical (MCWA). Formally established in July 1, 1946, the
Information Technology Adoption Varies Across organization was originally known as the
Physician Specialties,” Data Bulletin No. 34. Communicable Disease Center (CDC). The CDC’s
Washington, DC: Center for Studying Health System early work concentrated on malaria control in the
Change, 2007. United States. However, it was soon engaged in
Draper, Debra A., and Paul B. Ginsburg. “Health Care other public health problems such as polio by pro-
Cost and Access Challenges Persist: Initial Findings viding assistance to local governments and public
From the HSC’s 2007 Site Visits,” Issue Brief No. health departments facing epidemics and disasters.
114. Washington, DC: Center for Studying Health
Over time, the CDC’s mission continued to broaden,
System Change, 2007.
expanding beyond infectious diseases to include
Katz, Aaron, Melanie Au, Paul S. Ginsburg, et al. “Blue
chronic diseases, nutrition, and occupational and
Cross Influence Grows in Boston as State Revisits
environmental health. To reflect these changes, the
Reform Debates,” Community Report No. 11.
Washington, DC: Center for Studying Health System
organization has changed its name a number of
Change, 2005.
times; however, it has always kept the same acro-
O’Malley, Ann S., Hoangmai Pham, Deborah Schrag, nym, CDC. In 1970 it changed its name from the
et al. “Potentially Avoidable Hospitalizations for Communicable Disease Center to the Center for
COPD and Pneumonia: The Role of Physician and Disease Control, in 1980 to the Centers for Disease
Practice Characteristics,” Medical Care 45(6): Control, and in 1992 to its current designation, the
562–70, June 2007. Centers for Disease Control and Prevention.
Web Sites Goals and Strategic Areas of Focus

Center for Studying Health System Change (HSC): Currently, the CDC has four stated organizational
http://www.hschange.org goals. Specifically, it works to have (1) healthy
people in every state of life by reducing health
risks; (2) healthy people in healthy places by
Centers for Disease Control ensuring that all locations including where people
live, work, and play are healthy environments;
and Prevention (CDC) (3) people prepared for emerging health threats by
safeguarding them and responding to threats; and
The Centers for Disease Control and Prevention (4) healthy people in a healthy world through
(CDC), which is part of the U.S. Department of efforts to improve global health using medical
Health and Human Services (HHS), is the nation’s technology, international coalitions, government
premier and largest public health organization. interventions, and behavior changes.
The CDC is composed of the Office of the To reach these goals, the CDC focuses on six
Director, the National Institute for Occupational strategic areas: (1) health impact focus—align the
Safety and Health (NIOSH), and six coordinating CDC staff and other resources to maximize health;
centers and offices. With its headquarters in (2) customer-centricity—provide what people want;
Atlanta, Georgia, the CDC employs more than (3) public health research—create and disseminate
14,000 employees in 170 occupations. Most of its healthcare knowledge; (4) leadership—use the CDC’s
employees work at its headquarters, but others expertise to improve health; (5) globalization—ex-
work in Washington, D.C., in other cities in the tend the CDC’s knowledge around the world; and
nation, and in more than 40 foreign countries. (6) accountability—sustain confidence and trust.
History Organizational Structure

The CDC evolved out of a World War II malaria The current organizational structure of the CDC
control program—Malaria Control in War Areas includes the Office of the Director, the National
142 Centers for Disease Control and Prevention (CDC)
Institute for Occupational Safety and Health The National Center for Health Marketing pro-
(NIOSH), and six coordinating centers and offices: vides current, science-based information to the
(1) Coordinating Center for Health Information public. It conducts research in the area of health
and Services, (2) Coordinating Center for Health marketing and communicates and publishes the
Promotion, (3) Coordinating Center for Infectious results. This center is responsible for publishing
Diseases, (4) Coordinating Center for Environ the Morbidity and Mortality Weekly Report
mental Health and Injury Prevention, (5) (MMWR), which reports on disease trends and
Coordinating Office for Terrorism Preparedness outbreaks each week. The center also runs the
and Emergency Responses, and (6) the Coordi Health Alert Network (HAN), which provides
nating Office for Global Health. instant information regarding serious health threats
to a network of public health departments across
Office of the Director the nation. The Public Health Training Network,
another service of the center, is a professional
The Secretary of the HHS appoints the director development resource for public health workers,
of the CDC. The heads of each of the CDC’s six which provides listings of conferences and work-
coordinating centers and NIOSH as well as the shops, satellite broadcasts, and other learning
heads of nine offices directly report to the director. opportunities of which public health workers may
The reporting offices include the following: Office avail themselves.
of Chief Science Officer; Office of Chief of Public The National Center for Health Statistics
Health Practice; Office of Chief Operating Officer; (NCHS) collects data from a variety of sources.
Office of Strategy and Innovation; Office of Work The data are then used to identify and address
force and Career Development; Office of Enter health problems. The NCHS tracks trends in
prise Communication; Office of Chief of Staff; births, deaths, marriages, divorces, the aging popu-
Office of Dispute Resolution and Equal Oppor lation, hospital discharges, nursing home residents,
tunity; and the CDC Washington Office. and many other topics. Its data are widely used by
policymakers, researchers, and public health pro-
National Institute for fessionals to address various health problems.
Occupational Safety and Health (NIOSH) The National Center for Public Health
Informatics coordinates technology-based applica-
Headquartered in Washington, D.C., with research tions to achieve CDC’s goals. The use of comput-
laboratories in Cincinnati, Ohio; Morgantown, ers and associated applications has become
West Virginia; Pittsburgh, Pennsylvania; Spokane, increasingly important in the public health field.
Washington; and Atlanta, Georgia, and with a staff The center also works to support other CDC cen-
of more than 1,400 employees, NIOSH is the largest ters and offices.
division of the CDC. NIOSH is responsible for con-
ducting research on new safety and health problems
and making recommendations for the prevention of Coordinating Center for Health Promotion
work-related injury, illness, disability, and death. Its This CDC coordinating center oversees two
specific objectives include conducting research to centers: (1) the National Center on Birth Defects
reduce work-related illness and injuries; promoting and Developmental Disabilities and (2) the National
safe and healthy workplaces; and enhancing global Center for Chronic Disease Prevention and Health
workplace safety and health through international Promotion.
collaborations. The National Center on Birth Defects and
Development Disabilities conducts research and
health promotion efforts addressing the causes of
Coordinating Center for
birth defects and provides resources to people
Health Information and Services
dealing with these conditions. The center’s pro-
This CDC coordinating center oversees three grams work to educate women about healthy preg-
centers that provide the public with access to infor- nancy. It also strives to provide resources and
mation and statistics on a variety of health topics. information about developmental disabilities such
Centers for Disease Control and Prevention (CDC) 143
as hearing loss, cerebral palsy, mental retardation, and prevention activities related to environmental
and other conditions. public health emergencies. The programs within
The National Center for Chronic Disease this division address several health issues such as
Prevention and Health Promotion focuses on pre- the safe and healthy use of land, elimination of
venting chronic disease conditions such as heart chemical weapons, food and water safety, sanita-
disease, cancer, and diabetes. Chronic diseases are tion, housing, lead poisoning, and the health and
among the leading causes of death in the United well-being of refugees. In relation to disease inves-
States, and this center coordinates research and tigation, this division monitors cruise ships for
health promotion efforts to inform interventions cases of gastrointestinal illness.
and target illnesses. In addition to health disease, The Division of Environmental Health Hazards
cancer, and diabetes, the center’s programs also and Health Effects conducts research and educa-
address chronic conditions such as stroke, epilepsy, tion relating to the interaction of humans and the
and arthritis. environment, including activities that focus on air
pollution and respiratory health, asthma, carbon
monoxide, and radiation.
Coordinating Center for Infectious Disease The Division of Laboratory Sciences investigates
This CDC coordinating center oversees four exposure to toxic chemicals and other substances in
centers that target specific infectious diseases. The the environment, and their effects on human health,
four centers are (1) the National Center for HIV/ through the use of laboratory methods. Through
AIDS, Viral Hepatitis, STD and TB Prevention; (2) the testing of blood and urine samples, scientists in
the National Center for Immunization and the laboratory are able to measure the amounts of
Respiratory Diseases; (3) the National Center for chemical substances in a person’s system.
Zoonotic, Vector-Borne, and Enteric Diseases; and The Agency for Toxic Substances and Disease
(4) the National Center for Preparedness, Detection, Registry (ATSDR) is also housed with the coordi-
and Control of Infectious Diseases. Each of these nating center. The ATSDR is 1 of the 13 federal
centers targets a specific type of infection, such as agencies with the HHS. It is mandated by the U.S.
tuberculosis, sexually transmitted diseases, and the Congress to conduct specific activities that relate
West Nile virus, and focuses on its prevention, to hazardous substances in the environment. The
control, and treatment efforts. agency’s responsibilities include monitoring of
waste sites, health consultations, surveillance, edu-
cation and training, and research. The ATSDR is
Coordinating Center for
one agency that responds to emergencies caused by
Environmental Health and Injury Prevention
the release of hazardous substances. It also devel-
This CDC coordinating center oversees two ops information for the public regarding hazard-
centers: the National Center for Environmental ous substances.
Health/Agency for Toxic Substances and Disease The National Center for Injury Prevention and
Registry; and the National Center for Injury Control is the lead agency in the nation’s efforts to
Prevention and Control. prevent unintentional injuries. This center tracks
The National Center for Environmental Health cases of injury and assesses their associated risk fac-
conducts research, surveillance, and education tors. One well-known publication of the center is a
related to the interaction between humans and the list of the 10 leading causes of death. This list, which
environment. Its responsibilities include protecting is compiled annually by various age groups, is widely
the public from hazards in the environment. This used by educators, researchers, and public health
center has three divisions: (1) the Division of professionals in their efforts to prevent injury.
Emergency and Environmental Health Services, (2)
the Division of Environmental Health Hazards
Coordinating Office for Terrorism
and Health Effects, and (3) the Division of
Preparedness and Emergency Response
Laboratory Sciences.
The Division of Emergency and Environmental This office addresses emergency preparedness
Health Services works to develop policy initiatives for natural disasters and terrorist attacks. The
144 Centers for Medicare and Medicaid Services (CMS)
office educates first responders, healthcare profes- Further Readings

sionals, and the general public about the types of Centers for Disease Control and Prevention. “Historical
emergencies that may occur. It also provides infor- Perspective: History of CDC,” Morbidity and
mation on recent outbreaks, natural disasters, and Mortality Weekly (MMWR) 45(25): 526–30, June 28,
other emergency events. Additionally, state and 1996.
local health agencies take their lead from this Koplan, Jeffrey P. “CDC’s 60th Anniversary: Director’s
office, and the office oversees grants and support to Perspective—Jeffrey P. Koplan,” Morbidity and
state, local, and community preparedness efforts. Mortality Weekly (MMWR) 56(33): 846–50, August
24, 2007.
Parascandola, John. “From MCWA to CDC: Origins of
Coordinating Office for Global Health the Centers for Disease Control and Prevention,”
Public Health Reports 111(6): 549–51, November–
This CDC office partners with other health December 1996.
agencies and works to address global public health Ward, John W., and Christian Warren, eds. Silent
threats. The office’s International Experience and Victories: The History and Practice of Public Health
Technical Assistance Program trains public health in Twentieth-Century America. New York: Oxford
workers at the federal level to increase experience University Press, 2007.
at the international level. Its Division of
Epidemiology and Surveillance Capacity Develop
ment initiative works toward improving the dis-
Web Sites
ease investigation infrastructure at an international
level. This division provides technical assistance to CDC Foundation: http://www.cdcfoundation.org
foreign nations, partners with international orga- Centers for Disease Control and Prevention (CDC):
nizations to improve surveillance for infectious http://www.cdc.gov
diseases, and works toward disease prevention National Center for Health Statistics (NCHS):
efforts. The office’s Sustainable Management http://www.cdc.gov/NCHS
Development Program collaborates with global U.S. Public Health Service (USPHS):
partners to provide leadership and development of http://www.usphs.gov
public health systems worldwide. The program
attempts to look beyond theory and focuses on
skills-based initiatives.
Centers for Medicare and
Future Implications
Medicaid Services (CMS)
The CDC is the nation’s, and to a great extent The Centers for Medicare and Medicaid Services
the world’s, public health department. Its public (CMS), formerly known as the Health Care
health efforts, coordinated through the NIOSH Financing Administration (HCFA), is a federal
and its various coordinating centers and offices, agency within the U.S. Department of Health and
focus on disease prevention and health promo- Human Services (HHS). CMS is the nation’s larg-
tion, disease investigation and surveillance, and est purchaser of healthcare, it is responsible for
emergency and disaster preparedness. Today, and administering the Medicare program, and it works
in the foreseeable future, the CDC will remain the collaboratively with states to administer the
global leader in public health. Medicaid program and State Children’s Health
Insurance Program (SCHIP). Additionally, CMS
Kristin Hartsaw
also works to simplify the standards associated
See also Bioterrorism; Disease; Emergency and Disaster with the Health Insurance Portability and
Preparedness; Epidemiology; National Center for Accountability Act of 1996 (HIPAA), ensure qual-
Health Statistics (NCHS); Pan American Health ity standards in long-term care facilities through
Organization (PAHO); Public Health; World Health surveys and certification, and maintain clinical
Organization (WHO) laboratory standards of quality through the
Centers for Medicare and Medicaid Services (CMS) 145
Clinical Laboratory Improvement Amendments those with end-stage renal disease. Since its incep-
(CLIA). The agency employs nearly 4,100 employ- tion, the Medicare program has grown 130%,
ees and serves approximately 92 million individu- from 19.1 million enrollees in 1966 to 43.9 mil-
als through all its programs. The CMS headquarters lion in 2007.
is located in Baltimore County, Maryland, with an In 2003, one of the most significant changes
office at the Hubert H. Humphrey Building in to the Medicare program since its inception was
Washington, D.C., and 10 regional offices across signed into law. The Medicare Modernization
the country. Act (MMA) included provisions for an outpa-
tient prescription drug benefit for Medicare
beneficiaries and several other changes to the
Overview program.
President Lyndon B. Johnson signed the legisla-
tion that established the Medicare and Medicaid Medicaid
programs into law on July 30, 1965. Initially,
the Social Security Administration (SSA) admin- Medicaid is a joint state and federal program that
istered the Medicare program, while the Social provides healthcare coverage to certain groups of
and Rehabilitation Service Administration (SRA) low-income individuals and families who qualify.
ran the Medicaid program under the purview of The states administer the program, and they may
the Department of Health, Education, and set their own eligibility and benefits guidelines. To
Welfare (DHEW). However, because of grow- participate in the Medicaid program, certain
ing healthcare costs, the HCFA was formed requirements need to be met such as age, income,
in 1977 to coordinate both the Medicare and disability, and citizenship. The average monthly
the Medicaid programs under the auspices of enrollee for the Medicaid program in 2007 was
DHEW. In 1980, DHEW was divided into the estimated to be 48.1 million individuals, with the
Department of Health and Human Services largest group being children.
(HHS) and the Department of Education (DOE),
with the HHS overseeing the responsibilities of
the HCFA. State Children’s Health Insurance Program
The agency was later renamed the Centers for In 1997, SCHIP was created to address the needs
Medicare and Medicaid Services in 2001 to reflect of uninsured children. SCHIP is a program funded
its mission better. CMS’s vision is to transform and jointly by the federal government and states and it
modernize the U.S. healthcare system. is administered by the states. This program pro-
Today, CMS serves the elderly and disabled vides low-cost health insurance coverage to chil-
through its Medicare program, the low-income dren and families. Each state determines the
population through Medicaid, and children and eligibility, benefits, design, payment level, and
families through SCHIP. The Medicare and operating procedures for the SCHIP program
Medicaid programs combined account for nearly within federal guidelines. Under this program, the
one third of the nation’s healthcare expenditures. states are given a capped amount of matching
The agency is dedicated to administering its pro- funds by the federal government.
gram as efficiently as possible. In FY2009, the
estimated total benefit costs are expected to be
$703.9 billion. Research
CMS collects and maintains a wealth of quantita-
tive data on its programs and makes them avail-
Medicare
able to researchers. These data include information
CMS has the primary responsibility of administer- on claims, spending, and enrollment. The agency
ing the nation’s Medicare program. Medicare is a is also involved in conducting its own research
health insurance program for individuals aged 65 efforts, such as examining patterns in prescription
or older, individuals with certain disabilities, and drug use, risk-adjustment methods for different
146 Centers for Medicare and Medicaid Services (CMS)
payment systems, quality initiatives, and con- challenges remain, with increased enrollment and
sumer assessments. In addition, CMS performs rising healthcare costs, the agency strives to fur-
demonstration projects to examine alternative ther the vision of President Lyndon B. Johnson’s
policies for healthcare coverage and delivery. The Great Society to provide accessible, high-quality
Office of Research, Information, and Development healthcare for the elderly, disabled, and poor.
within CMS coordinates these activities.
Some of the agency’s initiatives include the Jared Lane K. Maeda and Raymond Swisher
Consumer Assessment of Health Providers and See also Health Insurance Portability and Accountability
Systems (CAHPS) Survey, Health Outcomes Survey, Act of 1996 (HIPAA); Medicaid; Medicare; Medicare
Hospital Compare, and pay-for-performance. CMS Part D Prescription Drug Benefit; Medicare Payment
also publishes a subscription journal, Health Care Advisory Commission (MedPAC); State Children’s
Financing Review. The review is dedicated to Health Insurance Program (SCHIP)
improving the understanding of the Medicare and
Medicaid programs and the U.S. healthcare system
by examining delivery and financing issues. Further Readings
Bell, Douglas S., and Maria A. Friedman. “E-Prescribing
Outreach and Education and the Medicare Modernization Act of 2003,”
Health Affairs 24(5): 1159–69, September–October
CMS provides numerous outreach and educa- 2005.
tion initiatives to assist healthcare providers, Darr, Kurt. “The Centers for Medicare and Medicaid
professionals, and volunteers with its programs. Services Proposal to Pay for Performance,” Hospital
The Medicare Learning Network (MLN) pres- Topics 81(2): 30–32, March 2003.
ents educational information to fee-for-service De Lew, Nancy. “Overview: 40th Anniversary of
healthcare providers and promotes the respon- Medicare and Medicaid,” Health Care Financing
siveness of the agency. MLN also helps provid- Review 27(2): 5–10, Winter 2005–2006.
ers deal with changes in Medicare policy. The Gluck, Michael, and Marilyn Moon. Financing
National Medicare Training Program (NMTP) Medicare’s Future. Washington, DC: National
provides training to professionals and volunteers Academy of Social Insurance, 2000.
to help Medicare beneficiaries make informed Hoffman, Earl D., Jr., Barbara S. Klees, and Catherine
decisions. The Provider Communications Group A. Curtis. “Overview of the Medicare and Medicaid
at CMS develops and disseminates provider edu- Programs,” Health Care Financing Review: Statistical
cation campaigns that involve Medicare fee-for- Supplement 1–281, 283–304, 2005.
service programs. Through these various outreach Kahn, Charles N., III, Thomas Ault, Howard Isenstein,
and educational efforts, CMS employs a diverse et al. “Snapshot of Hospital Quality Reporting and
set of methods using the Internet, fact sheets, Pay-for-Performance Under Medicare,” Health Affairs
brochures, videos, and Web-based training 25(1): 148–62, January–February 2006.
courses. U.S. Department of Health and Human Services, Centers
for Medicare and Medicaid Services, Office of
Research, Development, and Information. 2007 CMS
Future Implications Statistics. CMS Pub. No. 03480. Washington, DC:
U.S. Department of Health and Human Services,
The Medicare and Medicaid programs will face a
2007.
number of challenges in the future. The aging of
the nation’s population and the demand to meet
the growing entitlement has raised serious ques-
Web Sites
tions regarding the solvency of the programs.
Despite this, the CMS continues to serve the needs Centers for Medicare and Medicaid Services (CMS):
of its beneficiaries by ensuring healthcare cover- http://www.cms.hhs.gov
age to millions of Americans. Although many Hospital Compare: http://www.hospitalcompare.hhs.gov
Certificate of Need (CON) 147
By the mid-1960s, the nation’s total healthcare

Certificate of Need (CON) spending had accelerated to a point where the con-
cerns about hospital bed shortages of 20 years
Certificate of need (CON) is a state-level regula- before were replaced with concerns that the U.S.
tory process first established more than 40 years healthcare system was becoming too expensive and
ago for the purpose of rationalizing the growth that healthcare costs were out of control, largely
and distribution of hospitals, other health facili- because of unregulated construction, expansion,
ties such as nursing homes and ambulatory sur- and purchase of new technology. Since 1966, a
gery centers, and expensive healthcare equipment voluntary form of health planning and CON
and services. In this process, a hospital or other existed in a growing number of states. Rochester,
healthcare provider must establish through an New York, piloted the concept in 1964, where a
analysis that a need exists in a specific service coalition of local businesses and Blue Cross estab-
area for the new or expanded facility or proposed lished a community health planning council to
service. This analysis is reviewed by a state agency evaluate hospital need. Impressed by the Rochester
or appointed health services planning body, often experiment, and spurred by the federal
in a formal public hearing during which sponsors Comprehensive Health Planning Act (PL 89–749)
and opponents of the proposed expenditure can of 1966, New York State, followed closely by
argue their case. If a determination is made that a Maryland, Rhode Island, and the District of
need actually exists consistent with the sponsor’s Columbia, soon enacted CON legislation. Voluntary
proposal, a CON is issued that grants the sponsor CON was eventually established in 29 states prior
permission to proceed with the project. Currently to the federal mandate. In 1974, the U.S. Congress
(2007), 36 states plus the District of Columbia enacted the National Health Planning and Resources
and the Virgin Islands have CON legislation in Development Act (PL 93–641), making CON man-
place. CON has been controversial during most datory for all states as a condition for receiving
of its history, with much of the debate centering certain federal funds. By 1978, 42 states plus the
on whether it is necessary, if it actually works, District of Columbia had enacted CON laws, with
and more fundamentally, if a regulatory tool is an CON in place in all states except Louisiana by
appropriate way to plan and control aggregate 1986, when federal funding for CON ended.
health-related investment in the United States.
CON was established at a time when healthcare
Rationale
services in the nation were undergoing a period of
profound growth, driven by the expansion of employ- The rationale behind the use of CON to control
er-sponsored health insurance and the Medicare and the supply of medical services was based on a
Medicaid programs, along with federal subsidies for belief that normal economic market forces that
hospital construction. Prior to the end of World War bring demand and supply into balance for other
II, health services grew slowly, with little investment goods and services would not work for medical
for new hospitals or modernization. At that time, all services. There were several reasons why this was
but the largest teaching hospitals were sponsored by believed to be true. On the demand side, unlike
or affiliated with a specific community, a religious other goods and services in the marketplace, con-
denomination, or a fraternal organization. Hospital sumers don’t make an informed decision about
construction and modernization at that time was which medical care service they will receive. First,
financed by philanthropic and community fund rais- as medical care is highly specialized and complex
ing efforts. The expansion of private and public and beyond the understanding of most consum-
health insurance allowed hospitals to generate needed ers, this decision is usually made by the person’s
capital internally from patient revenues. Beyond this physician. Seldom will a person refuse a medical
internal source, the 1946 federal Hill-Burton Act service on cost grounds alone if the physician rec-
provided grants to hospitals for construction and ommends it. Second, with the growth of health
modernization. insurance coverage, patients don’t directly pay for
148 Certificate of Need (CON)
the services they receive. Third-party payment at a reasonable cost. This often-overlooked pur-
insulates patients from the costs of medical ser- pose connected CON to a common thread in
vices except for those that are paid out of pocket. prior federal health legislation, including Hill-
Third, without quality or cost information, Burton, the comprehensive health planning act,
patients usually don’t comparison-shop for medi- and the landmark Medicare and Medicaid legisla-
cal services; and, when they do, they often wait tion. This reflected a deeply rooted concern that
until the time when they need the services for the nation’s healthcare resources should be allo-
some acute medical condition. This puts the cated in an equitable manner. Medicare and
patient at a disadvantage in being able to behave Medicaid made healthcare services affordable to
as a consumer normally would. the elderly and the poor. CON was to ensure that
On the supply side, unlike the case with most healthcare capital investment would not bypass
other goods and services in the marketplace, health- low-income or rural communities as the U.S.
care providers did not compete on price. Indeed, healthcare system grew. This goal was linked to
prices of medical services were seldom made public, cost containment in recognizing that equal access
and patients usually never knew the price of the would not be possible if healthcare services were
service they were to receive until after they (or more not also affordable, and so controlling healthcare
accurately their insurance company) received the inflation was required to keep costs reasonable.
bill for the service. In addition, the supply of medi- Achieving this second purpose presented a chal-
cal services seemed to generate its own demand. lenge, as while CON provided a regulatory tool to
For example, a good predictor of surgical rates in a limit capital investment that was proposed, it
community was the number of surgeons, regardless could not compel investment in an area deemed
of population need. So if two communities of simi- financially undesirable to a healthcare provider.
lar size and population characteristics were com- However, by having the regulatory expectation
pared, the one with the greater number of surgeons that the needs of low-income communities should
would likely have more surgeries performed. For be considered, CON reviews were often able to
hospital services, this phenomenon was so pro- leverage consideration of these needs in proposals
nounced that it became known as the Roemer that otherwise would not have done so.
Effect, after the researcher who first noticed the
relationship where “a bed built, is a bed filled.” A
Scope
community with more hospital beds is likely to fill
those beds, regardless of population need. While hospital construction and expansion was
the initial focus of CON, given the relatively high
cost of hospital facilities, it was soon realized that
Goals
hospital building alone was not the only driver of
While cost containment was the overriding moti- healthcare costs. With advances in medical tech-
vation for CON, the 1974 federal health planning nology, new services, exotic imaging devices, and
legislation outlined two primary purposes. The sophisticated treatment modalities were also being
first was restraining skyrocketing healthcare costs, introduced. While most of these advances were
which was to be done through controlling the hospital based, some were being proposed for
expansion of new healthcare services and prevent- other noninstitutional sites, including freestanding
ing underutilization and unnecessary duplication facilities where the new service or technology
of healthcare resources, which was thought to be would be provided. These included most notably
the primary cause of skyrocketing healthcare diagnostic scanners (e.g., CT, MRI, PET) and
costs. The U.S. Congress at the time found the radiation beam treatment devices (linear accelera-
national need for additional hospital beds had tors and gamma knives). At the other end of the
virtually disappeared, and as of 1974, an aggre- technology spectrum, long-term care services were
gate surplus of 20,000 underused beds existed. also becoming a significant driver of runaway
CON had a second primary purpose, which healthcare cost, and so nursing homes were an
was to achieve equal access to quality healthcare early focus of CON in all states.
Certificate of Need (CON) 149
After 1986, the range of review of facilities, favorable local review was a strong consideration
services, and equipment covered by CON varied in the review at the state level.
from state to state. Currently, some states take a The composition of the local reviewing board
comprehensive approach covering upward of 30 often gave an advantage to the projects of local pro-
categories of service. Most states are less compre- viders over those proposed by outsiders. And pro-
hensive, targeting CON to those services thought viders were seen as having undue influence on
to be major cost drivers. Beyond service categories, decisions of the local planning agency, sometimes
states also adopted a financial threshold approach leading to rejection at the state level of locally
to CON, reviewing only those proposals that approved proposals. This attitude that CON was
exceed a dollar threshold. Since the end of federal better in principle than in practice, especially when
funding, state financial thresholds have varied applied to a well-supported hospital expansion proj-
greatly, ranging from under a $0.5 million to more ect, was one factor that led to its eventual unpopu-
than $10 million. The rationale for this approach larity, its limited effectiveness, and the repeal of the
is that the more expensive proposals are likely to federal mandate. Nonetheless, the linking of CON
make the most significant contribution to rising with planning at a local level provided an effective
health costs. context to apply CON as a tool for achieving
affordable access, as well as cost containment, as
proposals could be reviewed against a plan that had
Regulation Versus Planning
specified local needs and optimal service perfor-
CON is at best only a partially effective remedy mance. The local review process provided a mecha-
for achieving access points. It was never meant to nism to negotiate how those needs could be explicitly
be the only tool for either controlling cost or considered in the proposal under review.
enhancing access but was to be partnered with
health planning. The 1974 act set up a nationwide
Regulation Versus Competition
network of more than 200 community-based
health planning agencies or health system agencies Nationally, regulation and CON fell out of favor
(HSAs) whose principal function was to develop as an approach to control healthcare costs after
local and state health system plans that attempted 1980, driven by several forces. First was the
to bring into balance community needs with facil- growing unpopularity of CON among healthcare
ities and resources required to meet those needs. In providers and some communities whose projects
each state and region, plans were drafted by a staff did not receive CON approval. A second factor
of professional health planners under the direction was that, despite the existence of mandatory
of an agency governing body of healthcare provid- CON in 49 states, healthcare costs continued to
ers, consumers, educators, insurers, and local gov- rise at an alarming rate. So, at least on the surface,
ernment officials. Hospital and nursing home there was a lack of clear evidence that CON was
administrators, along with practicing physicians an effective cost containment tool. Third, and
and other healthcare professionals, were often perhaps most significant, was the election of
among agency board members. The plans devel- President Ronald Reagan. The year 1980 marked
oped were to provide the framework that was to the ascendancy of a conservative trend in American
guide new construction, modernization, and the politics and, with it, a belief that market forces
introduction of new expensive medical equipment and competition were more appropriate than
and services by hospitals and other providers in regulation, which was seen generally as a tool of
the community. CON was intended to “put teeth” big government. Managed competition and espe-
into the plans and the planning process. State cially managed care replaced planning and CON
CON laws usually called for an initial review by as the hope for controlling costs. Competition
the local health system’s agency prior to consider- held up the promise of introducing market forces
ation by the state CON body. A proposal would into healthcare, the lack of which was the reason
have to be judged consistent with the local plan to behind the need for planning, regulation, and
get a favorable review by the local agency, and the CON in the first place. In response to these forces,
150 Certificate of Need (CON)
in 1983, the U.S. Congress repealed the 1974 CON Today

Health Planning Act and with it the federal man-
date for CON (a continuing resolution maintained CON in the 36 states where it is still exists varies
state funding for another 3 years). Without the broadly from state to state but in general seems to
federal mandate, some states began to repeal and have shifted in some common ways. Without the
roll back their CON laws, and the network of existence of local plans against which to judge
local health planning agencies started to dissolve. need or at least place the need within a local con-
However, CON was retained in some form by text, CON determination is now largely based on
most states, with only a handful opting for an meeting state-established performance and charity
outright repeal. standards, oftentimes divorced from their local
Throughout CON’s history, healthcare provid- context. In one way, CON has become an even
ers have taken a contradictory posture toward it, more regulatory process despite the continued
largely reflecting the regulatory versus competi- national skepticism toward government regula-
tion debate. In the early years, hospitals, in par- tion. With this regulatory character, the CON
ticular, were generally supportive of CON, process has become as much concerned over pro-
recognizing the need for some form of planning. cedural issues as with the substance of need, access,
But as healthcare services began to look more like and costs, and the process has become as much an
an industry, a belief that market forces and com- arena for lawyers and economists as for health
petition should work began to take hold, and planners and regulatory analysts. Without local
opposition to CON increased. This opposition agencies to represent broader community interests,
was behind the repeal of CON laws in 14 states the CON process is often dominated by networked
and the paring down of CON’s scope or raising institutional providers, specialized medical practi-
reviewability thresholds in others. But hospitals tioners, and their lawyers, consultants, and lobby-
also recognized that too much competition would ists, who mount well-polished presentations to
not be good for existing hospitals, which might support their proposals. Opposition to a proposal
find themselves competing with neighboring facil- may be raised on technical grounds (standards and
ities or, worse, a new for-profit corporately owned criteria) by the staff of the state planning or CON
hospital, likely with better access to capital for agency, but the regulators, too, can be as much
new constructions and the latest medical technol- concerned about procedural issues as substance.
ogy. Under these conditions, CON resembled a The occasional effective opposition to a proposal is
franchising mechanism for existing facilities, pro- usually offered by a competing provider that has
tecting them from unwelcome competitors. Thus, the resources to mount a case. In this environment,
many hospitals came to support CON in princi- one of the original purposes of CON, which is
ple, but always looking for ways to reduce its achieving equal cost-effective access to quality
impact on them while using it as a barrier against healthcare, has taken a back seat.
competitors. Yet in many states, CON still retains much of its
Physicians as a group were less likely to support original character and function. And more recent
CON and were often the force behind hospital evidence now shows that it can be an effective tool
expansion and demands for new equipment and to control costs, expand access, and enhance health-
sophisticated services such as open-heart surgery. care quality. Studies reported by the American
In addition, as a profession, physicians have long Health Planning Association (AHPA) of healthcare
been more likely to exhibit an entrepreneurial costs in states where the big-three automakers have
streak. With the help of creative practice manag- a major presence have shown that employee and
ers, physicians soon saw opportunities to directly overall per-person healthcare costs are lower in
purchase new technology and offer new services in states with CON. Other studies have also found that
physician-owned freestanding diagnostic and treat- states with CON have lower costs for some regu-
ment centers. Consequently, physicians have lated healthcare services as well as lower mortality
usually been in the lead in opposing CON, a gov- for certain serious, but common, surgical procedures
ernment-sponsored program, which they saw as such as coronary artery bypass. Both of these find-
thwarting their private business plans. ings support the original purpose of CON.
Charity Care 151
The future of CON is likely to be determined Vaughan-Sarrazin, Mary S., Edward L. Hannan, Carol J.
not only by its effectiveness as a cost containment Gormley, et al. “Mortality in Medicare Beneficiaries
tool but also by its political support within each Following Coronary Artery Bypass Graft Surgery in
state and the broader national climate. CON may States With and Without Certificate-of-Need
continue to be one part of an evolving mix of strat- Regulation,” Journal of the American Medical
egies aimed at improving healthcare access, increas- Association 288(15): 1859–66, October 16, 2002.
ing quality, and controlling costs.
Patrick Lenihan Web Sites
See also American Health Planning Association (AHPA); American Health Planning Association (AHPA):
Cost of Healthcare; Health Planning; Health Systems http://www.ahpanet.org
Agencies (HSAs); Hospitals; Public Policy; Regulation; National Conference of State Legislators (NCSL):
Roemer, Milton I. http://www.ncsl.org
Further Readings
Campbell, Ellen S., and Gary M. Fournier. “Certificate- Charity Care
of-Need Deregulation and Indigent Hospital Care,”
Journal of Health Politics, Policy and Law 18(4):
Charity care may be generally defined as the
905–925, Winter 1993.
financially quantifiable costs of activities, services,
Chassin, Mark. “Achieving and Sustaining Improved
Quality: Lessons From New York State and Cardiac
or programs that a hospital provides for individu-
Surgery,” Health Affairs 21(4): 40–51, July–August als and for which the hospital does not expect to
2002. be compensated, whether fully or in part. This
Conover, Christopher, and Frank A. Sloan. “Does entry examines the role of charity care for non-
Removing Certificate-of-Need Regulations Lead to a profit hospitals, as compared with their for-profit
Surge in Health Care Spending?” Journal Health counterparts, the expectations, approaches, and
Politics, Policy and Law 23(3): 455–81, June 1998. measurement of charity care, and the legal ramifi-
Fisher, Elliott S. “Medical Care: Is More Always Better?” cations and policy implications of charity care.
October 23, 2003.
Harrington, Charlene, James M. Swan, John A. Nyman, Background
et al. “The Effect of Certificate-of-Need and During the 1980s, a period of rapidly escalating
Moratoria Policy on Change in Nursing Home Beds healthcare costs and changes in third-party reim-
in the United States,” Medical Care 35(6): 574–88,
bursement, nonprofit hospitals in the United
June 1997.
States adopted a number of different strategies to
Melhado, Evan M. “Health Planning in the United States
reduce costs and increase revenues. Hospitals
and the Decline of Public-Interest Policymaking,”
sought to increase operating or profit margins.
Milbank Quarterly 84(2): 359–440, June 2006.
Rather than being praised for adopting a business-
Nichols, Len M., Paul B. Ginsburg, Robert A. Berenson,
et al. “Are Market Forces Strong Enough to Deliver
like approach, however, nonprofit hospitals drew
Efficient Health Care Systems? Confidence Is criticism for abandoning their not-for-profit char-
Waning,” Health Affairs 23(2): 8–21, March–April itable missions. For reasons related to the percep-
2004. tions that nonprofit hospitals were focused more
Piper, Thomas R. National Directory of Health Planning, on profit and less on charitable services, and pres-
Policy and Regulatory Agencies. Columbus, MO: sure by local governments to find new revenue
American Health Planning Association, 2003. sources, the concept of charity care became the
Rivers, Patrick A., Myron D. Fottler, and Mustafa operative construct in the ensuing policy debate;
Zeedan Younis. “Does Certificate of Need Really nonprofit facilities, which benefit from local,
Contain Hospital Costs in the United States?” Health state, and federal tax exemptions, are expected to
Education Journal 66(3): 229–44, March 2007. provide a certain level of charity care through
152 Charity Care
contributions and services made available to their financial efficiencies by eliminating services that
local communities. If these hospitals do not offer were deemed loss leaders or unable to make reve-
charitable, non-revenue-generating services, should nues. Some of these services, such as trauma cen-
they keep their nonprofit status? ters, burn units, and maternity units, were often
high profile and attracted large numbers of people
who could not pay for primary or emergent health-
Changes in the Public’s Perception care services. Public perceptions, articulated by
Five factors largely accounted for the change in the legislators, jurists, and for-profit hospital competi-
public’s perception of the charity mission of non- tors, turned sour. In their efforts to generate reve-
profit hospitals and the resulting quid pro quo nue and serve as a business, nonprofit hospitals
between levels of charity care and a nonprofit hos- were seen as reneging on their charitable mission
pital’s tax-exempt status. These factors are the fol- to the community and foisting additional health-
lowing: (1) the distancing of local hospitals from care costs for the medically indigent on already
their locally supportive communities, which resulted financially strapped communities.
in the erosion of credibility and trust; (2) the move-
ment toward greater efficiencies through the elimi- Charges of Unfair Competition
nation of loss leader services; (3) charges of unfair
competition; (4) research finding few differences Owners of for-profit hospitals, also suffering
between nonprofit and for-profit healthcare pro- from rapidly escalating healthcare costs, began to
viders; and (5) the search for new revenue sources question the competitive advantage nonprofit hos-
by financially strapped municipalities. Each of pitals received through their exemption from a
these factors is discussed below in more detail. variety of local, state, and federal taxes; for-profit
hospitals have to pay these taxes. Further support-
ing this contention were local business people who
Distancing From Local Communities claimed that they were suffering from unfair com-
petition from untaxed nonprofit hospitals that
Whether hoping to realize financial efficiencies were trying to raise new revenues by running for-
or facing the prospect of closing, many single profit services such as gift shops, health clubs, and
community-based nonprofit hospitals were laundries that already existed in the community as
absorbed into large multihospital healthcare sys- for-profit enterprises.
tems. Subsequently, some hospitals with long and
distinguished histories of service to their local
communities not only lost their identities but also Research Finding Few Differences
traded their links to the very communities that had Attracted by contentions that there were few or
supported and governed them. Instead, they were no substantial differences between nonprofit and
now managed by entities that were geographically for-profit hospitals, health services research that
distant and had anonymous corporate account- examined differences between nonprofit, for-profit,
ability and control. Having lost ties to their local and public organizations increased. During the
communities, these hospitals began to suffer an 1980s, empirical research comparing nonprofit
erosion of credibility and trust. Distance and mis- and for-profit hospitals was inconclusive, largely
trust made nonprofit hospitals easier targets for due to measurement issues. These studies found no
those who questioned their charitable ethos when significant differences between the two types of
the move to efficiency seemed to supplant chari- hospitals in areas such as levels of uncompensated
table services. care, percentages of uninsured patients served,
percentages of Medicare and Medicaid patients,
and the range of often unprofitable services being
Movement Toward Efficiency
offered to the medically indigent. There were,
Whether as members of large multihospital however, sufficient data from reputable researchers
healthcare systems or as stand-alone healthcare to create doubts about the amount of charity care
facilities, many nonprofit hospitals tried to realize nonprofit hospitals were providing. This research
Charity Care 153
spurred ongoing debates about the competitive tax Court established a six-part test that the local tax
status of nonprofit hospitals and the expectation board could use to determine whether nonprofit
of charity care. hospitals made charitable contributions to the
community sufficient to make them eligible for tax
exemptions. In addition to examining the distinc-
Search for New Revenue Sources tions between nonprofit and for-profit hospitals,
the extent to which the two hospitals involved
At this time, many local municipalities were
were supported by donations and gifts, the profit
encountering significant funding shortages. The
derived from operation, the charges levied on
federal government was withdrawing revenue-
patients, and several other factors before conclud-
sharing funds that once supplemented funding for
ing that the hospitals did not qualify as charitable
local projects and programs, and local legislators
institutions, the court also examined the type and
were also imposing caps on property and sales
scope of charity care nonprofit hospitals provided.
taxes. Many local government officials seized on
It looked at whether nonprofit hospitals offered
the idea of generating new revenues by rolling
services at charges below the current market rate
back the generous property tax exemptions that
or through a substantial imbalance in the exchange
they traditionally accorded nonprofit organiza-
between what it costs the charity and what it costs
tions. These officials were facing a sluggish econ-
the recipient of its services or in the lessening of a
omy and diminished federal support, and they
government’s burden through the charity’s opera-
recognized a growing lack of trust between non-
tion. This case sought to determine if these hospi-
profit hospitals and the business community. As a
tals made unremunerated contributions to the
result, they required a certain level of charity care
community.
to qualify for property tax exemptions. Nonprofit
Lacking evidence of providing unremunerated
hospitals, they argued, should no longer be able to
contributions to the healthcare of the local com-
siphon off local services if they were unable to
munity, the Utah Supreme Court allowed Utah
meet their charitable responsibilities to a commu-
County to withdraw the tax exemptions of the two
nity that privileged them with tax exemptions.
hospitals. Evidence of providing charity care was
key to this newly established quid pro quo.
In addition to this state judicial decision, federal
Charity Care and the
legislators also flirted with federal income tax
Nonprofit Tax Exemption
exemption strategies to compel nonprofit hospitals
The 1980s brought a level of public scrutiny and to do more for the poor and uninsured. Concerned
criticism heretofore unknown to nonprofit hospi- about the enormous revenues many nonprofit hos-
tals. Even as they evinced financial stewardship, pitals were realizing in the mid-1980s during the
they were criticized for becoming too businesslike early days of Medicare’s prospective payment sys-
at the expense of providing charity care for those tem (PPS), two U.S. representatives proposed legis-
who could not afford it. Local, state, and federal lation in 1991 to require nonprofit hospitals to
governments treat nonprofit hospitals differently provide more charity care in return for their fed-
from for-profit hospitals and other proprietary eral income tax exemptions. This legislation was
enterprises, especially in terms of tax exemption; subsequently withdrawn. Although most of the
but are nonprofit hospitals able to justify their policy debates about charity care and the nonprofit
exemptions from a variety of taxes by making suf- hospital tax exemption are at the state and local
ficient contributions of charity care to their local levels, this legislation, at least for a time, gave the
communities? issue national prominence.
Such scrutiny was primarily academic until In 2002, the tax exemption issue reverted back
1985, when the Utah Supreme Court moved the to the states, only this time in Illinois. In a prece-
issue from theoretical bantering to the level of law dent-setting ruling by the Illinois Department of
and precedent. It denied property tax exemption to Revenue, Provena Covenant Medical Center of
two nonprofit hospitals in the Intermountain Urbana, part of the Provena Health System, a large
Health Care System. Specifically, the Utah Supreme Catholic health organization, was stripped of its
154 Charity Care
Champaign County property tax exemption. In a This type of charity care argument was easier
decision later upheld by the state, and having to make, however, when philanthropic activity
national implications, the director of the Illinois was more obvious in the fund-raising activities of
Department of Revenue ruled that the hospital was members of the community. When private insurers
providing insufficient charity care to needy people. and state and federal governments began to take a
Since 2003, the Provena Covenant hospital has more active role in paying for and providing
paid more than $6 million in property taxes. healthcare services, first through the Hill-Burton
In 2006, the Illinois Attorney General proposed legislation in 1946, then through Medicare
the Tax-Exempt Hospital Responsibility Act, which Prospective Payment in 1983, and later through
would mandate Illinois nonprofit hospitals to Medicare and Medicaid contractual reimburse-
invest at least 8% of total operating costs toward ments, nonprofit hospitals began to rely more on
medically necessary care for uninsured Illinois resi- third-party reimbursement and less on local phi-
dents with incomes below certain poverty levels. lanthropy. Lacking such community philanthropy,
The care provided would be entirely free of charge nonprofit hospitals had a difficult case, ensuring
or discounted. Such investments cannot be based that their activities were something other than
on foregone revenues from charges but rather on maximizing revenues or selling services to people
costs calculated as those measured by a hospital’s with diminishing abilities to pay.
Medicare cost-to-charge ratio. Proposed sanctions
for noncompliance would include the revocation of
Organizational Approach
tax exemption and monetary penalties. As of 2008,
however, no such law has been passed. From an organizational perspective, nonprofit
hospitals argued that they were charitable through
state laws of incorporation. Because they were
Nonprofit Hospitals’ Defense organized to be “not-for-profit,” they did not
of Their Charity Care Activity maximize profit to distribute to individual share-
holders. Rather, they were required to return any
These mandates and court decisions created threats
excess of revenue over expenses—any “profit”—to
to nonprofit hospitals that potentially impacted
their hospitals to provide new, better, or below-
the financial situation of all tax-exempt organiza-
costs services to the community. Such an organi-
tions. In response, the hospitals took historical,
zational structure, they argued, made them
organizational, and operational approaches to
inherently charitable. The charitable returns they
argue that they provided charity care to the com-
made to their hospitals, however, were asserted
munity. Each approach is discussed below.
and not measured. Those skeptical of the activi-
ties of nonprofit hospitals began to insist on
proof.
Historical Approach
Nonprofit hospitals argued that since they were
Operational Approach
founded, they were always engaged in charity care
by serving the poor and the medically indigent. For Increased skepticism about a nonprofit’s orga-
example, the ill who were wealthy, at least in their nizational test directed attention to the operational
earliest days, were cared for in their homes. Those test in Section 501(c)(3) of the Internal Revenue
individuals who lacked access to healthcare ser- Code. This section of the Internal Revenue Code,
vices, because of poverty, geography, or ethnic, which grants tax exemption to nonprofit organiza-
racial, or religious discrimination, found free or tions, states that nonprofit corporations seeking
subsidized care in nonprofit hospitals, whose tax exemptions cannot simply assert adherence to
charitable activities were supported through good- the organizational test or “non-distribution con-
will and local philanthropy. Using this rationale, straint,” where no “part of the net earnings inures
nonprofit hospitals clearly provided charity care to the benefit of any private shareholder or indi-
by serving those who could not pay at the time of vidual.” Rather, they must also be operated exclu-
their founding. sively for charitable purposes.
Charity Care 155
Although the Internal Revenue Code does not measure of charity care should be pure, one that is
define charitable specifically, a 1956 Revenue based on only the upfront write-offs of care.
Ruling recognized the expression of a hospital’s Others maintain that a measure of charity care
charitable purpose in “the extent of its financial should include bad debts: They consider that most
ability for those not able to pay for services ren- bad debts are really charges that the medically
dered.” By 1969, however, the Internal Revenue indigent cannot pay and that should have been,
Service (IRS) had modified this ruling and elimi- but were not, written off before service was ren-
nated the requirement that nonprofit hospitals dered. Additionally, consideration should be given
provide free or subsidized care. to whether to include the shortfall from Medicare
With the advent of the Utah case, and more and Medicaid in an operational definition of char
recently the Provena Covenant ruling, and with ity care. Such distinctions are germane, especially
changes in the nation’s political and economic cli- for those trying to justify the nonprofit tax exemp-
mate, nonprofit hospitals could no longer rely on tion, because the picture of a hospital’s charity care
history or organizational or operational forms as contributions improves dramatically—especially if
arguments for or indicators of charity care. Rather, measures include unreimbursed contractuals—
they have to begin to measure their charity care depending on the types of costs that are included
levels in order to justify ongoing favorable tax in the operational definition of charity care.
treatment.
Pure Charity Care
Measuring Charity Care The most restrictive and the easiest to quantify
Despite being a definition that relies on quantifi- form of charity care, pure charity care, is not one
able costs, an operational construct of charity care typically advocated by healthcare providers but by
is nevertheless problematic because the cost com- governments. Attorney generals, for example,
ponent of charity care is difficult to measure and challenge that nonprofit hospitals are providing
because there is disagreement over the types of insufficient charity care when, as a charity care
costs that should be included in measures of char- measure, they calculate the prior to service write-
ity care. offs of all charges to patients whom a hospital has
A charity care definition that depends on classified as being unable to pay. These write-offs,
costs, or that counts “foregone revenues” as a whether they are for all or part of the bill, consti-
proxy for measuring the costs of charity care, tute pure charity care.
may over- or understate charity care contribu-
tions. Despite the advent of Diagnosis Related
Uncompensated Charity Care
Groups (DRGs) and better information technol-
ogy, individual hospital patient costs are still dif- Uncompensated charity care includes both pure
ficult to calculate. Moreover, to rely on foregone charity care and the costs of bad debts. Bad debts
revenues as proxies for measures of costs is really are the charges for services that a hospital tries to
to rely on foregone charges. While charges are collect from a patient but cannot. Prior to rendering
easier to measure, they are typically higher than services, a hospital presumes such patients are able
costs because of markups. Thus, any charity care to pay, but they do not. Because it includes a bad-
measure that depends on charges or on deduc- debt component and reflects foregone charges
tions from revenue rather than actual costs rather than costs, economists, legislators, and policy
expenses would actually favor hospitals with analysts usually reject uncompensated care charity
higher markups. And hospitals with higher mark- care measures. While uncollected debt may be con-
ups do not necessarily make larger contributions strued as a reflection of poor management practices
of charity care. and inefficiencies, there is some evidence to suggest
Despite the difficulty of calculating costs, there that some part of a bad debt may actually be charity
is still little consensus about the types of uncom- care provided to indigent people who were below
pensated costs that should be included in an opera- 150% of the federal poverty level. Thus, it is not
tional measure of charity care. Some argue that a clear whether including a bad-debt component in
156 Charity Care
measures of charity care actually inflates or under- Future Implications

states a hospital’s charity care contributions.
Proposed changes in tax exemption policy based
Nevertheless, including bad debt as charity care
on measures of charity care could include tying
does not promote good management practices.
amounts of tax exemption subsidy to levels of
charity care, totally revoking the nonprofit tax
Unreimbursed Charity Care exemption, or targeting individual hospitals, as
seems to be the current practice. Depending on the
Measured as the sum of foregone charges of rates of subsidy, tying levels of the tax exemption
pure charity care and Medicare and Medicaid con- subsidy to outputs of charity care is a strong
tractual allowances and shortfalls, unreimbursed incentive for nonprofit hospitals to increase their
charity care reflects the differences between what a production of charity care. The complete revoca-
hospital charges to provide a service and the rate tion of current tax exemption policy, however, is
at which the federal or state government reim- clearly a disincentive to the production of charity.
burses a hospital for its services. Hospital adminis- Moreover, such a policy may actually increase the
trators argue that the government reimburses for financial distress of hospitals that serve large num-
Medicare and Medicaid programs at substantially bers of poor, underinsured, or uninsured patients
lower rates than what it costs to provide service, or high percentages of people whose healthcare
and believe that any charity care measure that does comes through Medicare or Medicaid. The cur-
not reflect these allowances severely understate the rent policy trend of a quid pro quo of tax exemp-
real value of the contribution a hospital makes to tions for charity care suggests that both the
society for care of the poor. In addition, they definition of charity care and the operational com-
argue, such shortfalls must be made up from other ponents needed to measure it will, in importance,
revenue sources, a strategy that pushes costs on to supplant prior arguments based on the historical
insured patients. activities of nonprofit hospitals or any IRS ruling
based on organizational and operational tests.
Total Charity Care Susan M. Sanders
The most inclusive of all measures of charity
See also Cost of Healthcare; For-Profit Versus Not-For-
care, total charity care, includes pure charity care, Profit Healthcare; Healthcare Financial Management;
bad debt, and Medicare and Medicaid contractual Hospitals; Public Policy; Safety Net; Uncompensated
shortfalls. While it is the most robust, this measure Healthcare; Uninsured Individuals
can be criticized for all the reasons for which its
individual components can be criticized.
Further Readings
Importance of a Common Currie, Janet, and John Fahr. “Hospitals, Managed Care,
and Operational Definition and the Charity Caseload in California,” Journal of
Health Economics 23(3): 421–42, May 2004.
As the courts and legislators become more asser- DeLia, Derek. “Caring for the New Uninsured: Hospital
tive in linking a hospital’s nonprofit tax exemption Charity Care for Older People Without Coverage,”
with the level of charity care it produces, the need Journal of the American Geriatrics Society 54(12):
to measure charity care becomes more important. 1933–36, December 2006.
It does not, however, become less complex. It is Engel, Jonathan. Poor People’s Medicine: Medicaid and
easier to define charity care than to measure it. American Charity Care Since 1965. Durham, NC:
Nonprofit hospitals can make a stronger case for Duke University Press, 2006.
a tax-exempt status if courts and legislators accept Garmon, Christopher. Hospital Competition and Charity
more inclusive operational measures of charity Care. Working Paper No. 285. Washington, DC: Federal
care. Of all components, however, Medicare and Trade Commission Bureau of Economics, October 2006.
Medicaid contractual shortfalls have the most dra- Internal Revenue Code, Rev. Rul. 56-185, 1956-1, C.B.
matic effect on the charity care measure. 202. http://www.irs.gov/pub/irs-tege/rr56-185.pdf
Chassin, Mark R. 157
Lefton, Ray B. “Developing Organizational Charity-Care successfully implemented Six Sigma quality-
Policies and Procedures,” Healthcare Financial improvement methods at the hospital and medical
Management 56(4): 52–57, April 2002. school. His research at Mount Sinai focused on
Sanders, Susan M. “The ‘Common Sense’ of the developing healthcare measures, using those mea-
Nonprofit Hospital Tax-Exemption: A Policy sures to improve quality, and understanding the
Analysis,” Journal of Policy Analysis and relationship of quality measurement and improve-
Management 14(3): 446–66, Summer 1995. ment to health policy. He also expanded interven-
Wolfskill, Sandra J. Charity Care: Tools to Manage the tion trials to reduce racial and ethnic disparities in
Uninsured Population. Marblehead, MA: HCPro, 2005.
healthcare.
Before joining the faculty at Mount Sinai, Chassin
served as the commissioner of the New York State
Web Sites
Department of Health from 1992 to 1994 under
Alliance for Advancing Nonprofit Health Care: Governor Mario M. Cuomo. From 1988 to 1992,
http://www.nonprofithealthcare.org he was the senior vice president and cofounder of
American Hospital Association (AHA): Value Health Sciences, Inc., a Santa Monica,
http://www.aha.org California, private-sector company that developed
Catholic Health Association of the United States computer software and systems for quality assess-
(CHAUSA): http://www.chausa.org ment and utilization review. Prior to that, he worked
National Council of Nonprofit Associations (NCNA): as a senior project director at RAND Corporation,
http://www.ncna.org where he led several major health services research
studies on the inappropriate use of various medical
and surgical procedures. From 1979 to 1981, he
served as the deputy director and medical director of
Chassin, Mark R. the Office of Professional Standards Review
Organizations at the federal Health Care Financing
Mark R. Chassin is a national leader in healthcare Administration (HCFA) (now the Centers for
quality, patient safety, and public policy. In 2008, Medicare and Medicaid Services [CMS]). At HCFA,
he became the president of the Joint Commission, he oversaw the development and application of fed-
the nation’s leading accrediting body in the United eral guidelines for determining which medical pro-
States. cedures were inappropriate for treating Medicare
Born in Brooklyn and reared in New York City patients. Before working at HCFA, Chassin prac-
and Long Island, Chassin earned his bachelor’s ticed emergency medicine in California.
degree and a medical degree from Harvard Chassin has received many awards and honors
University. He went on to earn a master’s degree in recognizing his contributions to the fields of qual-
public policy from the Kennedy School of ity measurement and improvement. He is a mem-
Government at Harvard, and a master’s degree in ber of the National Academy of Sciences, Institute
public health from University of California, Los of Medicine (IOM). In 2001, he was selected in the
Angeles. He is also a board-certified internist. first group of honorees as a lifetime member of the
Prior to joining the Joint Commission, Chassin National Associates of the National Academies, a
was the Edmond A. Guggenheim Professor of program of the National Academy of Sciences rec-
Health Policy and the chairman of the Department ognizing career contributions to the National
of Health Policy at the Mount Sinai School of Academies. He is the recipient of the Founders’
Medicine in New York. Chassin also was the Award of the American College of Medical Quality,
Executive Vice President for Excellence in Patient and the Ellwood Individual Award from the
Care at the Mount Sinai Medical Center. During Foundation for Accountability. He has also served
his 12 years at Mount Sinai, he led an initiative to as a member of the Board of Directors of the
achieve excellence in all aspects of patient care National Committee for Quality Assurance
including patient safety, clinical outcomes, the (NCQA) and AcademyHealth.
experiences of patients and their families, and the
working environment of caregivers. In addition, he Amie Lulinski Norris
158 Child Care
See also Accreditation; Health Report Cards; Joint Background

Commission; Medical Errors; O’Leary, Dennis S.; Patient
Safety; Quality of Healthcare; RAND Corporation According to the U.S. Census Bureau’s Survey of
Income and Program Participation of 1999, among
the nation’s 12.2 million children aged 5 and
Further Readings younger with employed mothers, 60% were in a
child care arrangement with someone other than a
Becher, Elise C., and Mark R. Chassin. “Improving the parent. The 22 million children of age 6 to 14
Quality of Health Care: Who Will Lead?” Health with an employed mother spent an average of 22
Affairs 20(5): 164–79, September–October 2001.
hours per week in the care of someone other than
Chassin, Mark R. “Achieving and Sustaining Improved
their parents before or after school.
Quality: Lessons from New York and Cardiac Surgery,”
The same survey also found that for children 4
Health Affairs 21(4): 40–51, July–August 2002.
to 35 months of age, about 55% had mothers who
Chassin, Mark R., and Elise C. Becher. “The Wrong
Patient,” Annals of Internal Medicine 136(11):
were employed either part-time or full-time. About
826–33, June 4, 2002.
61% of the children spent time in child care.
Chassin, Mark R., and Robert W. Galvin. “The Urgent About 38% of the children whose mothers were
Need to Improve Health Care Quality,” Journal of employed full-time spent 21 to 40 hours in child
the American Medical Association 280(11): care. In contrast, children whose mothers were
1000–1005, September 16, 1998. not employed often spent no time in child care
Halm, Ethan A. and Mark R. Chassin. “Why Do (59%).
Hospital Death Rates Vary?” New England Journal In 2003, 20% of all children in the nation below
of Medicine 345(9): 692–94, August 30, 2001. the age of 6 (4.7 million children) were living in
Hannan, Edward L., and Mark R. Chassin. “Publicly poverty. In low-income families, there is a demand
Reporting Quality Information,” Journal of the for child care but with limited child care facilities.
American Medical Association 293(24): 2999–3000, Opportunities are limited for care for school-age
June 22, 2005. children and adolescents. The existing range of
after-school programs and activities meets only
20% of the potential demand in urban areas.
Web Sites
Joint Commission: http://www.jointcommission.org
Child Care Settings
Child care offers developmental care and educa-
tion for children who live at home with a parent
Child Care or guardian. There are a variety of child care set-
tings. The National Health and Safety Performance
Some health services researchers examine the impact Standards, set by the American Academy of
of access, cost, financing, quality, and the organiza- Pediatrics (AAP) and other organizations in 2002,
tion of child care on the health and medical out- define several types of facilities offering child care.
comes of children. Child care consists of various Family Child Care Homes provide care and edu-
care services and the education provided to children cation in a residence that is usually, but not neces-
from birth to age 12. Child care can be licensed or sarily, the home of the caregiver. A Small Home
unlicensed care. Licensed care consists of programs cares for up to 6 children at one time, and a Large
that meet their state government’s minimum stan- Home cares for 7 to 12 children at a time, includ-
dards for health, safety, and quality. It can also be ing the preschool children of the caregiver. Center-
accredited by professional education associations based care refers to a facility that provides care
for meeting standards of quality, and its workforce and education to any number of children in a non-
is credentialed. Those programs that do not require residential setting. Centers include Head Start and
a license within their state are typically the paid Early Head Start programs. A center provides care
care provided by family members, friends, and for some children for more than 30 days per year
neighbors. per child, which may include summer camps.
Child Care 159
A drop-in facility provides care for fewer than 30 development, staff wage enhancements, and pat-
days per year per child on a consecutive or inter- ent involvement.
mittent basis. A school-age child care facility
offers activities to children before and after school, Child Care Policy
during vacations, and on nonschool days when
there are teachers’ in-service programs. A facility Though there is the National Health and Safety
for children with special needs provides special- Performance Standards, child care is regulated at
ized care and education for children who must be the state government level. States typically have a
accommodated in a setting with a smaller staff- statute that identifies the regulatory agency and
child ratio, such as for children with disabilities or mandates the licensing and regulation of all full-
certain chronic illnesses. A facility for ill children time and part-time out-of-home care for children,
provides care for 1 or more children who are tem- regardless of the setting of child care. States
porarily excluded from care in their regular child establish regulations for child care settings and
care setting. Facilities for ill children can serve up monitor compliance with those regulations. The
to 6 children and be integrated in a licensed facil- primary goal of state licensing is to ensure basic
ity for well children, or they can be a special facil- health and safety protection for the child and
ity for ill children that cares for only ill children or child care workers. In addition, local and state
for more than 6 ill children at a time. The National public health departments have the legal respon-
Health and Safety Performance Standards recom- sibility to control communicable diseases in their
mend facilities serving birth to 12 months have a jurisdictions.
child-to-staff ratio of 3 children to 1 staff member,
with a maximum group size of 6 children; for Child Health Issues in Child Care Settings
children 13 to 30 months old, the recommended
ratio is 4 to 1; for children 31 to 35 months old, An effective health intervention at a child care site
it is 5 to 1. As children get older, the child-to-staff should address nutrition services, mental health,
ratio can grow. For example, for 3-year-olds, the access to health services, quality of child care ser-
ratio is 7 children to 1 staff member. For 4- to vices, and systems of care.
5-year-olds, it increases to 6 to 1. The recommen-
dations suggest a child-to-staff ratio of 10 children
Nutrition Services
to 1 caregiver for 6- to 8-year-olds. For 9- to
12-year-olds, the recommended ratio is 12 to 1. Most child care sites provide nutritional ser-
Ratios for facilities serving children with special vices. The National Health and Safety Performance
health needs are significantly smaller. Standards used by state licensing agencies specify
During the summer, almost 30% of school-age guidelines for the implementation of nutrition stan-
children are in at least one child care arrangement dards to provide high-quality meals, and nutrition
that can be defined as an organized program (a education programs. Two major federal nutritional
summer program, summer school, or a before and/ programs are available to children in child care set-
or after school program). According to the Urban tings. The Child and Adult Care Food Program
Institute’s National Survey of America’s Families (CACFP) is a federal subsidy for meals, snacks, and
for 2002, 34% of children are in relative care dur- nutrition education in licensed child care centers,
ing the summer. The remainder is in patent care. and family and group day care homes. The pro-
Low-income parents spend 14% of their income gram primarily serves children whose income falls
during the school year for child care. below 185% of the federal poverty level. The pro-
Separate from state-regulated child care sites, gram, administered by the U.S. Department of
the U.S. Department of Defense (DoD) has devel- Agriculture (USDA), serves more than 2 million
oped high-quality child care programs for military children nationally. The department also adminis-
personnel at 800 sites worldwide. They have a ters the Summer Food Service Program (SFSP),
comprehensive system of child care options with which is intended to serve school-age children
accountability, oversight, and mandates for nutritious meals at child care sites in the summer,
accreditation, staff training and professional when they do not have access to the National
160 Child Care
School Lunch or School Breakfast Program. contexts that affect early child care for ethnic
Individual states also may have nutrition services minority families, including their healthcare.
funding child care sites. Children in child care arrangements with other
children experience more bouts of upper-respira-
tory tract illnesses between the ages of 36 months
Mental Health and 54 months than do those not in child care set-
The Comprehensive Community Mental tings. Therefore, centers have developed plans for
Health Services for Children and Their Families is care or exclusion of the sick child. These centers
a federal program that child care sites can use in have been developed to care for the sick child,
their referral and mental health consultation to allowing working parents fewer missed days of
staff. The Center for Mental Health Services, work due to a child’s illness.
Substance Abuse and Mental Health Services
Administration (SAMHSA), under the U.S.
Department of Health and Human Services Systems of Care
(HHS), funds 40 comprehensive mental health The quality child care programs provide are
systems of care throughout the nation. The Head linked to the local systems of healthcare, including
Start program has child mental health guidelines dental services and oral health education for the
and has established regional Technical Assistance child and family, and linkages with healthcare pro-
Centers that provide consultation to Head Start viders who offer immunizations, health screening,
Centers on mental health issues facing children and preventive pediatric care and nutrition services
and their families. for the child and family. There are partnerships
with healthcare professionals, mental health pro-
fessionals, and community social service agencies.
Access to Health Services
Some child care programs such as Head Start
have an integrated health service access and deliv- The Child Care Workforce
ery approach. Head Start Centers often partner A study by the Early Child Care Research Network
with local child healthcare systems to provide den- of the National Institute of Child Health and
tal services, health screening and pediatric care, Human Development (NICHD) in 2002 found
and nutrition services. that regulations regarding staff training and staff-
child ratios affect the quality in child care settings
and ultimately child outcomes.
Quality of Child Care Services
The National Health and Safety Performance
Quality care requires lower child-staff ratios, Standards recommend that any individual with
smaller group sizes, and developmentally appro- primary responsibility for child care have an official
priate activities, as well as well-trained staff to child care credential as granted by the authorized
prevent the spread of infectious diseases, provide a state agency. Among the standards for credentials
safe environment, and provide for safe evacuation are those of the National Association for the
and management of emergency situations. Education of Young Children (NAEYC) and the
Quality care provides health promotion and Child Development Associate (CDA). The national
child protection, including hygiene, sanitation, dis- standards recommend that staff should receive
infection maintenance, child and staff health ongoing training in health, psychosocial and safety
protection, accommodation of special medical con- issues, including information on the spread of com-
ditions in young children, and management of ill- municable diseases and their prevention, immuni-
ness. Quality child care settings offer nutrition zation requirements for children and staff, and the
education to the child and family and a nutritious management of common childhood illness, includ-
food service. They also focus on the prevention and ing exclusion policies. In addition, caregivers are
management of infectious diseases. They are set- trained in infection control and injury prevention,
tings that are sensitive to the cultural and ecological emergency procedures, management of a blocked
Child Care 161
airway, rescue breathing, and other first aid proce- Child Health Outcomes
dures. Caregivers learn nutrition, medication
When looking at child care centers and services,
administration policies and practices, behavior
child health outcomes should be considered in
management, and how to recognize and report
terms of general outcomes, economic impact, and
child abuse in compliance with state laws.
access to healthcare.
Health advocates in child care facilities, usu-
ally one of the caregivers on-site, are the primary
parent contacts for health concerns, including General Outcomes
health-related information and the provision of According to studies conducted by the NICHD,
resources. The National Health and Safety children have better school readiness and language
Performance Standards recommend that the comprehension and fewer behavior problems at 36
health advocate refer children without a regular months of age when they attended quality child
source of care to a healthcare provider who offers care that met recommended child-staff ratios and
competent routine child care services. In addition recommended levels of caregiver training and edu-
to the on-site health advocate, each center should cation. According to the NICHD’s Study of Early
have a health consultant who is a health profes- Child Care, a 10-site prospective study of more
sional with training and experience and expertise than 1,100 participants that began at birth, in
in child health and development. This person addition to education and developmentally appro-
should be knowledgeable about the special health priate activities, sites with positive child outcomes
and safety needs of children in out-of-home care had programs promoting and protecting children’s
settings, the child care licensing requirements, health and controlling infectious diseases, ensuring
and available health resources. Sites should have children’s nutritional well-being, and maintaining
registered nurses available on-site to provide a healthy environment. Within the sample, when
medical treatment, staff training, and ongoing only poor or near-poor children were in care for at
supervision of the health needs and practices of least 20 hours a week, a higher quality of care was
staff and children, which ensures appropriate found to be associated with more favorable devel-
administration of health education and prescribed opmental outcomes in the children.
medical treatment.
Facilities serving children with disabilities need
Economic Impact
the off-site availability of a variety of healthcare
professionals, including a physician, registered In another study conducted by NICHD (the
dietitian, registered nurse, psychologist, physical Study of Early Child Care and Youth Development)
therapist, occupational therapist, speech patholo- using a stratified random sample of more than
gist, and respiratory therapist. 1,300 children and their families from birth
Caregiver training in health and safety prac- through first grade, researchers found that the
tices, including injury prevention, infection con- total number of hours in child care was associated
trol, and health promotion, needs to be ongoing. with higher maternal wages and more hours of
The CDA credential includes training in five areas: employment when children were in first grade.
(1) the recommended immunization schedule, There was also a reduction in the number of par-
(2) reporting of communicable diseases, (3) tech- ent’s missed days of work, industry’s lost produc-
niques, (4) emergency medical services, and tivity, and employee absenteeism. A study by the
(5) emergency preparedness for disaster. The Federal Reserve Board in Minneapolis, Minnesota,
National Health and Safety Performance Standards estimated that high-quality early-childhood pro-
recommend caregiver training in health and safety grams could yield a 12% rate of economic return
practice, including injury prevention, infection to the public and a 4% rate of return to the indi-
control, and health promotion. Caregivers should vidual child and his or her family. To deliver this
also receive training in cultural diversity; nutrition rate of return, the child care program must meet
and healthy eating; the protocol to prevent, recog- high standards of quality, which some researchers
nize, and correct health and safety problems; and feel can be achieved through more private outlay
management of illness. and public investment.
162 Child Care
Access to Healthcare for whom the benefits are substantial. Finally,

public policies that address the financing and
As discussed earlier, the National Health and
investment in child care by government and the
Safety Standards recommend that the child care
private sector need to be developed, proposed, and
facility help families who have no regular health-
implemented.
care provider locate a resource that can meet their
needs. Referral to health services should be com- Sharon Telleen
prehensive and range from preventive services such
as immunizations, injury prevention, and nutri- See also Access to Healthcare; American Academy of
tion, to acute treatments to referral and evaluation Pediatrics (AAP); Health Insurance; Medicaid;
for potential chronic health problems. Child care Preventive Care; Primary Care; State Children’s Health
centers can serve as a linkage of families to the Insurance Program (SCHIP); Vulnerable Populations
healthcare system, and providers can assist fami-
lies in obtaining information about their child’s
eligibility for the State Children’s Health Insurance Further Readings
Program (SCHIP). Additionally, they can help American Academy of Pediatrics, American Public
families access a medical home and establish a Health Association, and the National Resource
regular source of care. Linkage and referral to Center for Health and Safety in Child Care and Early
child care resource center, county public health Education. Caring for Our Children: National Health
departments, Early, Periodic, Diagnosis, and and Safety Performance Standards—Guidelines for
Treatment (EPSDT) programs, and hospital and Out-of-Home Child Care Programs. 2d ed. Elk Gove
clinic pediatric departments are among the health Village, IL: American Academy of Pediatrics, 2002.
service use outcomes. Bud, Kristen L., and Kathleen McCartney. “On
Childcare as a Support for Maternal Employment
Wages and Hours,” Journal of Social Issues 60(4):
Future Implications 819–34, April 2004.
Child care is vital for families, industry, and soci- Capizzano, Jeffrey, Kathryn Tout, and Gina Adams.
ety. It affects education, childhood development, Child Care Patterns of School-Age Children With
and pediatric health. In terms of health services Employed Mothers. Assessing the New Federalism
research, there is a need for research on the bene- Occasional Paper, No. 41. Washington, DC: Urban
fit-to-cost ratio of preschool health services, Institute, 2000.
immunizations, health screenings, and preventive Committee on Evaluation of Children’s Health, National
care on child health status indicators. Further Research Council. Children’s Health, the Nation’s
research is also needed on the effects of the child Wealth: Assessing and Improving Child Health.
health standards for children with developmental
Committee on Family and Work Policies, National
delays or chronic health problems.
Research Council. Working Families and Growing
Health service researchers will need to focus on
Kids: Caring for Children and Adolescents.
effective treatments and best practices that effec-
tively address poor nutrition, infections, and expo- Gonzalez-Mena, Janet, and Dianne Widmeyer Eyer.
sure to environmental toxins, drugs, and other Infant, Toddlers, and Caregivers: A Curriculum of
biological hazards that affect healthy brain devel- Respect, Responsive Care, and Education. 8th ed.
opment. More studies with using experimental and New York: McGraw-Hill, 2009.
quasi-experimental designs will help establish best Rolnick, Arthur J., and Rob Grunewald. Early
practices for integrating child healthcare and child Childhood Development: Economic Development
care systems. With a High Public Return. Minneapolis, MN:
In terms of state and federal policy, quality pro- Federal Reserve Bank of Minneapolis, March
grams must ensure that all child care settings are 2003.
safe, stimulating, and compatible with develop- Sobo, Elisa J., and Paul S. Kurtin, eds. Child Health
mental needs. These settings need to be made more Services Research: Applications, Innovations, and
accessible to larger numbers of the working poor Insights. San Francisco: Jossey-Bass, 2003.
Chiropractors 163
Web Sites appropriate healthcare provider when chiropractic

American Academy of Pediatrics (AAP): care is not suitable for the patient’s condition or
http://www.aap.org when the condition warrants comanagement in
ChildCare.gov: http://www.childcare.gov conjunction with other members of the healthcare
National Child Care Information and Technical team.
Assistance Center (NCCIC): http://www.nccic.org
National Institute of Child Health and Human Philosophy
Development (NICHD): http://www.nichd.nih.gov
Doctors of chiropractic believe in a holistic “total
U.S. Census Bureau: http://www.census.gov
person” approach to healing, which typifies the
new and changing attitude toward health. It is
based on the concept of “maintaining health”
versus “treating disease.” Chiropractic philoso-
Chiropractors phy includes (a) a recognition that dynamics
exist between lifestyle, environment, and health;
Chiropractic is America’s most popular form of (b) understanding the cause of illness to eliminate
alternative healthcare, and more than 25 million it, rather than simply treat symptoms; (c) a rec-
patients annually visit chiropractors for pain relief ognition of the centrality of the nervous system
and other benefits. Chiropractic is a healthcare and its intimate relationship with the capacities
profession that focuses on disorders of the muscu- of the human body; (d) a patient-centered,
loskeletal system and the nervous system and the hands-on approach focused on influencing func-
effects of these disorders on general health. tion through structure; and (e) a focus on early
Chiropractic care is used most often to treat neu- intervention, emphasizing timely diagnosis and
romusculoskeletal complaints, including but not treatment of conditions that are wholly func-
limited to back pain, neck pain, pain in the joints tional and reversible.
of the arms and legs, and headaches.
Doctors of chiropractic—often referred to as
Treatment Methods
chiropractors or chiropractic physicians—practice
a drug-free, hands-on approach to healthcare that The most common therapeutic procedure per-
includes patient examination, diagnosis, and treat- formed by doctors of chiropractic is known as
ment. Chiropractors have broad diagnostic skills spinal manipulation, also called chiropractic
and are also trained to recommend therapeutic and adjustment. The purpose of manipulation is to
rehabilitative exercises, as well as to provide nutri- restore joint mobility by manually applying a con-
tional, dietary, and lifestyle counseling. trolled force into joints that have become hypo-
Chiropractors are considered first-contact pro- mobile—or restricted in their movement—as a
viders (i.e., primary-care providers) and are so result of a tissue injury. Tissue injury can be
defined in federal and state regulations, including caused by a single traumatic event, such as
within the Medicare program. For many condi- improper lifting of a heavy object, or through
tions, such as lower-back pain, chiropractic care repetitive stresses, such as sitting in an awkward
may be the primary method of treatment. When position with poor spinal posture for an extended
other health conditions exist, chiropractic care period of time. In either case, injured tissues
may complement or support medical treatment by undergo physical and chemical changes that can
relieving the musculoskeletal aspects associated cause inflammation, pain, and diminished func-
with the condition. tion for the sufferer. Manipulation, or adjustment
Doctors of chiropractic may assess patients of the affected joint and tissues, restores mobility,
through clinical examination, laboratory testing, thereby alleviating pain and muscle tightness and
diagnostic imaging, and other diagnostic interven- allowing tissues to heal.
tions to determine when chiropractic treatment is Chiropractic adjustment rarely causes discom-
appropriate or when it is not appropriate. fort. However, patients may sometimes experience
Chiropractors will readily refer patients to the mild soreness or aching following treatment (as
164 Chiropractors
with some forms of exercise) that usually resolves found “high-quality evidence” that patients with
within 12 to 48 hours. chronic neck pain showed significant pain-level
improvements following spinal manipulation. No
trial group was reported to remain unchanged, and
Research all groups showed positive changes up to 12 weeks
after treatment.
Throughout its history, the chiropractic profes-
With regard to headaches, a report released in
sion has had the difficult task of justifying itself to
2001 by researchers at the Duke University
the mainstream medical community. The chiro-
Evidence-Based Practice Center found that spinal
practic profession has undertaken an extensive
manipulation resulted in almost immediate
amount of research to show that chiropractic pro-
improvement for headaches that originate in the
vides effective treatment that is patient-focused,
neck and had significantly fewer side effects and
low-cost, low-risk, and noninvasive.
longer-lasting relief of tension-type headache com-
A 2007 study from the Chicago area found that
pared with a commonly prescribed medication.
patients visiting chiropractors who serve as pri-
Although there have been some isolated media
mary-care providers have lower utilization costs
reports of stroke following chiropractic neck
and higher patient satisfaction levels than do
manipulation, the findings in the current research
patients treated by conventional medical physi-
literature agree that adverse events such as stroke
cians. Researchers found that over the course of
or stoke-like symptoms associated with cervical
the 7-year study, which was published in the
manipulation are extremely rare. For example, a
Journal of Manipulative and Physiological Thera
medical review published in 2002 looked at 73
peutics, patients visiting chiropractors and other
studies of chiropractic care and found no serious
complementary and alternative medicine-oriented
complications reported in any of them. Studies
primary-care providers had 60% fewer hospital-
have also shown that when an adverse reaction
izations, 62% fewer outpatient surgical cases, and
does occur, it is often the result of an improperly
85% lower pharmaceutical costs when compared
trained person performing the procedure—rather
with total network HMO utilization rates and
than a doctor of chiropractic.
costs. The chiropractors and other complementary
and alternative medicine doctors treated and man-
aged cases ranging from upper-respiratory-tract
Origins and History
infections and allergies to headaches, orthopedic,
and other medical conditions. The word chiropractic comes from the Greek
A significant amount of evidence also shows words cheir (meaning “hard”) and praktos (mean-
that the use of chiropractic care for problems such ing “done”)—that is, done by hand. The developer
as acute and chronic lower-back pain, neck pain, of chiropractic, Daniel David Palmer (1845–1913),
headaches, and many other neuromusculoskeletal chose the name.
conditions can be more effective and less costly A prolific reader of all things scientific, Palmer
than traditional medical care. Most recently, the realized that although various forms of manipula-
report of a 2005 study in the Journal of tion had been used for thousands of years, no one
Manipulative and Physiological Therapeutics con- had developed a philosophical or scientific ratio-
cluded that chiropractic and medical care have nale to explain their effects. Palmer’s major contri-
comparable costs for treating low-back pain, with bution to the health field was the codification of
chiropractic producing better outcomes for chronic the philosophy, art, and science of chiropractic,
pain. In addition, the report of a 2003 study pub- which was based on his extensive study of anat-
lished in the medical journal Spine found that omy and physiology. Palmer performed the initial
manual manipulation provides better short-term chiropractic adjustment in 1895. Palmer examined
relief of chronic spinal pain than do a variety of a janitor who had become deaf 17 years earlier
medications. after he felt something “give” in his back. Palmer
A 2007 literature review in the Journal of examined the area and gave a crude “adjustment”
Manipulative and Physiological Therapeutics to what was felt to be a misplaced vertebra in the
Chiropractors 165
upper back. The janitor then observed that his musculoskeletal function, and manual treatment
hearing improved. methods.
From that first adjustment, Palmer continued to In the United States, all aspects of chiropractic
develop chiropractic and in 1897 established the education must meet official accreditation stan-
Palmer School of Cure, now known as the Palmer dards, and a graduate must also complete state and
College of Chiropractic in Davenport, Iowa, where national licensing board examinations before gain-
it remains today. Following the first adjustment, ing the right to practice.
many people became interested in Palmer’s new Furthermore, virtually all states have mandatory
science and healing art. Among his early students continuing education requirements for chiroprac-
were Palmer’s son, Bartlett Joshua Palmer, as well tors to maintain or renew a license to practice.
as members of the older healing arts of medicine Chiropractic colleges frequently offer postgraduate
and osteopathy. continuing education programs in specialty fields
Kansas was the first state to license chiroprac- ranging from sports injuries and occupational health
tors in 1913, and by 1931, 39 states had given to orthopedics and neurology. These programs
chiropractors legal recognition. Today, there are allow chiropractors to specialize in a healthcare dis-
more than 60,000 active chiropractic licenses in cipline or meet state relicensure requirements.
the United States. All 50 states, the District of
Columbia, Puerto Rico, and the U.S. Virgin Islands
officially recognize chiropractic as a healthcare Institutional Recognition
profession. Many other countries also recognize The public’s attitude toward chiropractic care has
and regulate chiropractic, including Canada, been instrumental to the profession’s growth and
Mexico, Great Britain, Australia, Japan, and acceptance into mainstream healthcare. A few
Switzerland. notable examples of chiropractic integration into
today’s healthcare system include the chiropractic
department at the National Naval Medical Center
Education, Licensing, and Regulation in Bethesda, Maryland, the successful Comple
Chiropractic education is much more regulated mentary and Alternative Medicine Center at the
and extensive than most people appreciate. The National Institutes of Health (NIH), and the doc-
Council on Chiropractic Education, an agency tors of chiropractic who work as consultants to the
certified by the U.S. Department of Education, Office of the Attending Physician at the U.S. Capitol
currently recognizes 15 chiropractic programs at Building. Furthermore, the federal government has
18 different locations. recognized the effectiveness and cost savings poten-
The typical applicant at a chiropractic college tial of chiropractic care by providing benefits
has already acquired nearly 4 years of premedical to veterans, active-duty military personnel, and
undergraduate college education, including courses Medicare patients.
in biology, inorganic and organic chemistry, phys-
ics, psychology, and related laboratory work. Once
Insurance Coverage
accepted into an accredited chiropractic college,
students receive an additional 4 or 5 academic Compared with complementary and alternative
years of professional study. Because of the hands- therapies as a whole (few of which are reim-
on nature of chiropractic, and the intricate adjust- bursed), coverage of chiropractic by health insur-
ing techniques, a significant portion of time is ance plans is extensive. As of 2002, more than
spent in clinical training. 50% of HMOs, more than 75% of private health-
In total, the chiropractic curriculum includes a care plans, and all state workers’ compensation
minimum of 4,200 hours of classroom, laboratory, systems covered chiropractic treatment, although
and clinical experience. Compared with medical chiropractic trade organizations have seen other
students, chiropractic students receive considerably more anecdotal and informal reports that put the
less instruction in pharmacology and surgery; how- percentage of PPOs offering chiropractic care at
ever, added emphasis is placed on biomechanics, around 90%.
166 Chronic Care Model
Chiropractors can bill Medicare for select ser- Further Readings

vices and more than two dozen states cover chiro- Chapman-Smith, David. The Chiropractic Profession.
practic treatment under Medicaid. Chiropractic West Des Moines, IA: NCMIC Group, 2000.
care is available to members of the armed forces at Cooperstein, Robert, and Brian J. Gleberzon. Technique
more than 40 military bases in the United States Systems in Chiropractic. London: Churchill
and is covered benefit for America’s veterans at Livingston–Elsevier Health Sciences, 2004.
nearly 30 U.S. Veterans’ Administration health Gatterman, Meridel I. Foundations of Chiropractic:
facilities. Furthermore, the Internal Revenue Service Subluxation. 2d ed. St. Louis, MO: Elsevier Health
(IRS) includes chiropractic services as a valid Sciences, 2005.
medical deduction. Gatterman, Meridel I. Chiropractic, Health Promotion,
and Wellness. Sudbury, MA: Jones and Bartlett, 2006.
Lenarz, Michael, and Victoria St. George. The
Chiropractors in Practice Chiropractic Way: How Chiropractic Care Can Stop
Your Pain and Help You Regain Your Health
Doctors of chiropractic represent the third larg- Without Drugs or Surgery. New York: Bantam, 2003.
est doctoral-level healthcare professionals in the National Board of Chiropractic Examiners. Job Analysis
United States, after medical physicians and den- of Chiropractic 2005: A Project Report, Survey
tists. Nearly 82% are in full-time practice, with Analysis, and Summary of the Practice of
the average chiropractor working between 40 Chiropractic Within the United States. Greeley, CO:
to 52 hours per week. The majority (61%) of National Board of Chiropractic Examiners, 2005.
chiropractors work in an office in which they Reizer, John. Chiropractic Made Simple: Working With
are the only doctor. Nearly one third (31%) the Controlling Laws of Nature. Albuquerque, NM:
share an office with one or more chiropractors, Wincan, 2002.
while the remaining doctors either work in a
multidisciplinary setting or work in other office
arrangements. Web Sites
American Chiropractic Association:
http://www.acatoday.com
The Chiropractic Patient Association of Chiropractic Colleges:
http://www.chirocolleges.org
The results of a 2005 survey conducted by the
Congress of Chiropractic State Associations (COCSA):
National Board of Chiropractic Examiners
http://www.cocsa.org
found that more than 35% of patients receiving
Council on Chiropractic Education: http://cce-usa.org
chiropractic care were being treated for mid- or Federation of Chiropractic Licensing Boards (FCLB):
low-back problems and almost 20% were being http://www.fclb.org
treated for neck pain. More than half of those Foundation for Chiropractic Education and Research
surveyed indicated that their symptoms were (FCER): http://www.fcer.org
chronic. Conditions commonly treated by chi- National Board of Chiropractic Examination (NBCE):
ropractors included, but were not limited to, http://www.nbce.org
back pain, neck pain, headaches, sports inju- National Center for Complementary and Alternative
ries, motor vehicle accident injuries, and repeti- Medicine: http://http://nccam.nih.gov
tive strains. Patients also sought treatment of World Federation of Chiropractic (WFC):
pain associated with other conditions, such as http://www.wfc.org
arthritis.
Angela M. Kargus
Chronic Care Model
See also Antitrust Law; Complementary and Alternative
Medicine; Licensing; Medicare; National Institutes of The Chronic Care Model (CCM) is a proposal for
Health (NIH); Pain; Physicians; Primary Care reorganizing primary medical care to address
Chronic Care Model 167
better the needs of patients with chronic illnesses. reimbursement to treatment of acute, urgent
This proposal creates a new clinical paradigm for medical problems.
delivering chronic disease care, with a major Although the HMO movement failed to trans-
emphasis on patient self-management and second- form the nation’s healthcare, several large inte-
ary prevention. The ideas behind the CCM were grated systems, such as Group Health Cooperative,
outlined in a series of landmark articles published Kaiser-Permanente Northern California, and the
in 2002 in the Journal of the American Medical Veterans Health Administration (VHA), did
Association that described a number of attempts develop innovative disease management approaches
to implement various aspects of the model in to providing coordinated chronic disease care.
diverse healthcare delivery systems across the These organizations were pioneers in adopting
United States. The principles of the model were medical management information systems that
originally developed by Edward H. Wagner, from could track utilization of care across multiple epi-
the Center for Health Studies at Group Health sodes of illness and provide computerized clinical
Cooperative of Puget Sound. guideline reminders and decision support to physi-
cians. In addition, these organizations were able to
Background offer multidisciplinary team-based care and proac-
tive telephone follow-up of patients—services that
During the 1970s and 1980s, with U.S. healthcare are generally not reimbursed in traditional fee-
costs regularly doubling the rate of inflation, many for-service practice settings. It was from these suc-
proponents of reforming the nation’s healthcare sys- cessful experiments in redesign of primary care for
tem turned to managed care. A centerpiece of health- chronically ill patients that Wagner and his col-
care expenditure increases during these decades, leagues distilled the CCM.
above and beyond the aging of the population, was
the rapid increase in the “intensity” of care, particu-
larly hospital care for older patients with chronic
Basic Principles of the Model
illnesses. Yet despite the increase in surgical proce-
dures and hospital-based specialty care, health ser- The CCM was developed to capitalize on the
vices researchers were simultaneously producing best features of primary care, defined by the
ample documentation of major quality problems in Institute of Medicine (IOM) as the provision of
basic chronic disease care for all Americans. integrated, accessible healthcare services by clini-
Early policy responses included the original cians who are accountable for addressing a large
federal health maintenance organization (HMO) majority of personal healthcare needs, develop-
acts of 1973 and 1976, which aimed at the cre- ing a sustained partnership with patients, and
ation of large integrated healthcare delivery sys- practicing within the context of family and com-
tems that combined hospital and outpatient care. munity. The CCM seeks to go beyond managed-
Such systems offered financial incentives, such as care gatekeeper models that attempt to reduce
capitation (a fixed fee per year) reimbursement unnecessary care (and costs) by requiring spe-
for a defined population of enrolled patients, to cialty referrals from primary-care physicians.
emphasize preventive health maintenance and Instead, recognizing that most chronically ill
avoidance of preventable exacerbations of chronic patients receive the bulk of their care from pri-
diseases. Because about 10% of the sickest mary-care physicians, and that the majority of
patients generate over two thirds of all health- them have multiple disease conditions, the CCM
care costs, there is a major financial incentive for advocates efficient integration of specialty care
prepaid delivery systems to better manage their into clinical case management while preserving a
highest-risk enrollees. It was hoped that capi- “whole”-patient perspective. Six synergistic
tated payment systems would initiate a new pre- “ingredients” of the model were distilled from
vention and health promotion paradigm that evaluations of successful disease management
could reverse the often perverse financial incen- and quality improvement efforts during the
tives of the fee-for-service system, which restricted 1990s. Each is discussed below.
Clinical Information go beyond traditional didactic patient education to

Systems and Disease Registries embrace strategies for patient empowerment. These
strategies focus on individually tailored action plans
Healthcare organizations that seek to improve
that are capable of overcoming barriers to lifestyle
care for a particular condition must first be able to
changes, based on patients’ existing health beliefs
identify patients with the condition as well as rel-
and readiness to make changes. Central to such
evant aspects of their care. Chronic disease regis-
behavior change is effective management of com-
tries, which ideally should include diagnostic,
mon psychological obstacles such as anxiety, fear,
laboratory, and pharmacy data, are thus essential
fatigue, and depression that so commonly afflict patients
to providing clinicians with information about all
with incurable illness (and complicate successful
patients with a particular diagnosis (e.g., diabetes)
medical treatment regimens). Self-management
in their practice. The registry is used to further
must therefore build on a patient’s own goals and
determine whether relevant evidence-based tests
aspirations, with clinicians playing the role of
and procedures have been performed (e.g., regular
coaches, providing feedback, and assisting in practi-
eye and foot examinations), to notify both patients
cal problem solving.
and physicians when important exceptions to
There is considerable evidence that differences
guidelines are identified or clinical services are
in the efficacy of self-management may explain
overdue, or to identify very high-risk patients
much of the widely observed socioeconomic and
requiring intensified follow-up care. Registries
ethnic and racial disparities in health outcomes of
provide an ongoing resource for quality improve-
patients with chronic illness. One of the greatest
ment and continuous monitoring and evaluation
challenges to self-management educational initia-
of therapeutic progress (e.g., hemoglobin A1c lab-
tives is limited health literacy, including the ability
oratory results).
to read and understand medical information.
Despite the potential of health information
Given a general lack of fee-for-service reimburse-
technology to improve care, less than a half of even
ment for psychosocial interventions, there remains
the largest physician group practices in the nation
a major deficit in funding for proven behavioral
(those with greater than 20 physicians) had even a
interventions such as smoking cessation, physical
single chronic disease registry in 2001. Far fewer
activity promotion, or weight loss.
of these practices had registries linked to clinical
data or that extended beyond a single condition
such as diabetes. Obviously, smaller medical prac- Delivery System Redesign
tices, which handle the majority of all physician
The CCM calls for a redesign of the traditional
visits in the nation, are even less likely to currently
physician office-based visit setting with its time
use chronic disease registries.
limitations and focus on acute care. A basic con-
cept is multidisciplinary, proactive team care,
which can be conducted outside traditional physi-
Support for Patient Self-Management
cian office visits by allied health professionals.
Central to the CCM is the concept of behavioral Nurses, case managers, health educators, and even
interventions in the way in which patients manage nonclinician support personnel, working in con-
their illnesses on an everyday basis. This is concep- junction with primary-care physicians, can be
tually distinct from shared decision making in clini- employed to schedule tests and visits, provide
cal encounters between clinicians and patients, coaching, monitoring and education, conduct tele-
which focuses on treatment planning and collabora- phone (or Internet) follow-up, and update chronic
tive decisions on medical management. Rather, self- disease registry information. Team members could
management theory stresses the psychosocial aspects also include pharmacists, psychologists, social
of coping with chronic illness and aims at both edu- workers, physical or occupational therapists, dieti-
cating patients and improving patients’ self-efficacy, cians, or information system specialists. One note-
or confidence in their ability and skills to undertake worthy innovation is group visits, where patients
preventive measures to limit disease progression and who share a chronic illness can find mutual sup-
symptom severity. Self-management initiatives thus port, problem-solving help, and role models. In
Chronic Care Model 169
theory, group visits can provide the type of social reminders can also be directly addressed to patients
persuasion that characterizes effective interven- outside the physician’s office when appropriate.
tions such as Alcoholics Anonymous or Weight Registries can also be used to generate aggregate
Watchers. Other potentially useful innovations clinical performance feedback or report cards on
include home visits (e.g., by social workers follow- panels of patients, displaying the percentage of
ing depressed patients), physician office open to each physician’s patients adhering to guidelines for
advanced access to walk-in appointments, and their care, or providing information about clinical
“one-stop shopping” visits when patients can outcomes such as blood pressure control. Efforts
access a full range of specialized ancillary services such as “academic detailing” (university-based
such as foot or vision care in a single visit. educational outreach) and specialized training and
There are many obvious barriers to implement- staff development programs for chronic care teams
ing these redesign features in smaller, fee-for-service are also advocated. Finally, by flagging more
physician office settings. One approach to encour- severely ill patients or those who require additional
age redesign has been pay-for-performance reim- medical resources, decision support may improve
bursement incentives. Insurers (potentially including the efficiency of specialty care referrals.
Medicaid and Medicare) may offer physician prac- Currently, decision support capabilities are lim-
tices additional payments for meeting goals on ited by the paucity of medical practices that use
“reportcard” measures that rate adherence to electronic clinical records, particularly systems
established clinical guidelines for chronic condi- that are capable of interfacing laboratory and
tions across all patients cared for by a healthcare pharmacy prescription data. While computerized
organization. This may spur more medical prac- clinical records can potentially improve both
tices to pursue chronic disease redesign initiatives. patient outcomes and economic efficiency, there is
a large initial investment required in hardware,
software, and training. Finally, the validity and
Accessing Community Resources reliability of physician performance measures
Community resources are critical in expanding remains controversial, and physician or practice
the reach of physician office care. The CCM sug- performance measures require adjustment for
gests developing ongoing linkages to community higher-risk patient populations.
institutions such as mental health centers, senior
citizen centers, hospital-based educational, smok-
Healthcare Organizational Leadership
ing cessation or diet programs, exercise facilities,
home health care agencies, and other community Echoing continuous quality improvement the-
support institutions. An additional function of ory, the CCM requires the enthusiastic endorse-
community resources might be assisting vulnerable ment of top-level healthcare leadership to be
or lower-income patients and their families with successful. Without top leaders supporting changes
navigating the healthcare system or helping them required by the CCM, traditional incentives for
find sources of health insurance, low-cost drugs, business as usual will undermine change efforts.
transportation, and child care or adult day care or CCM implementation requires significant reallo-
respite care arrangements. cation of resources from the health system
infrastructure, including information systems, use
of multidisciplinary personnel in new roles, and
Medical Decision Support
incentives for clinicians to change their practice
and Guidelines Implementation
style to accommodate new approaches. Imple
The CCM calls for readily accessible clinical mentation of the model will often require a major
data to provide physicians and other providers shift in organizational culture, to proactive fol-
with timely information and reminders, including low-up, emphasizing behavioral medicine, coop-
point of care reminders of the need for indicated erative teamwork, and shared decision making
services at the time of patient visits. In this way, with patients, skills that may conflict with tradi-
clinical guidelines and protocols can be imple- tional medical education as primarily experienced
mented with minimum burden on physicians. Such by physicians in the acute care hospital setting. It
is therefore not surprising that only about half of intimate knowledge of patients and familiarity
the largest medical practices in the nation reported with local conditions that might characterize a
using case management or performance feedback primary-care practice, disease management firms
to physicians for any chronic illness. have the resources to employ highly specialized
and trained personnel who are fully dedicated to
providing care management services. The future
Disease Management and interaction of disease management and the CCM
the Chronic Care Model remains controversial and presents a potential
financial conflict as disease management firms
Over the past decade, many of the functions of the
gain revenue that might otherwise be allocated to
CCM have been adopted by disease management
redesigning physician practices.
firms, which primarily sell their services to large
managed-care organizations, insurers, and health
plans. The growth of the disease management
Future Implications
industry has come in part as a response to the
failure of managed care and the HMO movement A number of meta-analyses have found that dis-
to directly transform the healthcare delivery sys- ease management and patient self-management
tem through intrusive and unpopular restrictions programs have been generally successful in improv-
on patient access and utilization review of physi- ing process quality of care and clinical outcomes
cians. Instead, large health plans hope to reduce for patients with chronic medical conditions. The
costs by changing patient behavior outside the best results have been reported for programs
physician practice environment. The primary dif- focused on care for diabetes, hypertension, asthma,
ference between the emerging disease management and depression, with somewhat more contradic-
industry and the CCM is that educational and tory results for congestive heart failure and arthri-
case management services are provided directly to tis. Data on whether self-management or case
patients by third-party firms contracting with the management reduces direct medical care costs
patient’s insurer rather than being administered remain mixed and inconclusive. There are also
directly through the patient’s medical practice. ongoing evaluations of attempts to implement
The disease management industry began with components of the CCM through support for
pharmaceutical benefit and behavioral and mental more than 100 demonstration projects from the
health management firms that negotiated carve- Robert Wood Johnson Foundation (RWJF) and the
out contracts with large health plans to manage Institute for Healthcare Improvement (IHI). These
care for specific populations of chronically ill evaluations have generally been positive with
patients. The industry has subsequently grown to regards to the fidelity of the model’s principles, but
include firms that provide many of the educa- the depth and extent of programs varied widely
tional, self-management, and monitoring functions among participating provider organizations.
associated with the CCM. Disease management Programs differ widely in what was done, the
firms use sophisticated data warehouses contain- usual care that the control groups received, and the
ing claims and utilization data for millions of severity of illness of the study populations.
patients and, increasingly, specialized electronic Because the studies to date cover only partially
home monitoring devices and patient self-assess- implemented aspects of disease management and
ments provided over the Internet. These data allow never a full CCM implementation and because the
the firms to identify high-risk patients for a par- literature may suffer from publication bias favor-
ticular insurance entity and to then provide directing successful programs, little is known about
to-patient services (usually by telephone) by which specific aspects of self-management or case
specialized personnel such as nurse case managers, management programs actually produce the best
with or without the participation of physicians. results. This ambiguity about disease management
These firms may also contact physicians directly and CCM outcomes has led to several calls for
when there is evidence of a divergence from prac- more standardized reporting of evaluations. As the
tice guidelines or optimal care. While lacking the nation’s population ages and chronic illness
Clancy, Carolyn M. 171
becomes more prevalent, the concepts behind the

CCM will undoubtedly continue to shape health Chronic Diseases
policy and delivery system innovation and will
remain a central focus of health services research. See Acute and Chronic Diseases
Joe Feinglass
See also Acute and Chronic Diseases; Case Management;

Disease Management; Health Maintenance Clancy, Carolyn M.
Organizations (HMOs); Long-Term Care; Managed
Care; Primary Care; Quality of Healthcare Carolyn M. Clancy is a health services researcher
and a general internist, and she is the director of
the U.S. Department of Health and Human
Further Readings Services’ Agency for Healthcare Quality and
Alt, Paula Stec, and Dori Schatell. “Shifting to the Research (AHRQ), the federal agency that is
Chronic Care Model May Save Lives,” Nephrology responsible for supporting research to improve
News and Issues 22(7): 28, 30, 32, June 2008. healthcare quality, reduce healthcare costs,
Bodenheimer, Thomas, Edward H. Wagner, and Kevin decrease medical errors, improve patient safety,
Grumbach. “Improving Primary Care for Patients With and increase access to care. Clancy served as act-
Chronic Illness,” Journal of the American Medical ing director of AHRQ from March 2002 until she
Association 288(14): 1775–79, October 9, 2002. was appointed director in February 2003. She
Bodenheimer, Thomas, Edward H. Wagner, and Kevin previously directed the Center for Outcomes and
Grumbach. “Improving Primary Care for Patients Effectiveness Research, which conducts and sup-
With Chronic Illness: The Chronic Care Model, Part ports research on the outcomes and effectiveness
2,” Journal of the American Medical Association of healthcare services and procedures, and the
288(15): 1909–1914, October 16, 2002. Center for Primary Care Research at AHRQ,
Cassalino, Lawrence P., “Disease Management and the
where she helped develop the U.S. Public Health
Organization of Physician Practice,” Journal of the
Service Primary Care Policy Fellowship. Prior to
American Medical Association 293(4): 485–88,
joining AHRQ in 1990, Clancy was an assistant
January 26, 2005.
professor in the Department of Internal Medicine
Pearson, Marjorie L., Shinyi Wu, Judith Schaefer, et al.
“Assessing the Implementation of the Chronic Care
at the Medical College of Virginia in Richmond.
Model in Quality Improvement Collaboratives,”
Clancy received her bachelor of science degree
Health Services Research 40(4): 978–96, August from Boston College and a doctorate of medicine
2005. degree from the University of Massachusetts School
Smith, Steven A., Nilay D. Shah, Sandra C. Bryant, et al. of Medicine. After completing medical school, she
“Chronic Care Model and Shared Care in Diabetes: did postdoctoral training at the Kennedy Institute of
Randomized Trial of an Electronic Decision Support Bioethics Intensive Course at Georgetown University
System,” Mayo Clinic Proceedings 83(7): 747–57. in 1989 and the Stanford Faculty Development
July 2008. Program in Clinical Teaching in 1988 and was a
Henry J. Kaiser Family Foundation Fellow in
General Internal Medicine at the Hospital of the
Web Sites University of Pennsylvania from 1982 to 1984.
American Academy of Family Physicians (AAFP): Clancy holds an academic appointment as a
http://www.aafp.org clinical associate professor at the George
Improving Chronic Illness Care: Washington University School of Medicine in the
http://www.improvingchroniccare.org Department of Medicine. She has edited or con-
Institute for Healthcare Improvement (IHI): tributed to seven books and has published exten-
http://www.ihi.org sively in peer-reviewed medical journals. Clancy
Robert Wood Johnson Foundation (RWJF): has served on various editorial boards, including
http://www.rwjf.org those of the Annals of Family Medicine, American
172 Clinical Decision Support
Journal of Medical Quality, and Medical Care Tunis, Sean R., Daniel B. Stryer, and Carolyn M.
Research and Review, and is a senior associate edi- Clancy. “Practical Clinical Trials: Increasing the
tor of the journal Health Services Research. Clancy Value of Clinical Research for Decision Making in
has also held leadership positions in many profes- Clinical and Health Policy,” Journal of the American
sional organizations, including the Society of Medical Association 290(12): 1624–32, September
General Internal Medicine. In addition, she is an 24, 2003.
elected member of the National Academy of Social
Insurance and the national Institute of Medicine
(IOM) and was elected a Master of the American Web Sites
College of Physicians in 2004. Her research inter- Agency for Healthcare Research and Quality (AHRQ),
ests have been strongly influenced by the field of Director’s Biography: http://www.ahrq.gov/about/
medical decision making and currently include the clancybio.htm
various dimensions of healthcare quality and AARP Speaker Biography: http://www.aarp.org/aarp_
patient care, including women’s health, primary benefits/natl_events/boston/speakers/carolyn_
care, access to healthcare, and the impact of finan- clancy.html
cial incentives on physicians’ decisions.
Jared Lane K. Maeda
See also Agency for Healthcare Research and Quality

Clinical Decision Support
(AHRQ); Clinical Practice Guidelines; Eisenberg, John
M.; Equity, Efficiency, and Effectiveness in Healthcare; Computer systems to augment medical decision
Health Services Research, Origins; Public Policy; making were introduced to the healthcare market-
Quality of Healthcare place in the late 1970s and early 1980s. Healthcare
organizations have been using decision support
in areas of marketing, cost accounting, strategic
Further Readings planning, and case-mix analysis. However, despite
decision support being generally considered an old
Clancy, Carolyn M. “AHRQ: Present and Future technology, relatively few organizations actively
Activities Impacting Hospital Medicine,” Journal of use it in the delivery of clinical work though many
Hospital Medicine 1(4): 253, 2006. are beginning to use this capability in various
Clancy, Carolyn M. “Closing the Health Disparities Gap:
ancillary department operations.
Turning Evidence Into Action,” Journal of Health
Decision support systems involve the capacity
Care Law and Policy 9(1): 121–35, 2006.
of combining data elements into information and
Clancy, Carolyn M. “Getting to ‘Smart’ Health Care,”
then transforming information into knowledge on
Health Affairs 25(6): 589–92, 2006.
which to base logical decisions. Decision support
Clancy, Carolyn M. “AHRQ’s National Healthcare
Quality and Disparities Reports: Resources for Health
goes beyond “who” and “what” questions to pres-
Services Researchers,” Health Services Research ent data in a logical way to answer “what if” and
41(2): xiii–xix, 2007. “why” questions.
Clancy, Carolyn M. “Emergency Departments in Crisis:
Opportunities for Research,” Health Services Benefits
Research 42(1): xiii–xx, 2007.
Clancy, Carolyn M., and Kelly Cronin. “Evidence-Based A variety of research studies on clinical decision
Decision Making: Global Evidence, Local Decisions,” support systems have been conducted and pub-
Health Affairs 24(1): 151–62, 2005. lished in the literature. There is a general consensus
Clancy, Carolyn M., and John M. Eisenberg. “Outcomes that clinical decision support technologies have the
Research: Measuring the End Results of Health potential to enhance patient care and at the very
Care,” Science 282(5387): 245–46, October 9, 1998. least have the potential to modify clinicians’ behav-
Danis, Marion, Carolyn M. Clancy, and Larry R. ior. Clinical reminders and alerts, adherence to
Churchill, eds. Ethical Dimensions of Health Policy. treatment plans, and suggested patient education
New York: Oxford University Press, 2002. have been reported as effective ways of changing
Clinical Decision Support 173
clinician practices. While some may say that these clinical situations, such as if the patient has “X”
are features that demonstrate the value of clinical diagnosis, the “Y and Z” classes of drugs are con-
decision support, others say that while clinicians’ traindicated, or if “A” medication is ordered, then
behavior may be shown to be modified, there is the patient must have laboratory values within the
little evidence of whether the actual thinking range of “B to C.” If the preestablished rule is
behind the practice modifications is indeed changed. violated, then an alert is sent back to the pre-
Furthermore, only limited data suggest any improve- scriber before the order is processed, thus giving
ment in actual patient outcomes. This represents an the prescriber the opportunity to change the order
opportunity for further research and study. or asking for an explanation as to why the action
The increasing pressures to monitor and reduce is to be taken. Rules and subsequent alerts are
healthcare costs and demonstrate improved out- usually developed and managed by the healthcare
comes are driving the national trend toward using organizations.
information as a strategy. Timely data are required
to reduce operational inefficiencies and enhance
Problems and Concerns
the delivery of patient care. Disparate systems by
themselves are inadequate, and data sharing A number of problems and concerns contribute to
through interfaces presents often inconsistent and the relatively limited use of clinical decision sup-
conflicting results. Thus, mechanisms are needed port. These problems must be overcome before
to consolidate patient data in a meaningful way to clinical decision support can become a trusted and
present only the requisite data to make clinical valuable tool in the delivery of patient care.
decisions. First, rules are too restrictive and the subse-
quent alerts are wedged into the patient care
thought process. Healthcare organizations that
Uses
establish too many rules restrict the thought flow
Clinical decision support systems have previously of its clinicians. Clinicians complain that the time
been used for a variety of retrospective analyses. required to respond to the rules inhibits productiv-
These concepts have expanded into the clinical ity; as a result, many just bypass them without
arena so that data are then presented to clinicians paying attention to the alert. Rules that are often
at the point of care and, more important, at the bypassed and retained in the system become cum-
precise time clinical decision making occurs. In its bersome and time-consuming. This diminishes the
foundation form, the clinical decision support overall value of the clinical decision support sys-
systems include at least one trusted knowledge tems and actually may contribute to additional
source (a database of known information about a patient care errors and reduced quality. It is critical
particular subject, such as drug data) and a set of that the organizations establish and endorse rules
software programs that establish intelligence (usu- that are truly meaningful to the delivery of patient
ally referred to as a “rules engine”) to process care and not overburden clinicians.
how the data from the knowledge source may Second, alerts must have meaning to the clini-
apply to a specific clinical situation. Preestablished cian. Healthcare organizations using clinical deci-
rules and guidelines, with corresponding alerts, sion support systems must realize that clinicians
are developed and edited as necessary by the need to be informed in a variety of specific ways if
healthcare organizations. These rules and guide- they are to derive value from these systems. Some
lines typically integrate a variety of clinical data attending physicians desire e-mail inbox or pager
from multiple sources to generate clinician alerts notification, while others may desire a direct tele-
and other treatment suggestions. phone call. This requires maintenance to keep alert
Most of these systems have been designed to notification as up-to-date as possible.
perform a specific function, such as using data from Third, extensive staff time is required to
the knowledge source to validate a medication research, establish, and monitor rules and alerts. A
order for potential drug or therapeutic interactions working committee must be established with
or against some predetermined range of laboratory executive endorsement, and staff must be assigned
result values. Specific rules are established to fit to maintain the clinical decision support system. In
174 Clinical Practice Guidelines
organizations that actively use these systems, the Medicine a Reality,” Journal of the Medical
committees meet regularly to discuss new rules Informatics Association 10(6): 523–30, November–
while monitoring established rules for usage and December 2003.
exception reporting. Some committee members Berner, Eta. S., ed. Clinical Decision Support Systems:
may be assigned research tasks and then are Theory and Practice. 2d ed. New York: Springer,
expected to report their findings at subsequent 2007.
meetings. Other clinician members who may be Greenes, Robert A., ed. Clinical Decision Support: The
assigned the responsibility of discussing often Road Ahead. Boston: Elsevier Academic Press, 2007.
Kuperman, Gilad J., Anne Bobb, Thomas M. Payne,
bypass rules with peers with the intent of modify-
et al. “Medication-Related Clinical Decision Support
ing behavior or changing the rules. In some cases,
in Computerized Provider Order Entry Systems: A
a valid reason exists for bypassing rules, which
Review,” Journal of the Medical Informatics
may then become a new rule in itself. Regardless,
Association 14(1): 29–40, January–February 2007.
this is a dynamic process that requires the organi-
zation’s continual commitment if clinical decision
support systems are to become a valuable clinical
Web Sites
tool and remain a viable tool over the long term.
Last, knowledge sources may not be up-to-date. American Medical Informatics Association (AMIA):
Healthcare knowledge continuously evolves and http://www.amia.org
changes. Out-of-date knowledge sources may actu- Healthcare Information and Management Systems
ally contribute to reduced quality and more errors. Society (HIMSS): http://www.himss.org
Healthcare organizations must implement pro-
cesses that ensure that knowledge sources are
updated as necessary to reflect current data avail-
able in the industry. Clinical Practice Guidelines
Establishing a true clinical decision support sys-
tem environment has become a high priority in Clinical practice guidelines are increasingly being
some healthcare organizations, but many must still used in the United States to reduce inappropriate
implement electronic medical records and bedside care and improve patient outcomes. Several fac-
medication administration applications before tors are fueling the use of guidelines, including the
rules and alerts have full utility. While many increasing costs of healthcare, new medical tech-
healthcare organizations recognize the value of nology, a growing aging population, and varia-
decision support, a thorough understanding of the tions in the service delivery of care by physicians,
need for foundation applications in addition to the hospitals, and geographic regions. Clinical prac-
critical success factors and the organizational com- tice guidelines are broadly defined as statements
mitment required to make clinical decision support that are systematically developed to assist clini-
a useful utility are the first steps to success. cians and patients in making decisions about
appropriate healthcare, given specific clinical con-
Lawrence M. Pawola ditions. Specifically, the major purposes for guide-
lines include the following: (a) assisting patients
See also Computers; E-Health; Electronic Clinical and practitioners in making clinical decisions,
Records; E-Prescribing; Forces Changing Healthcare;
(b) educating individuals and groups, (c) assessing
Healthcare Informatics Research; Health Informatics;
to ensure the quality of healthcare, (d) providing
Health Insurance Portability and Accountability Act of
1996 (HIPAA) guidance for allocation of resources, and
(e) reducing liability risk in cases of negligent care.
Primarily, clinical practice guidelines are of
most value to healthcare practitioners, patients
Further Readings and their families, and healthcare institutions. In
Bates, David W., Gilad J. Kuperman, Samuel Wang, et al. an effort to contain healthcare costs, public policy-
“Ten Commandments for Effective Clinical Decision makers, health benefit plans, and regulators may
Support: Making the Practice of Evidence-Based find them useful when making specific decisions
Clinical Practice Guidelines 175
about reimbursement. For patients, a consumer History

version of guidelines made available through leaf-
lets, audiotapes, videos, magazines, newspapers, While clinical practice guidelines, broadly defined,
and Web sites provides a summary of the benefits were in use for numerous aspects of healthcare for
and harm regarding healthcare options and poten- some time, a more formalized approach to guide-
tial outcomes. Guidelines empower patients to line development began in the United States when
become more educated consumers, active in choices an amendment to the Public Health Service Act in
about their own health. Guidelines may also help 1989 replaced the National Center for Health
the patient by calling attention to the need for Services Research (NCHSR) with the Agency for
changes in public policy regarding issues such as Health Care Policy and Research (AHCPR). The
preventive interventions to assist neglected or high- Omnibus Budget Reconciliation Act of 1989 (PL
risk groups or other areas requiring increased 101–239) mandated the AHCPR to have a stron-
attention. For healthcare providers, guidelines can ger emphasis on medical outcomes and effective-
improve the quality of clinical decisions by provid- ness research and to develop, disseminate, and
ing clear directions on how to proceed with an evaluate clinical practice guidelines. A newly cre-
intervention, keeping clinicians updated, improv- ated office, the Forum for Quality and Effectiveness
ing consistency of care, and providing an authori- in Health Care, was charged with this task. The
tative base for decision making. Healthcare AHCPR sought advice from the national Institute
organizations may primarily benefit from guide- of Medicine (IOM) on how best to approach its
lines by minimizing costs and optimizing the value newly appointed responsibilities involving clinical
of money spent through the greater standardiza- practice guidelines. The IOM is an advisory body
tion of care. of experts who provide science-based advice on
Despite all the perceived benefits, clinical prac- critical national issues in biomedical science,
tice guidelines have their limits. Recommendations medicine, and public health to the federal govern-
may not apply readily to an individual patient, ment and the public. The IOM appointed a study
requiring clinicians to tailor decisions based on the committee for technical assistance and advice on
patient’s unique medical history and personal cir- defining terms and determining key components
cumstances. Guidelines may also influence policy- of guidelines, implementation, and evaluation.
makers to refuse to pay for certain services. In This committee produced two reports, Clinical
terms of their development, guidelines may be Practice Guidelines: Directions for a New Program
flawed due to a lack of adequate scientific evi- (1990) and Guidelines for Clinical Practice: From
dence, inadequate evaluation of study design Development to Use (1992).
flaws, the bias of the group that developed the The legislation that spawned the work of the
guidelines, or a bias in favor of serving the needs AHCPR stemmed from a growing national con-
of payers or special interests groups rather than cern with the high cost of healthcare, inconsistency
with the patient’s best interest. In weighing their in medical-practice patterns, and the perceived low
advantages and disadvantages, guidelines may be value of some health services. The main goal of the
best viewed as one option for improving the qual- AHCPR was to expand knowledge rather than
ity of healthcare. focus on applications. The ultimate goal was to
The development of clinical practice guidelines rely less on purely professional judgment and
involves three basic stages: (1) development, (2) move more strongly toward a more structured
implementation, and (3) evaluation. This process approach to support healthcare decisions.
or cycle is dynamic in that the implementation and The Forum for Quality Effectiveness in Health
evaluation stages prompt periodic revisions when Care was charged with arranging the development
they become outdated due to new scientific evi- and periodic review of clinical practice guidelines.
dence, when omissions are found, or when other The guidelines were not to be created by the fed-
problems are identified. Historically, most of the eral government but could be contracted with
focus has been on the development phase. In more public and nonprofit private organization or pro-
recent years, however, the last two stages have duced by expert panels to develop and update
received growing attention. them. The goal was to have guidelines, standards,
performance measures, and review criteria for at appropriate for use by practitioners, medical
least three clinical treatments or conditions by educators, and medical care reviewers. After the
1991. Guidelines development has continued with sponsoring agency or organization has created
an array of developers. and disseminated an initial set of guidelines, the
guidelines may be transformed into various other
forms of presentation for various publications or
Developing Guidelines
groups who may benefit from them (e.g., journals,
Clinical practice guidelines are developed by many continuing medical education, specific user
organizations, including professional societies, groups).
public agencies, healthcare institutions, and To encourage the developers of guidelines to use
researchers. Insurers, health maintenance organi- criteria to improve their processes and products,
zations (HMOs), and other private organizations the IOM outlined eight desirable attributes of
have also been active in their development. guidelines: (1) validity (including strength of evi-
Guidelines may be developed through single or dence and estimated outcomes), (2) reliability/
collaborative effort. reproducibility, (3) clinical applicability, (4) clini-
In the medical professions, various academies, cal flexibility, (5) clarity, (6) multidisciplinary pro-
colleges, and societies have included the develop- cess, (7) scheduled review, and (8) documentation.
ment of guidelines in addition to their sponsorship A concern was that guidelines published in
of peer-reviewed clinical journals for given spe- peer-reviewed medical journals do not follow
cialties. Public agencies play a role in guideline standards for guideline development, often lack-
development mainly to promote public health and ing critical information to determine their validity.
welfare, to improve quality, and to control the To address the problem, in 2002, the AHRQ sup-
costs associated with government-funded health- ported the Conference on Guideline Standardization
care programs. Federal agencies such as the (COGS), which developed a checklist of compo-
Agency for Healthcare Research and Quality nents for the evaluation of the validity and usabil-
(AHRQ) (formerly the AHCPR) and National ity of guidelines.
Institutes of Health (NIH) also play key roles, Clinical practice guidelines are generally devel-
with related activities occurring in the Food and oped through a series of steps. The first step
Drug Administration (FDA), the Centers for involves initial decisions such as the selection of
Disease Control and Prevention (CDC), and the the topic (e.g., condition, procedure), selection of
Centers for Medicare and Medicaid Services panel members (e.g., physicians, nurses, dentists,
(CMS). epidemiologists, statisticians), and clarification of
The large number of organizations developing purpose (e.g., specification of the target condition,
clinical practice guidelines lends great breadth to type of patient, clinical presentations for use of the
the topics available and to the diversity in the man- guidelines, and interventions). Next, there is an
ner in which they are developed. These variations, assessment of the clinical appropriateness based on
however, lead to variable quality. According to the clinical benefits and harms, admissible scientific
IOM, the guidelines can vary in five key ways: (1) evidence, and expert consensus. A summary of
clinical orientation (clinical condition, technology, benefits and harms based on scientific evidence
or process); (2) clinical purpose (screening and and expert consensus is generated. This summary
prevention, diagnosis, aspect of treatment, more helps determine which practices are appropriate,
discrete aspects of healthcare); (3) complexity are inappropriate, or are of uncertain appropriate-
(high, medium, or low as indicated by the amount ness in the clinical situation. An assessment is then
of detail, complexity of logic, length of narrative made of public policy issues that affect the broader
or documentation); (4) format (free text, tables, society. Considerations involve limitations in
if-then statements, critical pathways, decision resources such as payment, opportunity, equip-
paths, algorithms); and (5) intended users (practi- ment, and personnel. Feasibility issues are also
tioners, patients, others). considered to determine if the research findings are
The U.S. Congress mandated that the AHCPR applicable to real-world situations. Guidelines are
present clinical practice guidelines in formats then drafted to provide clear recommendations
Clinical Practice Guidelines 177
and the rationale on which they are based. Content the group. A third option, the modified Delphi
experts review the guidelines to ensure scientific method, asks the participants to first express their
and content validity. A sample of practitioners may opinions by a mailed questionnaire that is sent to
be asked to pretest the guidelines and provide sug- the group. The group then meets to discuss their
gestions for improvements of the document. opinions and records their final judgments by a
Recommendations are then made through a plan questionnaire. Finally, a consensus development
for dissemination, evaluation, and updating. conference brings together a selected group of
Finally, guidelines outline recommended research about 10 people to meet over the course of a few
priorities to call attention to important gaps in days. Interest groups or experts unrelated to the
scientific evidence. Disclaimers and references decision-making group present evidence.
complete the document. Participants disperse to determine their opinions
Since the 1990s, with the growth of the evi- and then reconvene to reach consensus through a
dence-based medicine (EBM) movement, the chaired discussion.
development of clinical practice guidelines has Recently, systematic reviews of research have
increasingly been based on scientific research provided the foundation for guideline develop-
evidence where available, but it also relies on ment. The judgment of experts has been criticized
expert consensus, especially when such evidence as lacking sufficient objectivity and rigor. Basing
is lacking. Experts are selected based on expertise guidelines on scientific evidence rather than expert
in the appropriate area, and credibility with the opinion has been found to be more thorough but
target audience by random or purposeful sam- also more costly.
pling. Members of the selected group are asked
to take cues into account when making their
Implementing Guidelines
decisions. Cues are dimensions or indicators to
consider, such as a description of a situation as The implementation of clinical practice guidelines
part of a scenario or vignette, or the severity of a involves a cultural shift in the healthcare system
condition. from one that traditionally relied on professional
When using expert consensus, clinical practice judgment and discretion to one that requires
guidelines are generally developed by using one of accountability for judgments. Formal organiza-
three methods: (1) the nominal group technique tional structures and management must support
(NGT), (2) the Delphi method, or (3) a hybrid of the use of clinical guidelines. For the guidelines to
the two. The NGT aims to structure an interaction be relevant, it is important for physicians and oth-
within a group. Each participant independently ers to develop those that are tested in actual clini-
records his or her ideas. The facilitator then lists cal settings rather than solely in controlled clinical
one idea from each participant in turn until all trials. As practitioners adopt the guidelines, more
ideas have been recorded for the group. Each idea information becomes available in adapting and
is discussed in turn. Participants then return to revising them to make them more useful for clini-
privately record their opinions and vote. The cal outcomes.
group may reconvene to discuss and vote. Group The implementation of clinical practice guide-
judgment is aggregated statistically from individual lines is often considered more challenging than
opinions. In contrast, the Delphi method involves their development. Yet their true value lies in their
no direct interactions by the participants. Initial successful use. Many of the potential users may
views are collected via a mailed questionnaire. not be aware of the existence of guidelines that
Participants are asked to suggest the cues to be could be helpful in their decision making, or they
used in decision making. At the next stage, another may see them as only marginally related to their
questionnaire is sent that asks for the individual’s practical daily work. Guidelines may be seen as a
views, often using a Likert scale. The organizers threat to professional autonomy, resulting in rejec-
then compile the results and send a summary indi- tion of their use. While guidelines may be useful to
cating individual and group judgments. Over one patients, their implementation involves direct edu-
or more opportunities, individuals may modify cation to make the patients aware of guidelines
their judgment based on information provided by that could be useful to them.
Evaluating Guidelines (such as quality of life), when new interventions

supersede or complement other interventions, when
Clinical practice guidelines make explicit recom-
the gap between ideal and current practice narrows
mendations to influence clinical decision making.
to the point that a guideline is no longer needed,
They present evidence, costs, and a model for
when society changes values based on specific out-
making decisions but also contain a value judg-
comes, or when increases in service delivery war-
ment based on the groups that produced them.
rant an update. A suggestion that has received
Before a guideline is adopted for use, it should be
increasing favor is a model using the expert opin-
evaluated for validity. For example, it is important
ion of a multidisciplinary group and focused litera-
to determine what methods were used and if the
ture reviews based on target review articles,
evidence was collected systematically. All reason-
editorials, commentaries, new guidelines found in
able practice options and potential outcomes
registries, and articles that reference the guidelines
should be considered with an estimation of how
to determine when a guideline requires an update.
likely the outcome will occur. It is important to
Based on this method, some guidelines may remain
note if the guideline is current with recent devel-
valid, while others may become obsolete.
opments by looking at the data on the guideline
and the date that final recommendations were
made. To account for individual value differences,
it is necessary to determine if the guideline was Locating Guidelines
subject to peer review and testing. The recommen- Clinical practice guidelines are available through a
dations should provide practical and unambigu- number of agencies, organizations, and resources,
ous advice. The strength of the recommendations including the National Guideline Clearinghouse,
should be indicated based on the literature and the Cochrane Collaborative, and several databases.
taxonomies that measure “levels of evidence” as The National Guideline Clearinghouse is an
deemed appropriate for the given specialty. Of initiative of the AHRQ. Hosted on the AHRQ’s
utmost importance is evaluating whether the rec- Web site, the clearinghouse provides a publicly
ommendations are applicable to the patient in available comprehensive database consisting of
question based on medical history, individual cir- more than 1,000 evidence-based clinical practice
cumstances, or other factors. guidelines. It provides structured abstracts of the
guidelines and their development and links to full-
text guidelines, when available, or information for
Updating and Withdrawing Guidelines
ordering print copies. A guideline comparison fea-
Clinical practice guidelines need to be evaluated ture is available that allows a comparison of two
periodically, in terms of both content and validity, or more guidelines side-by-side along with other
to avoid potential breakdowns in the process of components and features noted on the Web site.
care or poor patient outcomes. Guidelines may The Cochrane Collaboration provides a compi-
become obsolete as new scientific information lation of five databases for finding evidence to
becomes available. The volume of research assist in deciding on the best treatment for a given
advances, and the amount of time between reviews condition. These include the following: (a)
will determine how thorough the update needs to Cochrane Database of Systematic Reviews; (b)
be. Conducting a traditional systematic literature Database of Abstracts of Reviews of Effects; (c)
review can be both time-consuming and costly. Cochrane Central Register of Controlled Trials;
Most commonly, it is recommended that guide- (d) Cochrane Methodology Register; (e) Health
lines receive a scheduled review date. Guidelines Technology Assessment Database; and (f) the
may require an update when new information National Health Service (NHS) Economic
becomes available. However, the optimal timing Evaluation Database.
for such an update is unclear. Clinical practice guidelines may also be found
Updating guidelines should occur when changes by searching the CINAHL (Cumulative Index to
in clinical evidence make a preexisting guideline Nursing and Allied Health Literature) and PubMed
invalid, when new outcomes become important databases. In CINAHL (available by subscription),
Cochrane, Archibald L. 179
the phrase practice guidelines may be selected from Institute for Clinical Systems Improvement (ICSI):
the “Publication Type” menu. In PubMed (freely http://www.icsi.org
available from the National Library of Medicine), National Guideline Clearinghouse (NGC):
under the “Limits” tab, the box for “practice http://www.guidelines.gov
guideline” can be checked in the section under National Heart, Lung, and Blood Institute (NHLBI):
“Type of article.” http://www.nhlbi.nih.gov/guidelines
Institutions and centers within the NIH often
post guidelines on their Web sites. These may be
searchable via the Web search feature on the page Cochrane, Archibald L.
by using the search terms guidelines, practice
guidelines, or clinical practice guidelines.
Archibald L. (Archie) Cochrane (1909–1988) was
Barbara Nail-Chiwetalu a British physician who contributed greatly to the
development of epidemiology, and he was a pio-
See also Agency for Healthcare Research and Quality neer in evidence-based medicine. His ideas eventu-
(AHRQ); Clinical Decision Support; Evidence-Based ally led to the creation of the international
Medicine (EBM); National Guideline Clearinghouse Cochrane Collaboration, which tracks down,
(NGC); National Institutes of Health (NIH); evaluates, and synthesizes the results of clinical
Outcomes Movement; Quality of Healthcare; United
trials and other studies in all areas of medicine.
Kingdom’s National Institute for Health and Clinical
Cochrane was born in 1909 in Scotland to a
Excellence (NICE)
wealthy family. He began his medical studies in
1934 at the University College Hospital, London,
Further Readings after receiving first class honors in the Natural
Sciences Tripos from King’s College, Cambridge.
American Academy of Pediatrics. Pediatric Clinical
In 1936, he served in a field ambulance unit in
Practice Guidelines and Policies: A Compendium of
Evidence-Based Research and Pediatric Practice. 8th ed.
the International Brigade in the Spanish Civil
Elk Grove, IL: American Academy of Pediatrics, 2008. War. In 1938, he qualified in medicine (receiving
Bowker, Richard, Monica Lakhanpaul, Maria Atkinson, what is equivalent to a medical degree in the
et al., eds. How to Write a Guideline From Start to United States). With the outbreak of World War II,
Finish: A Handbook for Healthcare Professionals. Cochrane enlisted and served as a captain in the
New York: Churchill Livingston Elsevier, 2008. Royal Army Medical Corps. While on duty in
Eden, Jill, and the Committee on Reviewing Evidence to Crete in 1941, he was captured and taken prisoner
Identify Highly Effective Clinical Services, eds. by the Nazis. For the rest of the war, he was as a
Knowing What Works in Health Care: A Roadmap medical officer in various prisoner-of-war camps
for the Nation. Washington, DC: National Academies in Greece and Germany. Many prisoners he treated
Press, 2008. suffered from tuberculosis, and he became inter-
Hewitt-Taylor, Jaqui. Clinical Guidelines and Care ested in studying the disease. After the war,
Protocols. Hoboken, NJ: Wiley, 2006. through a Rockefeller scholarship, he attended the
Rao, Goutham. Rational Medical Decision Making: A Diploma in Public Health program at the London
Case-Based Approach. New York: McGraw-Hill School of Hygiene and Tropical Medicine. In
Medical, 2007. 1947–1948, he left Britain to study the epidemiol-
Skolnik, Neil S., Doron Schneider, Richard Neill, et al., ogy of tuberculosis at the Henry Phipps Institute in
eds. Essential Practice Guidelines in Primary Care. Philadelphia.
Totowa, NJ: Humana Press, 2007. Returning to the United Kingdom, from 1948
to 1960, Cochrane was a member of the Medical
Research Council’s (MRC’s) Pneumoconiosis
Web Sites Research Unit in Penarth, Wales. His work at the
Agency for Healthcare Research and Quality (AHRQ): council included the study and classification of
http://www.ahrq.gov pneumoconiosis, a common occupational lung
Cochrane Collaboration: http://www.cochrane.org disease of coal miners in Wales. At his work, he
180 Codman, Ernest Amory
became increasingly interested in the reproducibil- “Cochrane’s Legacy” [Editorial]. Lancet 340(8832):
ity of all clinical and related measurements, as 1414, December 5, 1992.
well as many aspects of field epidemiology, such as Hill, Gerry B. “Archie Cochrane and His Legacy: An
the standardization of collected data and the vali- Internal Challenge to Physicians’ Autonomy?”
dation of diagnoses. Journal of Clinical Epidemiology 53(12): 1189–92,
In 1960, Cochrane was appointed the David December 2000.
Davies Professor of Tuberculosis and Chest Diseases Maynard, Alan, and Iain Chalmers, eds. Non-Random
at the Welsh National School of Medicine in Reflections on Health Services Research: On the 25th
Anniversary of Archie Cochrane’s Effectiveness and
Cardiff. He also became the director of the Medical
Efficiency. London: BMJ, 1997.
Research Council Epidemiology Research Unit.
In 1972, Cochrane gave the Rock Carling
Lecture “Effectiveness and Efficiency: Random
Web Sites
Reflections on Health Services,” which was subse-
quently published as a book. In the book, which he Cochrane Collaboration: http://www.cochrane.org
is best known for, Cochrane stressed the need to
use the evidence from randomized controlled trials
(RCTs).
In 1974, he presented the Dunham Lectures at Codman, Ernest Amory
Harvard University; and in 1975, he became an
honorary fellow of the American Epidemiological Ernest Amory Codman, MD (1869–1940), had a
Society. guide star for his life’s work: the end results idea.
Archibald Cochrane died in 1988 at the age of He argued that patients and physicians should
79. His autobiography, One Man’s Medicine, writ- know the end results of the medical care they
ten with the assistance of Max Blythe, was pub- receive and give so that patients can choose good
lished in 1989. care and physicians can learn from their mistakes
Cochrane’s ideas were instrumental in the and improve their care.
founding of the Cochrane Collaboration in 1993. In 1889, even before he graduated from Harvard
The collaboration is an international, nonprofit, College (class of 1891) and Harvard Medical
independent organization that produces and dis- School (class of 1895), he started a yearly log of
seminates systematic reviews of healthcare inter- his bird-hunting efficiency. He recorded the num-
ventions and promotes the search for evidence ber of shots fired (process) and birds killed (out-
from clinical trials and other studies. Its major come or end results of hunting) and the rates of
product is the Cochrane Database of Systematic birds to shotgun shells expended (efficiency).
Reviews, which is published quarterly as part of In those days, medical students at the
the Cochrane Library. Massachusetts General Hospital gave anesthesia
during surgery. Codman bet his classmate and best
Rosemary Walker friend, Harvey Cushing (1869–1939), who later
became a renowned neurosurgeon, to see who
See also Epidemiology; Evidence-Based Medicine (EBM); would have better outcomes of their care. The result
Physicians; Public Health; Quality of Healthcare;
was the first use of anesthesia charts, graphing the
Randomized Controlled Trials (RCTs)
patients’ pulse and respiration every 5 minutes.
Briefly Codman became the first radiologist at
the Boston Children’s Hospital. He ran the fluoros-
Further Readings copy for the landmark physiological experiments
Cochrane, Archibald L. Effectiveness and Efficiency: of Walter B. Cannon (1871–1945) showing a
Random Reflections on Health. Originally printed in goose swallowing a radiologically opaque button.
1972. London: Royal Society of Medicine Press, 1999. Codman become a junior surgeon at the
Cochrane, Archibald L., and Max Blythe. One Man’s Massachusetts General Hospital and followed up
Medicine: An Autobiography of Professor Archie on the outcomes of all patients he cared for. He
Cochrane. London: British Medical Journal, 1989. urged others to do the same. Unsatisfied with the
Codman, Ernest Amory 181
willingness of this hospital to adopt his ideas, he he received no patient referrals, and he had few
created his own proprietary “End Result Hospital” patients and little income. When he died, he was
nearby, where he could pursue his ideas about hos- too poor to afford a headstone and was buried in
pital efficiency. His hospital existed from 1911 an unmarked grave. However, Codman realized he
until 1918. All patients treated at the hospital were was ahead of his time and thought that future gen-
followed up after discharge, with the results erations would appreciate his end result ideas.
reported, patient by patient, and published at In 1996, the Joint Commission established
Codman’s own expense for all to read. an award in his honor. The Codman Award is
Here is an example of what was written (Case awarded annually to recognize the achievements of
#17): “February 10, 1912, Female, 39, Hemorrhoids individuals and organizations in the use of process-
Operation (EAC) clamp and cautery. Complications: and-outcome measures to improve the quality and
none, Result Sept. 8, 1913. Well, except for annoy- safety of healthcare.
ance from skin tabs which were not removed (E-j).”
Note that for the case, the surgeon is named Duncan Neuhauser
(Codman), the process of care is described, a post- See also Health Report Cards; Joint Commission;
discharge follow-up of the patient’s perception and Medical Errors; Outcomes Movement; Patient Safety;
physical condition is included, and the public record- Quality Indicators; Quality of Healthcare
ing of the surgeon’s error in judgment (E-j) is given.
His error classification is another of his many
contributions. In this case, Codman decided that Further Readings
he had made an error in not removing the skin Codman, Ernest Amory. Bone Sarcoma: An
tabs. This brief description is as plausible to us Interpretation of the Nomenclature Used by the
today as when Codman wrote it. Committee on the Registry of Bone Sarcoma of the
In 1910, Codman helped start the American American College of Surgeons. New York: Paul B.
College of Surgeons. He chaired its Committee for Hoeber, 1925.
Hospital Standardization, which studied hospital Codman, Ernest Amory. The Shoulder: Rupture of the
outcomes (end results) and how they could be Supraspinatus Tendon and Other Lesions In or About
improved. Eventually the committee led to the cre- the Subacromial Burse. Boston: Thomas Todd, 1934.
ation of the Joint Commission. Codman, Ernest Amory. A Study in Hospital Efficiency:
On January 8, 1915, Codman unveiled a large As Demonstrated by the Case Report of the First Five
cartoon at a local surgical society meeting showing Years of a Private Hospital. Boston: Thomas Todd,
his colleagues as being more interested in money 1918–1920. (Reprinted by the Joint Commission on
than end results. This was the peak of his undiplo- Accreditation of Healthcare Organizations, 1996)
matic outspokenness in advocacy of his end results Crenner, Christopher. “Organizational Reform and
Professional Dissent in the Careers of Richard Cabot
beliefs. His colleagues were offended, his medical
and Ernest Amory Codman,” Journal of the History
income fell, and his hospital was closed in 1918,
of Medicine and Allied Sciences 56(3): 211–37, July
when he entered military service. Codman would
2001.
eventually create end result cards for all the sol-
Donabedian, Avedis. “The End Results of Health Care:
diers he treated in World War I. Ernest Codman’s Contribution to Quality Assessment
After the war, Codman returned to surgical and Beyond,” Milbank Quarterly 67(2): 233–56, 1989.
practice in Boston. He started a registry of bone Mallor, William J. Ernest Amory Codman: The End
sarcoma, which is the forerunner of all cancer reg- Result of a Life in Medicine. Philadelphia: W. B.
istries. In 1934, he wrote the first book ever writ- Saunders, 1999.
ten solely on the shoulder, which is considered a Neuhauser, Duncan. “Ernest Amory Codman, M.D.”
classic work in orthopedic surgery. The book’s Quality and Safety in Health Care 11(1): 104–5,
preface contains his autobiography, while the last 2002.
chapter of the book discusses the influence of eco-
nomics on surgery.
Web Sites
Codman received no appreciation during his
lifetime. He was ostracized by many of his peers, Joint Commission: http://www.jointcommission.org
182 Cohen, Wilbur J.
Security Act, the most well-known provision of

Cohen, Wilbur J. which was insurance for the elderly. Cohen, at the
age of 22 years, had played a part in drafting it.
Wilbur J. Cohen (1913–1987) was the Secretary A provision of the act created the Social Security
of the Department of Health, Education, and Board—later known as the Social Security
Welfare (DHEW) under President Lyndon Johnson, Administration—and Altmeyer, a board member,
but today Cohen is often credited with a larger offered Cohen a job. For the next 20 years, Cohen
role in public service. He is seen as the key archi- served as a staff member of the board, and in that
tect of the American social welfare system. A par- time he worked to expand the provisions of the
ticipant in drafting the Social Security Act of original Social Security Act well beyond its original
1935, Cohen was also closely associated with the coverage. In 1939, for example, he was much
passage into law of Medicare legislation in 1965. gratified when amendments to the act added survi-
Between those two watershed events in American vor benefits to the original legislation.
welfare history, Cohen proved himself a tireless As director of the Bureau of Research and
advocate of federal assistance for America’s most Statistics within the Social Security Administration,
vulnerable members. Cohen developed a keen knowledge of the technical
The conditions of Cohen’s early life likely con- aspects of the Social Security programs, which he
tributed to his later advocacy for social welfare. used to good effect as a congressional liaison, pro-
The son of immigrants, Cohen grew up in viding crucial assistance in drafting public policy
Milwaukee in modest circumstances. His father language, statements, and scripts. Cohen was a
was a grocer. And from an early age, Cohen was technocrat—a technical expert—but he was by no
keenly aware of economic disparities. Cohen was means a minor bureaucrat only handy with statis-
also intelligent and a good student in school. At tics. Instead, he played an important part in draft-
the University of Wisconsin–Madison, he majored ing national welfare policy and persuading legislators
in economics, influenced in his choice by the great to embrace it and make it their own cause.
depression that had settled on the nation in the In the 1940s and 1950s, Cohen played a part in
early 1930s. There he distinguished himself as an advancing the idea of national health insurance,
energetic and hardworking student and, more which to him seemed a logical extension of the
important, made contacts that were to prove original Social Security legislation, leading to
immensely helpful in launching him into a career healthcare for all Americans. While Cohen was
in government. unsuccessful in that effort, he was nonetheless able
After graduating in 1934, Cohen considered to help expand incrementally the benefits of Social
graduate school and a career in academe but Security, which by the 1950s had become a popu-
instead accepted a job as a research assistant with lar program receiving bipartisan support. In 1956,
a former professor in Washington, D.C. Edwin the U.S. Congress passed legislation that added
Witte was one of a number of academics who were disability benefits to the Social Security program.
drawn to Washington to assist in writing the New In the same year, Cohen made a significant career
Deal legislation of President Franklin D. Roosevelt. change, leaving Washington for Ann Arbor, where
Witte was then executive director of the Committee he became a professor of public welfare adminis-
on Economic Security, working under Arthur tration in the School of Social Work at the
Altmeyer (another Wisconsin alumnus), the University of Michigan.
Assistant Secretary of Labor. After the 1960 national elections, Cohen was
Cohen arrived in Washington in 1934 and found invited to join President John F. Kennedy’s team as
it much to his liking, a heady place for a bright Assistant Secretary for Legislation in the Department
young college graduate with liberal leanings and of Health, Education, and Welfare. In New Frontier
boundless energy. Working under Witte on the Washington, Cohen set to work on national health
Committee on Economic Security, Cohen helped insurance for the elderly. This was to be part of
write language that eventually became the basis of Kennedy’s vision of a “second generation” of
the nation’s first social insurance legislation. In social welfare programs, and Cohen, as an expert
1935, President Roosevelt signed into law the Social on Social Security, was a logical choice to play a
Cohort Studies 183
central role in it. After President Kennedy’s death, to note that he maintained a home near Washington
Cohen remained in Washington, a member of after leaving federal employment in 1969. Until
President Johnson’s Great Society team, where he the end of his life, Cohen traveled to Washington
was able to continue much of the work begun from Ann Arbor and later Austin, staying at his
under Kennedy. home near the city that had been the scene of so
Cohen threw himself into the push for Medicare. many of his personal triumphs.
He assisted in writing legislation; he worked with
legislators to get the bill through Congress; and James Hill and Samuel Levey
later, he helped implement its provisions. In that See also Access to Healthcare; Health Insurance; Health
effort, he was fortunate in having the support of Services Research, Origins; Medicaid; Medicare;
Arkansas Congressman Wilbur D. Mills, the pow- National Health Insurance; Public Health; Public Policy
erful Democratic chairman of the House Ways and
Means Committee, and in securing other political
alliances to ensure its passage. The year 1965 was Further Readings
a watershed for social welfare legislation, as
Altmeyer, Arthur. The Formative Years of Social Security.
Medicare became law and Medicaid expanded Madison: University of Wisconsin Press, 1968.
healthcare to the poor. It was also the high water- Berkowitz, Edward D. America’s Welfare State.
mark of Social Security expansion, just as it was, Baltimore: Johns Hopkins University Press, 1991.
on a personal level, among the high points of Berkowitz, Edward D. Mr. Social Security: The Life of
Cohen’s career in Washington, second in impor- Wilbur J. Cohen. Lawrence: University Press of
tance to his confirmation as Secretary of the Kansas, 1995.
Department of Health, Education, and Welfare Fein, Rashi. “Wilbur J. Cohen 1913–1987: An
(DHEW) in 1968. At the swearing-in ceremony for Ombudsman for America,” Milbank Quarterly 65(2):
the new DHEW Secretary, President Johnson 149–52, 1987.
acknowledged Cohen’s “role in every piece of
social legislation in the last 35 years.”
When President Johnson left public office in Web Sites
1969, Cohen returned to teaching at the University Social Security History, Cabinet Officers:
of Michigan. But he could not put his political http://www.ssa.gov/history/cabinet.html
agenda behind him. Settled into academe, Cohen
was never far from the ongoing social welfare bat-
tles in Washington, which he viewed from a distance
with a passionate interest and outspoken advocacy.
Cohen retired from the University of Michigan in Cohort Studies
1978, but he returned to the classroom 2 years later,
accepting a professorship in the Lyndon B. Johnson Cohort studies represent a type of epidemiological
School of Public Affairs, University of Texas at approach to investigating the incidence and preva-
Austin. Until his death in 1987, Cohen continued to lence of disease across a fixed population group
speak out in support of social welfare legislation over time. Using this type of approach, researchers
and in defense of the Social Security programs he compare outcomes between a cohort, or group, of
had done so much to build. individuals who have a risk factor (e.g., smoking)
From Roosevelt’s New Deal to Johnson’s Great believed to be associated with a disease (e.g., lung
Society, Wilbur Cohen played a part in shaping cancer) and a group without the factor (e.g., non-
national welfare policy. A technocrat with a keen smokers). Cohort studies can be conducted either
understanding of the statistical arguments for prospectively or retrospectively.
Social Security expansion, Cohen was also a skill-
ful salesman of the programs he promoted. He was
Prospective Cohort Studies
a man with the political contacts and know-how
for guiding legislation through the U.S. Congress. Prospective cohort studies involve following a large
It is a telling comment on Cohen’s lifelong passions group of individuals who are initially free of the
184 Cohort Studies
disease of interest over time (often years and some- the progression of rheumatic heart disease, was
times decades). Typically, cohort studies do not released in 1956. The original cohort was studied
employ a randomized design because of potential until 1971, when a second-generation cohort was
ethical problems. That is, it is neither ethical nor recruited. In 2002, the third cohort, grandchildren
easy to randomly assign people to be exposed to a of the original cohort, consisting of 3,900 individu-
potential risk factor for the disease of interest. als, became the latest cohort to join the study.
Instead, the individuals in the group and their vari- Over the years, the Framingham Study has
ous exposures to risk factors are determined, and the uncovered and popularized the major underlying
development of the specific disease is determined. risk factors of heart disease, including high cho-
The advantages of prospective cohort studies lesterol, high blood pressure, diabetes, obesity,
are as follows: They are able to develop and test and cigarette smoking. The study has also identi-
hypotheses about the cause-and-effect relation- fied the interactions between and among these
ships between identified risk factors and disease risk factors. Additionally, it has focused on the
outcomes because the temporal ordering of events effects of social and psychological factors, such
can be determined; they can measure multiple out- as stress and the genetic links to heart disease.
comes of a single risk factor to study relatively rare The study continues to further identifying and
exposures to risk; and they measure the absolute determining a myriad biological, social, psycho-
or true risk of the factor under study. logical, lifestyle, and genetic effects of cardiovas-
The disadvantages of prospective cohort studies cular disease.
are as follows: They take a long time to complete; The most recent results from the Framingham
they are very expensive to conduct; they require Heart Study, investigating the genetic links associ-
considerable monitoring and management effort; ated with cardiovascular disease, indicate that
and they may have high rates of participant attri- individuals with a sibling having a stroke or arte-
tion or many individuals lost to follow-up. rial disease have a 45% increased risk of develop-
Prospective cohort studies are also not well suited ing the same disease.
to study rare diseases because of the limited num-
ber of potential cases and the often long time
Retrospective Cohort Studies
between exposure to a risk factor and the develop-
ment of a disease. Retrospective cohort studies are sometimes con-
ducted using old records of individual groups.
These studies attempt to determine a group’s past
The Framingham Heart Study
exposure to a risk factor and an outcome. For
Because of their high costs, long-term, prospec- example, to investigate the risk of exposure to a
tive cohort studies are relatively rare. Perhaps the particular chemical and the development of a dis-
best-known and most famous prospective cohort ease, researchers may use the employment records
study is the Framingham Heart Study. This study, of past workers at a factory to identify their expo-
which began more than 60 years ago, is still ongo- sure and medical and death records to determine
ing. The Framingham Heart Study is heralded as the outcome.
being responsible for the discovery of the major It should be noted that the term retrospective
risk factors associated with cardiovascular disease. studies often refers to retrospective case-control
Originally funded by the National Heart Institute studies, which do not follow individuals over time
(now the National Heart, Lung, and Blood Institute) but rather look in the past for measures of asso-
in 1948, the study recruited a cohort of more than ciation. These types of studies are generally viewed
5,000 adults aged 30 to 62 living in the small town as a subset of cohort studies. Typically, a retro-
of Framingham, Massachusetts. These individuals, spective case-control study involves using existing
who did not have cardiovascular disease when they medical records as the primary data source.
started the study, were studied and received medical Individuals are selected for inclusion into the
tests every 2 years to determine the underlying fac- study based on the outcome or disease of interest
tors associated with the later development of heart (the cases). And a comparable group without the
disease. The study’s first report, which focused on outcome is selected as a control group.
Coinsurance, Copays, and Deductibles 185
One major advantage of the retrospective case- Web Sites

control studies is their ability to study the effects of American College of Epidemiology:
risk factor exposure to the development of rare http://www.acepidemiology.org
diseases. This is because the case group can be Framingham Heart Study:
identified from a broader population and because http://www.framinghamheartstudy.org
the researcher knows the subjects have the disease National Center for Health Statistics (NCHS):
compared with waiting for the disease to occur http://www.cdc.gov/nchs
after the risk exposure. Retrospective studies have
become more popular as the quality and efficacy of
diagnostic procedures and the quality of medical
record information have improved. There are a
number of additional advantages to the case- Coinsurance, Copays,
control approach. They are relatively inexpensive and Deductibles
to conduct because they do not require as much
management; they allow the study of diseases
Coinsurance, copays, and deductibles are utiliza-
where there is a long time period between the
tion management tools used by health insurers to
exposure to a risk factor and the development of
limit the extent of moral hazard. Moral hazard is
the disease; and they are far less time-consuming
the tendency of individuals to use more healthcare
than prospective studies.
services because they are insured. Coinsurance is
Retrospective studies, however, also have sev-
defined as the percentage of the agreed-on pro-
eral disadvantages. First, although several risk fac-
vider charge that the insured is obligated to pay
tors can be analyzed at one time, the study can
out of pocket. A copay is a fixed dollar amount
only focus on one disease. Second, since many
per service that the insured is obligated to pay
clinical records are not specifically designed for
regardless of the amount the insurer has negoti-
research purposes, their completeness may be
ated with the health services provider. A deduct-
questionable. Third, exposure to extraneous fac-
ible is an amount of expenditure for covered
tors cannot be completely controlled for using a
health services that an insured individual must
case-control approach.
pay before the health plan has any obligation to
Ralph Bell pay for services.
See also Acute and Chronic Diseases; Disease;

Epidemiology; Morbidity; Mortality; Public Health; Overview
Randomized Controlled Trials (RCTs); Risk
Traditionally, an insured individual was expected to
pay 20% of a bill for healthcare services he or she
used. Higher percentages of coinsurance are now
Further Readings sometimes used for out-of-plan use by the insured
in preferred provider organizations (PPOs).
Gordis, Leon. Epidemiology. 3d ed. Philadelphia:
A copay is paid for by the insured individual at
Elsevier Saunders, 2004.
Hulley, Stephen B., Steven R. Cummings, Warren S.
the time of the provider visit. A typical copay may
Browner, et al. Designing Clinical Research: An
be $20 per physician office visit or $70 for an
Epidemiologic Approach. 3d ed. Philadelphia: emergency department visit.
Lippincott Williams and Wilkins, 2007. Historically, $250 or $500 deductibles were
Kuzma, Jan W., and Stephen E. Bohnenblust. Basic common. Today, high deductible health plans
Statistics for the Health Sciences. 5th ed. Boston: often require that an insured individual incur
McGraw-Hill Humanities, 2005. expenditures of $5,000 before the plan begins to
Levy, Daniel, and Susan Brink. A Change of Heart: How pay. Deductibles are also sometimes used for spe-
the Framingham Heart Study Helped Unravel the cific services rather than aggregate expenditures.
Mysteries of Cardiovascular Disease. New York: For example, a health plan may require that the
Knopf, 2005. insured individual satisfy a $500 deductible for
186 Coinsurance, Copays, and Deductibles
hospital services if he or she chooses to use some setting but use differential copays and/or coinsur-
hospitals in the community but will not require ance for services that are more price sensitive.
the deductible for other, preferred hospitals. The success of copays and coinsurance in limit-
Moral hazard in healthcare occurs because ing utilization will depend in part on the opportu-
people who are insured do not bear the full cost nity cost of the patient-consumer’s time. The “full
of their care. If patients are very price sensitive, price” of a visit to a physician includes not only the
meaning they are responsive to price, a small amount of money the patient must pay but also the
decrease in the out-of-pocket price will result in value of the time associated with getting to the phy-
large increases in the use of the service. sician’s office, waiting to be seen, being seen, and
Analogously, if a small coinsurance rate or copay returning to other activities. If these activities take
is imposed, patients substantially reduce their use 2 hours and the patient is an attorney who could be
of some health services. A deductible also obli- billing clients at $400 an hour, the full price of the
gates the patient to pay a portion of the bill and visit is $800 plus the actual money price paid to
would reduce health services utilization. the physician. For someone earning $10 an hour,
the full price is $20 plus the physician’s fee. If the
same copay or coinsurance rates were applied to
Empirical Evidence
the physician’s fee, it would obviously have a
The key issue surrounding the use of these utiliza- smaller impact on the attorney’s use of services. The
tion management tools is the extent to which they implication is that smaller copays or coinsurance
actually do reduce utilization and affect health. rates may be effective in reducing the utilization of
The RAND Health Insurance Experiment contin- lower-income groups, whereas substantially higher
ues to be the general definitive study of the effects amounts would be required to have the same effect
coinsurance and deductibles have on the use of on upper-income consumer-patients.
services. Differential or tiered copays have become com-
The basic finding from the RAND Health mon, particularly for prescription drugs, where
Insurance Experiment is that health services, gen- there are different copays for generic, preferred
erally, have a price elasticity of about −0.2. This brand, and nonpreferred brand drugs. One study
means that a 10% increase in the out-of-pocket by Geoffrey Joyce and associates in 2002 com-
price reduces the use of services by about 2%. pared insured individuals with one regime of
However, the effects of changes in price differ copays relative to another. In every tier, for each
rather substantially across particular types of drug type, those with higher copays had lower
health services. Ambulatory mental health visits, drug expenditures. The price elasticities ranged
for example, are much more price sensitive than from −0.22 to −0.40, with the three-tier nonpre-
are physician visits. Dental care exhibits a large ferred brand name prescriptions being the most
transitory effect not seen with other services, and price sensitive. The study also demonstrated expen-
hospital care is much less price-responsive than diture reductions in moving from a one- to a two-
physician services. tier drug plan or from a two- to a three-tier drug
This has important implications for the struc- plan. The price sensitivity in the nonpreferred
ture of health insurance plans and the use of other brand tier was greatest because it is in this tier that
utilization management techniques. It suggests, for the patient-consumers have the greatest availabil-
example, that coinsurance and copays are much ity of lower-priced substitutes.
more likely to be used for ambulatory services, Deductibles have become a potentially more
such as physician visits, prescription drugs, and important insurance utilization management tool
mental health services, than for inpatient care. with the advent of consumer-driven health plans
Because of this, one would expect to see other uti- (CDHPs) and health savings accounts (HSAs). The
lization management techniques used on the inpa- RAND Health Insurance Experiment found that a
tient side. Thus, managed-care plans tend to rely on $4,160 family deductible (in 2006 dollars) fol-
preadmission certification and concurrent review lowed by free care reduced medical care expendi-
to reduce moral hazard in the inpatient hospital tures by 31%. More recent work from the
Committee on the Costs of Medical Care (CCMC) 187
Netherlands found reductions of 28% for a similar composed of 48 members, including physicians,
insurance program with a $1,280 or more deduct- dentists, public health professionals, and econo-
ible (in 2006 U.S. dollars). This study suggested mists, was established to study the escalating costs
that a family deductible of $1,000 U.S. dollars of medical care, access to care problems, and dis-
might reduce spending by approximately 14%. tribution of health services in the nation. Starting
in 1927, the committee published 27 research
Michael A. Morrisey reports on its findings. The committee’s final
See also Consumer-Directed Health Plans (CDHPs);
report, published in 1932, made recommendations
Health Economics; Health Insurance; Health Insurance for more economical and effective healthcare. It
Coverage; Health Savings Accounts (HSAs); Medicare; discussed health insurance mechanisms, increased
Moral Hazard; RAND Health Insurance Experiment national and state funding, and the role of preven-
tive health. However, the committee could not
reach a consensus, and its final report included a
Further Readings majority report and two minority reports. Many
Hoffman, Beatrix. “Restraining the Health Care of the committee’s recommendations regarding
Consumer: The History of Deductibles and health insurance coverage, group medical practice,
Co-Payments in U.S. Health Insurance,” Social and community health centers would come to
Science History 30(4): 501–28, Winter 2006. fruition in the second half of the 20th century.
Joyce, Geoffrey F, Jose J. Escarce, Matthew D. Solomon,
et al. “Employer Drug Benefit Plans and Spending on
History
Prescription Drugs,” Journal of the American Medical
Association 288(14): 1733–39, October 9, 2002. After a meeting on medical economics at the
Morrisey, Michael A. Health Insurance. Chicago: Health American Medical Association’s (AMA’s) annual
Administration Press, 2007. convention in 1926, where several delegates dis-
Newhouse, Joseph P., and the Insurance Experiment cussed healthcare reform, a small group was con-
Group. Free for All? Lessons From the RAND Health vened to explore these issues in greater depth. This
Insurance Experiment. Cambridge, MA: Harvard initial group, referred to as the Committee of Five,
University Press, 1993. included Winford H. Smith from Johns Hopkins
Van Vliet, Rene C. J. A. “Deductibles and Health Care Hospital; Llewellyn F. Barker from the Johns
Expenditures: Empirical Estimates of Price Sensitivity Hopkins Medical School; Walton H. Hamilton, an
Based on Administrative Data,” International Journal
economics professor from the Brookings Institution;
of Health Care Finance and Economics 4(4):
C. E. A. Winslow, a public health professor from
283–305, December 2004.
Yale University; and Michael M. Davis, who was
previously the director of the Boston Dispensary
Web Sites and a well-known author on the sociological
America’s Health Insurance Plans (AHIP):
aspects of healthcare. Harry M. Moore, who
http://www.ahip.org
served as an economist for the U.S. Public Health
RAND Health Insurance Experiment: Service, was appointed secretary, although he was
http://www.rand.org/health/projects/hie not a formal member of the committee. Smith
served as the chairman of this group.
This group asked Ray Lyman Wilbur, president
Committee on the Costs of Stanford University and a past president of the
AMA, to preside over the meeting at the 1927
of Medical Care (CCMC) annual convention of the AMA. The Committee
on the Cost of Health Care (CCHC) was formed
The Committee on the Costs of Medical Care following this meeting, and Wilbur was appointed
(CCMC) was the most influential health services to serve as chairperson. Moore was appointed the
research group in the United States during the late director of research, assuming research oversight
1920s and early 1930s. The CCMC, which was and administrative responsibilities.
188 Committee on the Costs of Medical Care (CCMC)
The CCMC, an independent entity, received the nation’s healthcare system. First, it advocated
funding from private philanthropic sources for its for group practice between physicians and dentists
research and administrative costs. Specifically, the in a hospital setting and the development of com-
Carnegie Corporation, Josiah Macy, Jr. Foundation, munity health centers. Second, it proposed the
Milbank Memorial Fund, New York Foundation, expansion of public health services, especially at the
Rockefeller Foundation, Julius Rosenwald Fund, state and local levels. Third, it recommended group
Russell Sage Foundation, and Twentieth Century payment for healthcare, calling for health insurance
Fund contributed a total of nearly $1 million to coverage to be provided by private sources, govern-
the committee. This financial support allowed ment, or a combination of both; it did not specify
the committee to delve into issues concerning the the type of insurance mechanism because a few
affordability of medical care for Americans, the members advocated for universal compulsory cov-
training and earnings of medical professionals, and erage, while others endorsed voluntary insurance
the distribution of health resources in the nation. schemes. Fourth, it called for stronger coordination
In 1928, Isidore S. Falk, a young medical of medical and health services, proposing the estab-
researcher, joined the CCMC to serve as its associ- lishment of state and local agencies to study and
ated director of studies. His involvement was key evaluate these services. Last, it proposed improving
to the prolific nature of the committee’s publica- the education and training of medical professionals,
tions, reports, and collaborations. The committee including physicians, nurses, dentists, pharmacists,
officially changed its name in 1930, becoming the and healthcare administrators.
Committee on the Costs of Medical Care, this new
title reflecting the multitude of financial factors
Final Report: Minority Reports
beyond the expenses associated with physicians
that affect medical care. The CCMC’s final report contained two minority
reports. While the first minority report agreed with
the majority report on extending public health ser-
Final Report: Findings and
vices, improving medical education, and coordinat-
Majority Recommendations
ing medical services better, it strongly opposed the
The CCMC’s final report detailed many of its group practice and group payment recommenda-
findings over the 5 years that it was in existence. tions. The first minority report felt that group
The report found that in 1929, the national health practice would encourage contract practice and
expenditures totaled $3.7 billion, representing 4% commercialization. Moreover, several signers of the
of the nation’s gross domestic product (GDP) and first minority report disagreed with the proposal
$30 per individual and $123 per family. It also for voluntary group health insurance because they
found that only 60% of the nation’s population believed that it would lead to a compulsory health-
was responsible for these costs, the majority of care system. Specifically, the first minority recom-
which were paid directly by patients and their mendations were as follows: Limit the government’s
families; that less than 60% of the nation’s coun- medical activities to care for the indigent, govern-
ties had a hospital; that half of the population ment institutions, public health, and veteran’s
visited a physician each year; that only 20% of the affairs; expand government care of the indigent,
population received dental care annually; that relieving the burden on medical professionals to
many poor Americans could not afford adequate provide charity care; improve coordination of ser-
medical and dental services; and that the middle vices; restore the role of the general practitioner to
class was not able to pay for the expenses of a the center of medical practice; eliminate the corpo-
major illness. The report also found that physi- rate practice of medicine; and examine and tailor
cians’ salaries varied across geographic regions payment methods to fit institutions and practices.
and that one third of general practitioners earned Eight members of the CCMC signed the first
less than $2,500 per year. minority report, seven of whom were physicians.
In its majority report, the CCMC presented five The second minority report, signed by two den-
recommendations to address the economic issues of tists, agreed with much of the majority report but
Commonwealth Fund 189
raised issues with the development of community Further Readings

health centers and the inadequate understanding Committee on the Costs of Medical Care. The Five-Year
of problems within dental group practice. Program of the Committee on the Costs of Medical
Two members of the CCMC did not join any Care. Washington, DC: Committee on the Cost of
report; instead they wrote personal statements— Medical Care, 1928.
one called for compulsory insurance coverage, Committee on the Costs of Medical Care. Medical Care
while the other expressed dissatisfaction with the for the American People: The Final Report of the
committee’s ability to deal with the fundamental Committee on the Costs of Medical Care. Chicago:
economic question brought before the group. University of Chicago Press, 1932.
Perkins, Barbara Bridgman. “Economic Organization of
Medicine and the Committee on the Costs of Medical
Criticism Care,” American Journal of Public Health 88(11):
1721–26, November 1998.
The AMA strongly opposed the majority report’s Ross, Joseph S. “The Committee on the Costs of Medical
endorsements of voluntary health insurance and Care and the History of Health Insurance in the
group medical practice, launching an attack on its United States,” Einstein Quarterly Journal of Biology
efforts. The AMA supported the first minority and Medicine 19: 129–34, 2002.
report and encouraged its membership to do the Walker, Forrest A. “Americanism Versus Sovietism: A
same. In addition to mainstream media headlines Study of the Reaction to the Committee on the Costs
calling the CCMC’s stance on group payment of Medical Care,” Bulletin of the History of Medicine
“socialized medicine,” editorials appeared in the 53(4): 489–504, Winter 1979.
Journal of the American Medical Association that
described it as “Sovietism.” Local medical societ-
ies also criticized the majority recommendations Web Sites
and endorsed the first minority report.
National Information Center on Health Services
Research and Health Care Technology (NICHSR):
http://www.nlm.nih.gov/nichsr
Future Implications
The CCMC’s efforts helped the emergence of pri-
vate health insurance and eventually the federal
Medicare and Medicaid programs. The commit- Commonwealth Fund
tee’s promotion of group medical practice can also
be seen in present-day managed-care organiza- The Commonwealth Fund is a large New York
tions and the large number of community health City–based, private, nonpartisan foundation that
centers in the nation. Its emphasis on the need for supports independent research on healthcare issues
national data collection systems to monitor trends and provides grants to help improve healthcare
in healthcare will eventually be accomplished by practice and policy. The Commonwealth Fund’s
the National Center for Health Statistics (NCHS) mission is to promote a healthcare system with
and other federal agencies. Finally, the committee better access, improved quality, and greater effi-
significantly contributed to the growth of the field ciency, especially for those most vulnerable in our
of health services research, training a number of society—low-income individuals, children, the
distinguished health economists, healthcare admin- uninsured, minorities, and the elderly.
istrators, and public policymakers.
Kathryn Langley History
See also American Medical Association (AMA); Blue In 1918, Anna M. Harkness founded the
Cross and Blue Shield; Cost of Healthcare; Davis, Commonwealth Fund with the broad mandate
Michael M.; Health Economics; Health Insurance; that it should do something that would benefit the
Medical Group Practice; Rorem, C. Rufus welfare of mankind. The foundation was initially
190 Commonwealth Fund
endowed with a gift of nearly $10 million. Edward future of health insurance, Medicare’s future,
Harkness, Anna M. Harkness’s son, was the high-performance health system, patient-centered
fund’s first president. Both Edward and his mother primary care, state innovations, quality of care
were committed to building a responsive and for underserved populations, child development
socially concerned philanthropy, donating gener- and preventive care, quality of care for frail
ously to the fund’s endowment over the years. In elders, minority health policy, and health policy
fact, between 1918 and 1959, the Harkness fam- and practice. Additionally, the fund administers
ily endowed more than $53 million to the fund. several fellowship programs, including the
From the 1920s through the 1940s, the fund Commonwealth Fund/Harvard University Fellow
helped develop the field of child guidance and sup- ship in Minority Health Policy, Harkness Fellow
ported public health departments in communities ship in Health Care Policy, Packer Policy
around the country, and the construction of rural Fellowship, Australian-American Health Policy
hospitals. In 1925, the fund launched the Fellowship, and the Ian Axford Fellowship in
Commonwealth Fund Fellowships, an interna- Policy. The Commonwealth Fund also dissemi-
tional program that brought young professionals nates information, knowledge, and experience—
to the United States for extended studies and all in an effort to influence policymakers to
travel. The Commonwealth Fund Fellowships later achieve the fund’s goal of a high-performing
became known as the Harkness Fellowships. healthcare system.
After World War II and into the 1980s, the fund
concentrated on addressing the needs of communi-
ties that lacked healthcare services. It did so in sev- Grants and Publications
eral ways: The fund assisted in developing new
medical schools, which addressed the issue of physi- The Commonwealth Fund has not only been a
cian shortage, and medical school curricula. It also grant maker but also a professional publisher. The
contributed to bringing healthcare to underserved fund’s professional staff works with its grant
communities, including troubled urban areas. The recipients to develop and implement projects and
fund played a role in bringing attention to the prob- communicate project results. The fund also devel-
lems facing elderly Americans as well as those faced ops and publishes books, reports, and other mate-
by academic health centers. In addition, the fund rial that inform clinicians, healthcare administrators,
helped stimulate several programs and movements, and the public about the fund’s research and ways
including youth-mentoring programs and the to achieve a better healthcare system.
patient-centered care movement of the 1980s. Each year, the Commonwealth Fund produces
Since 1995, the Commonwealth Fund has numerous scholarly publications, written by the
focused on healthcare issues, specifically health fund’s grant recipients, staff, and invited experts—
insurance coverage, access to care, and improving all of which are available on the Commonwealth
healthcare quality and efficiency. Through its Fund Web site free of charge. In addition, each
international base, the fund is able to encourage year fund staff and grantees publish articles in
communication and collaborations on health poli- peer-reviewed journals. The fund ensures the qual-
cies and practices among developed countries. ity of its publications through internal peer review
As was the Harkness family’s intent, the and sometimes independent external peer review.
Commonwealth Fund has sought to identify prom- The Commonwealth Fund continues to seek out
ising practices and solutions that could help the ways to improve the quality, efficiency, and access
United States achieve a high-performing healthcare to America’s healthcare system. By bringing health
system. services research and health policy together and
continuing its mission of promoting a high-
performing healthcare system, the fund will likely
Activities have a sustained impact on the access, costs, and
quality of healthcare for all Americans.
The fund operates programs in the following areas:
healthcare quality improvement and efficiency, Lubina Perez
Community-Based Participatory Research (CBPR) 191
See also Access to Healthcare; Davis, Karen; Healthcare knowledge and action to achieve social change. In
Reform; Health Insurance; National Health Insurance; the health services research arena, this achieve-
Public Policy; Uninsured Individuals; Vulnerable ment often leads to improved health outcomes
Populations and reduced health disparities.
The CBPR model serves to establish a structure
within which community and academic partici-
Further Readings pants work together to achieve a balanced set of
Davis, Karen. “Toward a High Performance Health research methods, tools, and priorities. When
System: The Commonwealth Fund’s New members of communities affected by the issue
Commission,” Health Affairs 24(5): 1356–60, being studied are invited to participate in the
September–October 2005. research process, they are given unique opportuni-
Davis, Karen, and Andrew T. Huang. “Learning From ties to influence their surroundings. As a result,
Taiwan: Experience with Universal Health the CBPR approach is a powerful means of satis-
Insurance,” Annals of Internal Medicine 148(4): fying the rigors of scientific research and add
313–14, February 19, 2008. ressing the needs of the communities involved—
Phillips, Charles D., Anne-Marie Kimbell, Catherine communities that often consist of underserved and
Hawes, et al. “It’s a Family Affair: Consumer marginalized individuals.
Advocacy for Nursing-Home Residents in the United
States,” Ageing and Society 28(1): 67–84, January
2008.
History
Schoen, Cathy, Stuart Guterman, Anthony Shih, et al.
Bending the Curve: Options for Achieving Savings CBPR is rooted within social psychologist Kurt
and Improving Value in U.S. Health Spending. Lewin’s “action research” school, which rejected
Publication No. 1080. New York: Commonwealth traditional notions that objectivity could only be
Fund, 2007. achieved by removing oneself from the commu-
Smith, Vernon K., Kathleen Gifford, Sandy Kramer, et nity of interest. In the 1940s, Lewin’s research
al. State E-Health Activities in 2007: Findings From a focused on creating mutually beneficial relation-
State Survey. Commonwealth Fund Issue Brief. Pub. ships between researcher and community and
No. 1104, 2008. helping community leaders use research data to
Stuart, Bruce C. How Disease Burden Influences achieve social change. Lewin’s approach empha-
Medication Patterns for Medicare Beneficiaries: sized a continuous cycle of planning, action,
Implications for Policy. Commonwealth Fund Issue reflection, and decision making that resembles a
Brief. Pub. No. 1106, February 2008.
spiral of cascading steps.
In the first step, a general issue is identified. Part
of what makes the action research approach inher-
Web Sites
ently unique is the belief that this initial issue
Commonwealth Fund: http://www.commonwealthfund.org should come from the community of interest itself,
rather than from academia. The results of this
community involvement from the start include a
Community-Based community’s sense of empowerment, trust in the
research team, and investment in the project itself.
Participatory Research (CBPR) The next step is a careful examination of the
issue within the context of the community, from
Community-based participatory research (CBPR) which comes an overall plan to guide the research.
is a collaborative research approach that directly Action is taken in the next step, after which an
and equitably links researchers and communities evaluation occurs. Whether formal or informal,
to jointly study an issue. A key feature of CBPR is the evaluation usually results in a revision of the
the recognition that researchers and communities plan and additional action steps, and the cycle
each bring unique strengths and perspectives to continues with the constant reciprocation between
the research process, enabling a combination of researcher and community.
192 Community-Based Participatory Research (CBPR)
In the 1970s, early examples of participatory both qualitative and quantitative components.
research in action appeared in several developing The concept of “empowerment” within the par-
nations, where scholars such as Brazilian educator ticipating community and its members is a major
Paolo Freire rejected “colonial” research methods factor in the discrimination between CBPR and
in favor of more community-oriented ones. Freire’s more traditional methods.
approach built on the critical pedagogy he put for- The primary principle of CBPR is that the com-
ward as a response to the traditional formal mod- munity be actively and continuously involved in all
els of education in Latin America. Using the same aspects of the project. As a result of this collabora-
continuous cycle of steps employed by Lewin, tive partnership, the research belongs jointly to the
Freire examined the process of learning as a way to researchers and the community, and all parties
stimulate critical thinking and raise students’ criti- mutually benefit from the results. Additional core
cal awareness of their environment. Inherently principles of the CBPR approach include recipro-
political in nature, his approach triggered social cal transfer of expertise among all research part-
changes that reduced the divide between the pow- ners, shared resources and decision-making power,
erful and the marginalized. and mutual ownership of the results. These are
In 1984, the Centers for Disease Control and usually facilitated by mutual respect between com-
Prevention (CDC) established the Prevention munity and researchers, clear and open communi-
Research Centers (PRC) Program, a network of cation, adherence to ethical standards, credit for
academic researchers, public health agencies, and participation as appropriate, and long-term com-
community members that conducts applied research mitment to the project.
in disease prevention and control. The CDC set Both community and researcher must have the
forth four core values in keeping with the funda- capacity and the empowerment to express needs
mental goals of the CBPR: respect, trust, integrity, and goals as they pertain to the research at hand.
and accountability. Key activities of the PRC The true partnership required by a rigorous CBPR
Program include establishment of multidisciplinary approach is one that combines knowledge with
research teams, creation of research networks for action to achieve the goal of improved health out-
priority health issues, generation of long-term rela- comes and reduced health disparities.
tionships for engaging communities as partners in A successful CBPR project is focused locally on
research, and development of public health the relevance of the health issue at hand and the
researchers’ skills for working with communities. geographic, cultural, and socioeconomic contribu-
There are currently more than 30 PRCs located in tions to it. Such a project recognizes the commu-
schools of public health and medicine, enabling nity’s resources and knowledge and incorporates
academic researchers to easily identify and partner them into the research process. In turn, the knowl-
with public health agencies and communities. In edge and resource bases of the community will be
1997, the Institute of Medicine (IOM) recom- bolstered by participation in the project and the
mended CBPR as one of eight new areas in public dissemination of its results in the interest of
health education. improving social practice and community health.
In recent years, the focus of CBPR has shifted
from disease identification and management to
Implementation and Best Practices
prevention and education. Rooted in action
research and evolving through programs set forth As part of the reciprocation of expertise between
by Freire, the CDC, and the IOM, CBPR has researcher and community, a mechanism must be
become a widely accepted and respected approach created for shared decision making. This often
to health services research. requires formation of a community advisory board,
a task force, or various planning and implementa-
tion committees. These bodies develop and adhere
Community-Based
to guiding principles for collaboration within the
Participatory Research Approach
particular community involved.
CBPR is not an explicit methodology but an Throughout the project, the collaboration
approach to applied research that may combine should be evaluated by both the researcher and the
community. The research team should remain findings, and results should be communicated openly,
aware and respectful of the community’s needs and even when they may be considered undesirable.
priorities, and emergent problems and concerns
should be addressed. Incorporation of feedback
loops into the project’s design can help ensure Major Benefits and Challenges
proper collaboration, reflection, and relevance Benefits
throughout the intervention.
A CBPR project often begins with an issue or In many communities that are the focus of
question brought forth by a community. Inviting research projects—often underserved populations—
the community to identify health-related issues of contact with researchers occurs solely during data
greatest importance to them may increase motiva- collection. As a result, communities may become
tion to participate in the research process. As with resentful or distrustful of the research community,
most health services research projects, the issue and future participation becomes unlikely. However,
must be one for which epidemiologic data exist or the CBPR approach requires that a relationship be
can be gathered, and funding sources must be iden- formed on the basis of respect and trust before the
tified. Many CBPR projects incorporate educa- research begins and be maintained throughout the
tional “workshops” during which both researchers process and beyond.
and communities explore each other’s resources CBPR may also be useful in developing and test-
and strengths. Interviews with community mem- ing quantitative measures for use within certain
bers may be used to discover concerns about populations and cultures. Through the communi-
research and participation and may also be used to ty’s involvement in the design and testing phases of
alleviate those concerns. an instrument, researchers may gain an insight into
During the study design phase, community rep- the cultural sensitivities and preferences of the
resentatives work closely with investigators to community, leading to more appropriately designed
achieve an optimal balance between scientific rigor and implemented methods with improved internal
and community acceptability. Community repre- validity. This insight is also inherently useful in the
sentatives are critical to the development of par- analysis and interpretation of the results due to the
ticipant recruitment and retention strategies as “insider” perspective presented by the community
they are attuned to the needs and desires of com- members involved in the project.
munity members. The study must also be designed Another major benefit of the CBPR approach
to remove existing and potential barriers to com- for investigators is that the results may be dissemi-
munity participation. Measurement instruments nated almost immediately and are sustainable due
should be developed with continued guidance to the continuous involvement and feedback from
from community members to increase the reliabil- community members. This unique aspect of CBPR
ity and validity of the measures and to present strikes a balance between research and practice that
research questions in a manner acceptable and is rarely found in a traditional empirical study.
accessible to the community.
As the project is implemented, community
Challenges
members continue to assist researchers with deter-
mining the cultural and social relevance of the CBPR has gained a great deal of acceptance
intervention. Doing so increases the likelihood of among public health researchers and practitioners
achieving social change as a result. Finally, the in recent years. However, unlike more traditional
community is involved with the interpretation and research methodologies, there is a great deal of
dissemination of findings and their translation into variation in methodologies and reporting require-
practice. ments, leading to a gap in the ability of researchers
Before submitting manuscripts or making presen- to compare such studies.
tations at conferences, the research team should Although the ideal start to a CBPR project is
discuss findings with the study’s shared decision- one in which a community brings an issue or prob-
making body. Results should be framed in such a lem to the attention of researchers, there are often
way as to limit potential “blame” for any negative numerous real and perceived barriers to doing so.
194 Community-Based Participatory Research (CBPR)
Many communities that may benefit from a CBPR Examples

project are distrustful of researchers or simply do
REACH
not know how to access them. If the investigators
broach the CBPR issue with the community, they The CDC’s Racial and Ethnic Approaches to
are wise to assess the true importance of the issue Community Health (REACH) program is the cor-
within the community. Active participation is nerstone of its efforts to eliminate racial and eth-
maximized when both the community and the nic health disparities as part of the Healthy People
researcher are fully invested in the issue or problem 2010 initiative. The strategic goals of REACH are
and are committed to addressing it together. To to address health disparities in critical life stages
achieve this, incentives for both community mem- using innovative approaches within communities,
bers and the research team must be adequate. healthcare settings, schools and after-school pro-
Even when both parties are fully committed to grams, and workplaces.
the research, some degree of division between them Communities of focus include African
may still exist. The researcher must overcome his Americans, Alaska Natives and American
or her role as an “outsider” to truly collaborate Indians, Asian Americans, Hispanic Americans,
with the community. This can be a significant bar- and Pacific Islanders. The six areas targeted
rier when a community’s members are extremely for elimination of disparities are (1) infant mortal-
marginalized and are unlikely to identify the investi- ity, (2) breast and cervical cancers, (3) cardiovascu-
gators as anything but outsiders—often with per- lar diseases, (4) diabetes, (5) HIV/AIDS, and
ceived knowledge and power. Such barriers can be (6) immunizations.
ameliorated through involvement with community REACH grantees are implementing local inter-
leaders in the initial stages of the project. Elders, ventions that include continuing education for
religious leaders, and others in either real or per- healthcare providers, health education and health
ceived roles of power within their communities promotion programs that use lay health workers
provide excellent opportunities for investigators to to reach community members, and health com-
gain a benevolent foothold in the community. munication campaigns. Evaluation of the REACH
Identification of appropriate representatives may program includes gathering evidence on com-
also prove challenging. A selection bias may occur munity capacity building, targeted intervention
if participating community members are not repre- actions, community and system changes, wide-
sentative of the community’s overall makeup. spread behavior changes, and reduction in health
As in any research endeavor, researchers and disparities.
communities must concern themselves with the
issues of ownership and confidentiality. Because
California’s Health Interview Survey
investigators work so closely with the communities
and individuals, ethical issues may arise as relation- California’s Health Interview Survey, the
ships evolve. Discussions early in the process about nation’s largest state health survey, represents a
these issues and how they will be addressed can successful combination of CBPR with traditional
alleviate the tension with regard to these issues. quantitative research. At the start of each survey
Because CBPR relies on robust relationships development cycle, more than 145 individuals
with communities, the investments of time and from state and local policy-making bodies, public
resources can be large for both researcher and health agencies, advocacy groups, research orga-
community. Such relationships must be properly nizations, and healthcare organizations collabo-
brokered, equitably managed, and carefully sus- rate with survey research staff as members of
tained to maintain the ideal partnership without advisory boards, technical advisory committees,
unfairly burdening one party. Finally, because of and work groups. This collaboration shapes top-
the relatively recent acceptance of CBPR as an ics, measures, and the design of the survey, and
empirical method, funding mechanisms can be survey results and data are provided to the com-
scarce and inadequate. munities involved.
Environmental Justice: Additional types of community partnerships

Partnerships for Communication Program and additional underserved communities will con-
A partnership between several federal agencies tinue to be explored. A standardized set of compe-
led to the 1994 launch of the Environmental tencies, terminologies, quality assessments, and
Justice: Partnerships for Communication Program. well-defined outcome measures must be estab-
The program was designed to bring together lished for CBPR to remain a viable approach to
community organizations, environmental health rigorous research. New investigators will be edu-
researchers, and healthcare professionals to develop cated about the CBPR approach and its applica-
tions, benefits, and challenges. Similarly, communities
models and approaches, build communication,
will be educated about the opportunities available
and increase community participation in research.
for their participation in CBPR. Tools to help com-
More than 30 CBPR studies have been funded
munities locate and contact potential research
under the program. For example, the Partnership
partners are being developed and implemented,
to Reduce Asthma and Obesity in Latino Schools
increasing the scope of CBPR.
focuses on developing a better understanding of
Expansion of CBPR policies will allow more
the impact on asthma and obesity of the school
communities to become involved with researchers
environment and school district policies that influ-
in the interest of bettering the health of their mem-
ence this environment. The Environmental Health
bers. Communities previously excluded from CBPR
and Justice in Norton Sound, Alaska, is a program
and traditional research will benefit from a narrow
funded to identify, limit, and reduce the effects of
focus, which will allow specific attention and col-
harmful contaminants in the natural food sources
laboration to decrease disparities and increase
of indigenous people in Alaska. The Community-
participation in health-related activities.
Based Participatory Research in Environmental
Finally, the results of CBPR must move from local
Health program, based at the University of Texas
dissemination and action into policy and practice.
at El Paso, seeks to improve the capacity of the El
Engaging community members in the policy process
Paso, Texas/Juarez, Mexico, binational commu-
will increase the joint ownership of the research, and
nity to participate in research on lead exposure
putting the results into practice will allow similar
among low-income Hispanic children.
communities to benefit from the results.
Future Implications Halle R. Amick
As more comprehensive approaches to public See also Agency for Healthcare Research and Quality
health research continue to gain traction in the (AHRQ); Centers for Disease Control and Prevention
scientific and academic communities, attention (CDC); Community Health; Epidemiology; Health Dis
and resources will increasingly focus on CBPR. parities; Kellogg Foundation; Public Health; Public Policy
Public health agencies, seeking to reduce health
risks and improve outcomes effectively and effi- Further Readings
ciently, are calling for more participatory studies. Cashman, Suzanne, Sarah Adeky, Alex J. Allen, et al.
The shift of research focus in recent years from “The Power and the Promise: Working With
disease identification and management to preven- Communities to Analyze Data, Interpret Findings,
tion and education has attracted the attention of and Get to Outcomes,” American Journal of Public
both private and governmental organizations. Health 98(8): 1407–17, August 2008.
These funding agencies are beginning to require Faridi, Zubaida, Jo Anne Grunbaum, Barbara Sajor
community partnerships in their requests for Gray, et al. “Community-Based Participatory
applications and proposals. In addition, top-tier Research: Necessary Next Steps,” Preventing Chronic
health services research journals will likely increase Disease 4: A7, July 2007.
the number of CBPR-related articles published, Israel, Barbara A., Eugenia Eng, Amy J. Schulz, et al.,
continuing to lend credence to the scientific rigors eds. Methods in Community-Based Participatory
of this approach. Research for Health. San Francisco: Jossey-Bass, 2005.
196 Community Health
Minkler, Meredith, and Nina Wallerstein, eds. and extra-individual factors. This framework
Community-Based Participatory Research for Health: moves beyond a traditional focus on person-level
From Process to Outcomes. 2d ed. San Francisco: factors and reframes both causes of disease and
Jossey-Bass, 2008. sources of health as interactions between individu-
Stanton, Bonita, Jennifer Gailbraith, and Linda Kaljee, als and their social and physical environments.
eds. The Uncharted Path From Clinical-Based to Community health as a perspective is a relatively
Community-Based Research. New York: Nova new concept. The time since 1980 has been cited
Sciences, 2008. as seeing enormous growth in the awareness of the
Shelton, Deborah. “Establishing the Public’s Trust
need to attend to environmental causes of health.
Through Community-Based Participatory Research: A
Rather than focusing only on modifying individual
Case Example to Improve Health Care for a Rural
behavior, a community health perspective pre-
Hispanic Community,” Annual Review of Nursing
scribes both behavior- and environmental-based
Research 26: 237–59, 2008.
strategies. The rise of this perspective has been
credited to the acknowledgment that most public
health problems are too complex to be understood
Web Sites simply as a product of individual behavior.
Agency for Healthcare Research and Quality (AHRQ): Possibly because of its interdisciplinary nature
http://www.ahrq.gov and lack of one core disciplinary home, the con-
American Public Health Association (APHA): cept of community health is still in its formative
http://www.apha.org stage. In discussing community health as a concep-
National Institute of Environmental Health Sciences tual framework, researchers have referred to two
(NIEHS): http://www.niehs.nih.gov similar, more established frameworks, including
Prevention Research Centers (PRC): the socioecological model and empowerment the-
http://www.cdc.gov/prc ory. Both of these perspectives are based on the
assumption that individual and environmental fac-
tors come together to influence health and illness,
and both offer a set of principles guiding the
Community Health approach to understanding health and disease,
preventing disease, and promoting health.
The socioecological model specifies the follow-
Although community health is a popular concept,
ing three assumptions: (1) environmental settings
it lacks a clear working definition in research and
have multiple physical, social, and cultural dimen-
practice. One reason is that the concept of com-
sions that affect a variety of individual physical,
munity health belongs to multiple disciplines,
emotional, mental, and social health outcomes; (2)
including public health, medicine, and psychology.
individual characteristics such as genetics, psycho-
An inherently interdisciplinary concept, commu-
logical characteristics, and behavior affect health
nity health has no one home; however, common
and, moreover, interact with the environment to
elements can be found across disciplines in terms
affect individual outcomes; and (3) the variety of
of how it is discussed. Throughout these discus-
diverse settings within an individual’s life interact
sions, community health has been presented as a
to affect health. Community health has ecological
conceptual framework that can be applied to
roots and similarly views individuals as being
understand health, a process by which health inter-
nested within a series of embedded systems that
ventions can be designed and implemented, and an
are interrelated and interdependent. These systems
outcome with implications for measurement.
range from social dynamics to physical organiza-
tions and can include families, neighborhood
groups, schools, places of worship, government
Community Health as a policies, and both explicit and unspoken preju-
Conceptual Framework dices. A community health perspective acknowl-
As a conceptual framework, community health edges the dynamic interaction between the systems
offers a view of health as the product of individual in which individuals exist and acknowledges the
Community Health 197
importance of both systems being able to effec- approach to keeping individuals healthy: The
tively meet the needs of individuals, and individu- environment can be a protective factor for indi-
als effectively accessing systems of support. A vidual health. Opportunities afforded (or not
community health perspective sees the effective afforded) by the environment are essential to the
functioning of these systems as vital to the health health and well-being of an individual. In the
of individuals. reframing of health and disease as interactions
Empowerment theory views health as the prod- between individuals and environments, strategies
uct of an individual’s social, economic, and envi- such as self-help, community development, and
ronmental condition. Using an approach slightly social action have been discussed as being key to
different from the socioecological model, empow- community health practice. Central to this process
erment theory has at its core the need for authen- is the concept of collaborative practice.
tic involvement of community members throughout A community health framework advocates col-
the process of understanding the contributors to laboration both among individual members of the
health and disease, and ultimately promoting community and among various community sys-
health. Empowerment theory states that different tems. The process of community health involves
groups in a society hold different levels of power the mobilization of community members to work
and that this power affects the control that indi- collectively on their own behalf; there is an explicit
viduals have over their own health. Under this focus on capacity building, which involves the
framework, community health stems directly from sharing of information, skills, and resources to
the ability of individuals to be involved in decision organize community members into leadership
making in their communities. Empowerment roles. Community members are involved in the
advocates for the creation of more comprehensive process of understanding the contributors to health
networks of support and views healthy relation- and disease, as well as the delivery of health inter-
ships between a community and other effective ventions. Community health acknowledges that no
organizations as critical—organizations such as one knows the community better than its mem-
criminal justice systems, school systems, and bers; as a result, these individuals can play an
healthcare providers. Participation is essential to important part in recognizing barriers to health in
this process as community members are vital to their communities as well as making decisions
building and maintaining relationships across about how to address these barriers. These col-
healthy settings. laborations can lead to more authentic, effective,
Though differing in their approaches to pro- and sustainable interventions.
moting health, these models demonstrate the key Collaboration among community organizations
assumptions of a community health framework: provides an overall environment of care for indi-
the recognition of individual and environmental viduals. Because this step can appear more daunt-
causes of health, a focus on the interaction between ing than the task of involving individual community
individual and environmental factors, and an members in the health promotion process, efforts
acknowledgment of the importance of including have often fallen short of coordinating various
community members in the process. needed systems to create healthy systems of care.
Calls have been made for better integration among
community organizations as essential to facilitat-
Community Health as Process
ing the health of community members, and research
Researchers and theorists have also discussed has begun to demonstrate that organizational and
community health as a process, specifically focus- environmental infrastructure and support are
ing on approaches to intervention. The presump- essential to the effectiveness of health-related pro-
tion of health as being defined by both individual gramming. However, more needs to be done. A
and environmental factors necessitates changing community health approach advocates for a series
not only individual behavior but also those social of systems that provide what is needed for a
factors causing disease or preventing optimum diverse group of individuals to stay healthy:
health. A community health framework posi- healthcare systems that reach out to multiple
tions community-level intervention as a distinct groups of people in culturally appropriate ways,
198 Community Health
educational systems that meet the needs of a An important part of health promotion programs
diverse group of learners, employment and recre- not mentioned is the need to teach individuals to be
ational opportunities for those with varying ability aware of and advocate for the types of settings and
levels, opportunities for the building of social con- setting characteristics that they need.
nections and exchange of social support, and
neighborhood environments that promote physical
Community Health as an Outcome
safety and protection from environmental pollut-
ants. To be effective, a key requirement is that Community health can also be discussed as an
these systems should work in concert with each outcome. What does a healthy community look
other, offering multiple opportunities for person- like? Following from the above, a healthy com-
environment fit, in that individual needs and munity is free from physical violence, environ-
resources are complemented by the multiple envi- mental pollutants, disease, and discrimination.
ronments in which a person lives. Furthermore, it is one in which community mem-
A number of efforts have been made to lay the bers are active and involved in decision-making
groundwork for community health practice. For processes, systems of care are coordinated and
example, in the early 1990s, the Minnesota Heart accessible to all community members, and multiple
Health Program developed an intervention to fos- opportunities are available for person-environment
ter heart health in three communities. It began fit. A healthy community focuses on keeping its
with a survey intended to identify community lead- members healthy through disease prevention and
ers who would then be asked to become members health promotion as well as providing effective
of an advisory board with government officials treatment for those who are sick. These are but
and health professionals to provide guidance on some of the characteristics that operationalize the
programs, health education campaigns, and related theory and process presented above.
policy. This effort resulted in a public education In addition to discussing how to achieve these
media campaign and a number of programs outcomes, it is also important to discuss how such
involving multiple organizations in the commu- outcomes can be monitored and measured. The
nity, including school curricula on smoking, exer- measurement of community health presents a chal-
cise, and nutrition; and an annual communitywide lenge because of the complexity of the concept.
quit smoking contest and work site smoking policy The fact that community health views health as an
planning assistance. An evaluation of the program interaction between individual, social, and physi-
demonstrated greater participation in heart disease cal environmental factors necessitates the measure-
health promotion and a greater sense of “social ment of at least three constructs: (1) individuals,
connectedness,” although more so among stable (2) the environment, and (3) the interaction
organizations whose current needs and interests between them. Currently, the most sophisticated
were in line with the goals of the intervention. measures are available for individual-level con-
A number of guidelines for community health structs. For measurements of individual outcomes,
promotion programs have been developed. Many morbidity and mortality rates can be computed,
emphasize the importance of understanding the which permit a picture of the health of a group of
relevant aspect of the social and physical environ- people to be obtained. For example, mortality
ment, which can influence a variety of health out- rates from heart disease, cancer, and stroke can be
comes, as well as the interactions between these used to assess the physical health of a community.
environmental characteristics and pertinent indi- Examining these rates can be helpful in under-
vidual factors. Once these factors and interactions standing trends in health and disease, particularly
are better understood, interventions can be devel- in understanding health disparities between sub-
oped to enhance the person-environment fit, which groups of the population.
can occur when individuals enjoy a high degree of Techniques related to both environmental assess-
control over their environment and are able to ment and the measurement of individual-environment
modify it according to their needs. Interventions interactions need further development; however,
can therefore work to facilitate the flexibility and strides have been made regarding extraindividual
responsiveness of social and physical environments. assessment. Environmental assessments developed
Community Health 199
to date can be divided into two broad categories: health records) are necessary for capturing the
(1) those that assess the environment subjectively multiple components and levels of analyses
(i.e., from the perspective of individuals assessing involved in the health equation. How then can
that environment) and (2) those that assess the variables be identified for study? How can health
environment more objectively. Examples of the professionals and researchers decide on a course of
former include the variety of environmental scales action in intervention? One approach is to use
developed that allow individuals to rate their satis- strategies based on “middle-range” theories of the
faction with different aspects of their environment. variety of factors that contribute to and are likely
Such measures have been adapted to classrooms, to alleviate a particular health problem. Assessing
family environments, and work settings. Examples and attempting to either eliminate or bolster a set
of the latter involve counting up the number of of variables thought to affect the condition in
businesses in a community with handicap-accessi- question provides a productive start to under-
ble entrances or the number of available health standing health.
clinics in a community. Each of these broad classes
of measurement provides important information
Future Implications
about the environment, with the subjective mea-
sures actually providing some information about The concept of community health advocates for
the interaction between an individual and his or health as the product of the individual and his or
her environment and the objective measures pro- her environment. A community health approach
viding information about the environment that involves enhancing the environment to become
perhaps individual community members cannot more health promoting as a way to facilitate indi-
observe or will not report. Ideally, these measure- vidual health. One vehicle for action includes
ment strategies should be used to complement each public health policy. Each of the different levels of
other in describing the environment. community health—framework, process, and out-
Finally, efforts must be made at assessing the come—includes a number of overlapping implica-
interaction between individuals and the environ- tions for public health policy.
ment to understand how it affects health. In addition Working within a community health frame-
to the subjective environmental measures discussed work, public health policymakers must acknowl-
above, measures of the individual and environmen- edge and address individual and environmental
tal components of community competence can also factors, and the interaction between them, as the
assist in approximating this interaction. Community determinants of health. The community health
competence involves two components: (1) the com- perspective broadens what is considered “public
petence of community resources in meeting the health” policy because every aspect of society
needs of individual community members and (2) the potentially affects health. Public health policy
competence of individuals in accessing these should therefore focus not only on topics that are
resources. Assessing the first component involves clearly related to health but also those whose link-
measuring the effectiveness of various social sys- ages may not be as explicit. Examples include
tems, for example, the healthcare, education, employ- promoting community development, creating safe
ment training, housing, and criminal justice systems. communities with functioning resources, and allo-
Evaluation research has made strides in developing cating resources in such a way to build a solid
methodologies for assessing the process and out- infrastructure both with and between communities
comes of such service delivery systems. Assessing the for health-promoting initiatives to thrive. Policy
second component involves measuring an individu- around the implementation of services and pro-
al’s ability to effectively use resources in the com- grams should mandate a thorough assessment of
munity. Viewing results of both types of assessments the local community resources and needs, building
can begin to uncover the level of fit between indi- on the former to address the latter. Furthermore,
viduals and their communities. policies across the board should promote citizen
The task of measuring these multiple compo- participation: Authentic opportunities for commu-
nents can become overwhelming, particularly as nity members to be involved in making decisions
multiple methods (e.g., surveys, observations, and about their communities should be built in as an
200 Community Health Centers (CHCs)
essential part of the process. An understanding of Association for Community Health Improvement
the relevant individual and environmental charac- (ACHI): http://www.communityhlth.org
teristics affecting health is critical to beginning any National Association of Community Health Centers
type of policy initiative. (NACHE): http://www.nache.com
Community health provides a conceptual frame- National Rural Health Association (NRHA):
work, a set of intervention guidelines, and out- http://www.nrharural.org
comes to target by understanding health as a World Health Organization (WHO): http://www.who.int
product of individual and environmental factors.
Because community health is a relatively new con-
cept, the specific mechanisms by which environ-
ments interact with individual factors in affecting
individual health have not been understood well. Community Health
Further work must continue to identify the process Centers (CHCs)
by which these interactions occur and foster health
promoting communities to positively affect the Community health centers (CHCs), called neigh-
health of individual community members. borhood health centers until 1975, were created
Erin Hayes Kelly in 1964 by the U.S. Office of Economic Opportunity
(OEO) as a component of President Lyndon
See also Disease; Epidemiology; Health; Health Johnson’s “War on Poverty.” These local, public
Disparities; Health Planning; Medical Sociology; or nonprofit, community-run healthcare centers
Preventive Care; Public Health serve low-income and medically underserved com-
munities. Community health centers provide com-
prehensive, affordable primary care and preventive
Further Readings visits. Many of these centers provide services such
as case management, home visits, community out-
Bellerose, George. Caring for Our Own: A Portrait of reach, dental care, diagnostic laboratory and radi-
Community Health Care. Middlebury, VT: Painter ology services, and pharmaceutical, mental health,
House Press, 2006. and substance abuse services. Currently, more
Bensley, Robert J., and Jodi Brookins-Fisher, eds.
than 1,000 community, migrant, and homeless
Community Health Education Methods: A Practical
health centers serve more than 15 million people
Guide. 3d ed. Sudbury, MA: Jones and Bartlett, 2008.
in the United States, about half in rural communi-
Butterfoss, Frances Dunn. Coalitions and Partnerships in
ties and half in economically depressed inner-city
Community Health. San Francisco: Jossey-Bass, 2007.
communities. Two thirds of health center patients
McKenzie, James F., Robert R. Pinger, and Jerome E.
Kotecki. An Introduction to Community Health. 6th
are members of racial and ethnic minority groups,
ed. Sudbury, MA: Jones and Bartlett, 2008. and 29% are reported as best served in a language
McMurray, Anne. Community Health and Wellness: A other than English. More than 90% of health cen-
Socio-Ecological Approach. 3d ed. New York: Mosby ter patients are low income, and 71% have family
Elsevier, 2007. incomes at or below the federal poverty level.
Palley, Howard A., ed. Community-Based Programs and About 40% of patients are uninsured, and 36%
Policies: Contributions to Social Policy Development. are covered by Medicaid.
New York: Haworth Press, 2008.
Rosenbert, Jessica, and Samuel J. Rosenberg, eds.
Community Mental Health: Challenges for the 21st Early Health Centers
Century. New York: Routledge, 2006.
Precursors to CHCs included 19th-century dispen-
saries, turn-of-the-century settlement houses, rural
outreach efforts such as the Frontier Nursing
Web Sites
Service in eastern Kentucky, city-operated clinics,
American Public Health Association (APHA): and social medicine departments of progressive
http://www.apha.org institutions such as Montefiore Hospital in New
Community Health Centers (CHCs) 201
York City. During the first two decades of the One of the early leaders of the community
20th century, health centers, which coordinated health center movement was H. Jack Geiger, a
the health, welfare, and recreational services of young physician and civil rights activist, who had
multiple agencies in one location, were established studied with Sidney and Emily Kark in South
in many cities in the United States. They focused Africa and witnessed how a community-oriented
on preventing disease through education, maternal primary-care model had improved the health of
and child healthcare, food inspection, and immu- the Zulus. In 1964, while serving as Mississippi
nization. By 1926, there were more than 1,000 of field coordinator with the Medical Committee for
these health centers across the country. By offering Human Rights, he recruited physicians and nurses
only preventive services, they avoided competition to take care of the civil rights workers as well as
with the therapeutic services of private practitio- the local population. Count Gibson, the chair of
ners. Organized medicine opposed and defeated a the Preventive and Community Medicine depart-
proposed bill in New York State in 1920 that ment at Tufts Medical School, was one of the
would have established and funded health centers volunteers in Mississippi. Working with the OEO,
throughout the state to provide both preventive Geiger and Gibson founded the first two neighbor-
and therapeutic services to laborers. hood health center demonstration projects. The
In 1920, the Rockefeller Foundation formed the first was established at the Columbia Point public
Committee on Dispensary Development, directed housing project in Boston in 1965, and the other
by Michael M. Davis, which gave grants to “new was built in Mound Bayou, Mississippi, in 1967.
concepts in ambulatory care.” One of the demon- At these model health centers, teams of health
stration projects was a clinic at Cornell Medical professionals provided personal healthcare in
School, which employed salaried physicians in a convenient locations, with a focus on community
group practice, provided comprehensive ambula- outreach, child care, transportation, attention to
tory care services, and used a sliding-scale system the economic and environmental factors that con-
for payment. During the 1940s and 1950s, patients tributed to poor health, and involvement of the
who could not afford the cost of private physicians patients themselves in how the programs were set
mostly relied on hospital outpatient departments up and managed.
or emergency rooms. In 1966, the Office of Comprehensive Health
In 1960, the Social Security Act was amended Services was established within the Community
with the passage of the Kerr-Mills measure, Action Program to administer neighborhood
which provided states with grant money for the health center grants, and an Office of Health
medically indigent. The Migrant Health Act of Affairs was created within the OEO to coordinate
1962 called for the development of health clinics its medical and health programs. U.S. Senator
dedicated to providing a broad array of medical Edward Kennedy of Massachusetts, an early sup-
and support services to farm workers and their porter of the idea of health centers, helped secure
families. the addition of authorizing language to the OEO
Act in April 1967 that earmarked $51 million for
health centers. During the first 4 years of the pro-
Establishment of Community Health Centers
gram, medical schools and teaching hospitals
Under the Economic Opportunity Act of 1964’s received the majority of grants to start health cen-
Community Action Program, hospitals, medical ters. By 1971, 100 neighborhood health centers
schools, community groups, and health depart- had been established under the federal Economic
ments received grants to plan and administer Opportunity Act.
neighborhood health centers in low-income areas. While the OEO was funding neighborhood
Health center advocates hoped that, in addition to health centers, the U.S. Public Health Service (PHS),
providing high-quality healthcare to low-income part of the Department of Health, Education and
populations that lacked access to such care, health Welfare (DHEW), began providing its own grants
centers would serve as a model for the reorganiza- to establish comprehensive health centers in low-
tion of healthcare services for the nation’s popula- income areas beginning in 1968. The PHS funded
tion as a whole. 24 centers in 1968 and 1969 through section 314(e)
of the Comprehensive Health Planning and Public potentially leading to a nationalized healthcare
Health Services Act of 1966, amended in 1967 by system, tried to combine health centers with other
the Partnership for Health Amendments. health programs into a primary-care block grant.
However, opposition from individual health centers,
state and regional primary-care associations, the
Community Health Centers After 1970
National Association of Community Health Centers
Under his New Federalism program, President (NACHC), and senators Edward Kennedy and Orrin
Richard Nixon transferred OEO’s operating Hatch led to the 1986 repeal of the block grant.
responsibilities to the relevant cabinet agencies While there were overall funding cuts in the health
and moved the entire health center program in the center program during the early years of the Reagan
early 1970s from the OEO to the DHEW’s Public administration, later the program experienced some
Health Service. In 1972, DHEW issued regula- growth due to increases in regular appropriations
tions asserting that federal support was no longer and temporary funds to help the centers meet rising
needed for the health centers as they could collect demand from the unemployed. An increase of avail-
reimbursements from Medicare, Medicaid, and able healthcare providers from the National Health
private insurers and become self-sufficient. In Service Corps, a program that pays for professional
1973, Nixon asked the U.S. Congress to phase out education in exchange for service in underserved
the legislation that funded health centers. However, areas, enabled many urban sites to expand.
the General Accounting Office (GAO) determined During the George H. W. Bush administration,
that Medicaid only covered about one third of the Senator John Chafee of Rhode Island and the
nation’s poor, and in many states reimbursement NACHC helped develop the Federally Qualified
rates were too low to cover health center costs. Health Centers (FQHC) legislation, which increased
Congressmen Paul Rogers and Edward Kennedy health center reimbursement for Medicaid in 1989
led the effort to preserve federal funding for and Medicare in 1990.
health centers and to broaden the mandate of the President Bill Clinton’s Task Force on National
centers so that comprehensive primary and pre- Health Reform proposed to replace nearly all
ventive services were provided to all patients who health programs with “purchasing cooperatives”
sought care. DHEW’s Bureau of Community or “health alliances.” A background paper on
Health Services developed a system of account- healthcare for the underserved presented conflict-
ability for the health centers that required each ing views on whether health centers should con-
health center to report on numbers and types of tinue as a separate entity or be consolidated with
staff, patients, and encounters as well as revenues insurance funds run by the purchasing coopera-
and expenditures. Despite a veto by President tives. After the White House Task Force was dis-
Gerald Ford, the U.S. Congress authorized the banded, the HHS proposed combining federal
Special Health Revenue Sharing Act of 1975. Title health programs and channeling the funds through
V of this act authorized $215 million for health states. When health center advocates protested this
center operations in 1976 and $235 million for proposal, which recommended block grants simi-
1977, plus an additional $5 million each year for lar to those of the Reagan years, the Clinton
planning grants. Health Security Act continued separate legislative
President Jimmy Carter and his DHEW secre- authorities for programs such as health centers.
tary, Joe Califano, were strong supporters of Donna Shalala, the secretary of HHS, preferred
increased funding for health centers. In 1978, edu- “marrying the health centers to teaching hospi-
cation was moved to its own cabinet department, tals” rather than expanding services provided by
and DHEW changed its name to the Department the health center. Between 1995 and 2001, the U.S.
of Health and Human Services (HHS). By 1980, Congress increased health center appropriations
there were 872 grantees, an increase from 158 65% from $757 million to $1.2 billion.
grantees in 1974. President George W. Bush made expansion of
In the early 1980s, President Ronald Reagan, rely- health centers a top priority. In 2001, he launched
ing on advice from the conservative Heritage the 5-year President’s Health Care Expansion
Foundation, which distrusted health centers as Initiative to establish or expand 1,200 health
Community Health Centers (CHCs) 203
center sites to serve an additional 6.1 million reduced prices. FQHCs are paid by Medicaid and
patients annually by the end of 2006. The U.S. Medicare for services on a per-visit basis rather
Congress generally supported this effort until than separately for each service provided when a
2005, when it cut the proposed increase from $219 patient visits a health center. FQHCs also have
to $116 million as part of across-the-board cuts access to medical malpractice insurance through
due to rising deficits. In 2006, health centers the Federal Tort Claims Act.
received only a $48 million increase despite Bush’s
proposed $304 million increase. Bush cited an
Federal Grant Requirements
Office of Management and Budget (OMB) report
that reviewed hundreds of HHS programs and To receive Section 330 grant funds, a CHC must be
found health centers to be 1 of only 10 deserving located in a federally designated medically under-
the highest effectiveness rating. served area (MUA) or serve a federally designated
The Health Resources and Services Admini medically underserved population (MUP). It must
stration (HRSA), Bureau of Primary Health Care also have nonprofit, public, or tax-exempt status;
(BPHC), currently administers the health center provide comprehensive primary healthcare services,
program within the HHS. The Health Centers referrals, and other services needed to facilitate
Consolidation Act of 1996 combined the previ- access to care, such as transportation, interpreter
ously separate community, migrant, homeless, and services, and case management. Additionally, the
public housing authorities under Section 330 of CHC must have a governing board, with a majority
the Public Health Service Act (PHSA) to create the of members as patients of the health center, provide
consolidated health centers program. The federal services to all patients in the service area regardless
Health Care Safety Net Amendments of 2002 of their ability to pay, and offer a sliding fee scale
reauthorized the consolidated health centers pro- based on family income.
gram through 2006. The governing board, with at least a 51% con-
sumer majority, must meet monthly to select the
CHC’s services and hours, approve the CHC’s
Financing
annual budget, select the CHC’s director, and
CHCs are funded by a variety of sources. Medicaid establish general policies.
provides the greatest part of their revenues, In 2004, federally funded health center grant-
accounting for 36% of total funding, followed by ees provided care at 3,650 sites to more than 13.2
federal 330 grants, which cover 22%. The remain- million patients. Federal grant funding for the
der comes from state and local funding, including consolidated health centers program totaled
foundations (12%), Medicare (6%), private insur- $1.47 billion in 2003 and $1.57 billion in 2004.
ance (6%), self-pay (6%), other federal grants Federal grants constitute 25% of overall health
(4%), and other sources (8%). center revenues.
Four types of FQHCs are funded under Section As health center grants are given to fund direct
330 of the PHSA: (1) CHCs, under section 330[e], services, HRSA limits the use of grant money for
receive 81.5% of program funding; (2) migrant capital-related purposes. From 1978 to 1996,
health centers, under section 330[g], account for health centers could use grant funds for construc-
8.6% of program funding; (3) homeless health tion, renovation, acquisition, and equipment pur-
centers, under section 330[h], receive 8.7% of pro- chases. However, the U.S. Congress revised the
gram funding; and (4) public housing health cen- health center statute to prohibit the use of grant
ters, under section 330[i], receive 1.2% of program dollars for construction in 1996. Currently, HRSA
funding. Federally Qualified Health Center Look- allows grantees to use up to $150,000 from their
Alikes are health centers that meet the require- first year’s budget for equipment or capital altera-
ments for federal funding but do not receive a tions. HRSA also provides a loan guarantee pro-
grant. FQHCs and Look-Alikes are eligible to gram to grantees and funds state primary-care
receive enhanced reimbursement from Medicaid associations and the National Association of
and Medicare and to participate in the 340B pro- Community Health Centers (NACHC) to provide
gram, which allows them to purchase drugs at technical assistance to CHCs.
Organizations 75% of all uninsured people nationally. Uninsured

adults who use health centers are more likely to be
In 1970, the nonprofit National Association of
counseled about diet and eating habits, physical
Neighborhood Health Centers (NANHC), with
activity, smoking, drinking, drug use (55% vs.
support from the OEO, was founded with a mis-
39%), and sexually transmitted diseases than are
sion to enhance and expand access to high-quality,
U.S. uninsured adults. Medicaid and uninsured
community-responsive healthcare for America’s
patients who go to CHCs are more than 50%
medically underserved and uninsured. The same
more likely to have up-to-date pap smears and
year, the New York Association of Neighborhood
mammograms than the overall U.S. Medicaid and
Health Centers and the Massachusetts League of
uninsured population. Health centers have been
Neighborhood Health Centers were also founded
shown by the Institute of Medicine (IOM) and the
to pool each state’s respective technical resources,
GAO to reduce racial and ethnic disparities in
train board and staff members, influence the
infant mortality, prenatal care, rates of tuberculo-
development of DHEW regulations, and negotiate
sis, and death rates. Ninety-nine percent of health
with the state government about the level of
center patients surveyed reported that they were
Medicaid reimbursement for health centers. Both
satisfied with the care they received at CHCs.
of these groups received DHEW funding. In 1973,
CHCs also serve as models for diagnosing and
after the transfer of all health center programs to
managing chronic conditions such as diabetes,
DHEW, the state groups gave up their individual
asthma, depression, cardiovascular disease, cancer,
grants and became subcontractors of the national
and HIV. The Bureau of Primary Care runs the
association in an attempt to encourage the cre-
Health Disparities Collaboratives (HDC), which
ation of additional regional associations to form a
led to improved health outcomes and lowered
network of technical assistance groups.
costs of treating patients with chronic illness. More
In 2007, the NACHC represented a network of
than two thirds of CHCs participate in these
more than 1,000 FQHCs, serving 16 million peo-
HDCs, which are a model of care that supports
ple at 5,000 sites in all 50 states, Puerto Rico, the
patients in their goal of self-management by a care
District of Columbia, the U.S. Virgin Islands, and
management team. This team may include a health
Guam. The NACHC serves as the major source for
educator, nurse care manager, social worker, health-
information, data, research, and advocacy on key
care provider, and specialists such as ophthalmolo-
issues affecting community-based health centers
gists and podiatrists. More than 75,000 CHC
and the delivery of healthcare for the medically
patients with chronic diseases have been enrolled
underserved and uninsured in America. It provides
in these HDC registries for cancer, diabetes,
education, training, and leadership development to
asthma, and cardiovascular disease. A study in
health center staff and boards to promote excel-
South Carolina showed that diabetic CHC patients
lence and cost-effectiveness, and it builds partner-
in the Diabetes Collaborative had annual health
ships to stimulate public- and private-sector
costs of $343 per patient, while diabetic patients
investment in the delivery of quality healthcare to
seeing other, non-CHC providers had annual costs
medically underserved communities. The NACHC
of $1,600 or $1,900 with specialists. The CHC
works closely with state and regional organiza-
patients in the Diabetes Collaborative registry had
tions, including primary-care associations and
dropped their hemoglobin A1c or average blood
health center networks.
sugar from 11 to 8.
Health centers provide cost-effective care, with
the average annual expenditure about $250 less
Quality and Costs of Care per patient than at an office-based medical pro-
CHCs help improve access to primary and preven- vider. Health centers also reduce Medicaid expen-
tive care to vulnerable populations who otherwise ditures due to reduced specialty care referrals and
would not have access to services such as immuni- fewer hospital admissions. A study conducted in
zations, health education, and screening tests. 1980 found that Medicaid patients who used
Ninety-nine percent of uninsured health center community health centers had a 30% to 65%
users have a usual source of care compared with lower hospitalization rate and used 12% to 48%
Community Mental Health Centers (CMHCs) 205
less total Medicaid funds than a similar group of Politzer, Robert M., Ashley H. Schempf, Barbara
Medicaid patients who did not use CHCs. A more Starfield, et al. “The Future Role of Health Centers in
recent study showed that communities served by Improving National Health,” Journal of Public
health centers had 5.8 fewer preventable hospital- Health Policy 24(3–4): 296–306, 2003.
izations per 100 people over 3 years than other Shi, Leiyu, Gregory D. Stevens, John T. Wulu, et al.
medically underserved communities not served by “America’s Health Centers: Reducing Racial and
a health center. Health centers serve about 10% Ethnic Disparities in Perinatal Care and Birth
of all Medicaid enrollees nationally, but in actual Outcomes,” Health Services Research 39(6 Pt 1):
1881–1902, December 2004.
Medicaid dollars, this amounts to less than 1% of
Taylor, Jessamy. The Fundamentals of Community
all Medicaid payments to all providers. A 2004
Health Centers. Washington, DC: National Health
study showed that FQHCs improve access to pri-
Policy Forum, 2004.
mary care for the uninsured and underinsured,
and reduce emergency room visits and hospital
stays. Web Sites
Bureau of Primary Health Care (BPHC):
Future Implications http://bphc.hrsa.gov
CHCs provide essential healthcare services to vul- (NACHC): http://www.nachc.com
nerable populations and continue to improve National Health Policy Forum (NHPF):
health outcomes for the underserved. They have a http://www.nhpf.org
strong presence in their neighborhoods, helping
bolster local business and stimulate economic
growth. As the number of uninsured Americans
continues to grow and health reform becomes a Community Mental
topic of national policy, CHCs will continue to
increase access for patients, improve quality of
Health Centers (CMHCs)
services, and maintain affordable care for low-
income populations. Community mental health centers (CMHCs) offer a
full array of community-based mental health ser-
Sarah-Anne Henning Schumann vices addressing problems such as depression, anxi-
ety, and schizophrenia. They also provide support
See also Access to Healthcare; Community Mental Health services such as stress management, support groups,
Centers (CMHCs); Federally Qualified Health Centers and job training and placement. These centers
(FQHCs); Health Disparities; Medicaid; Primary Care; incorporate a public health approach to prevention
Uninsured Individuals; Vulnerable Populations and the treatment of mental health problems. By
doing so, they aim to reduce healthcare costs by
lowering expensive inpatient hospital stays without
Further Readings reducing the availability and quality of services. The
centers provide inpatient and outpatient services,
Hurley, Robert E., Lurie E. Felland, and Johanna Lauer.
Community Health Centers Tackle Rising Demands
including counseling therapy, medication manage-
and Expectations. Issue Brief No. 116. Washington, ment, daycare services, hospital referral, and case
DC: Center for Studying Health System Change, management of drug and alcohol problems.
2007. Physicians, psychologists, social workers, psychiat-
Iglehart, John K. “Spreading the Safety Net: Obstacles ric nurses, and other mental health professionals
for the Expansion of Community Health Centers,” usually work at CMHCs. And administration staff
New England Journal of Medicine 358(13): 1321–23. provide the organization and leadership needed to
March 27, 2008. effectively coordinate the services. Together, they
Lefkowitz, Bonnie. Community Health Centers: A provide community-based services and resources
Movement and the People Who Made It Happen. that improve the general physical and social func-
New Brunswick, NJ: Rutgers University Press, 2007. tioning of individuals, families, and communities.
206 Community Mental Health Centers (CMHCs)
History health delivery system. Results from the study indi-

cated that the nation’s mental health system required
CMHCs have been in existence in the United
a reexamination of health policy and systems. It
States since the early 1960s. President John F.
was found that fragmented mental health services
Kennedy signed the Community Mental Health
caused problems for both patients and providers
Services Act in 1963. With the passage of PL
because there was a lack of continuity of care. The
88–164 (also known as the Mental Retardation
study identified six national goals to transform the
Facilities and Community Mental Health Centers
nation’s mental health system: (1) increased educa-
Construction Act of 1963), federal health policy
tion about the importance of mental health; (2) the
shifted from providing mental healthcare at large
development of consumer- and family-driven
state-run hospitals to community health centers
approaches to seeking services; (3) the elimination
across the nation. The National Institutes of
of disparities to accessing mental health services; (4)
Health (NIH) supports and conducts research on
early mental health screening, assessment, and
mental illness through its Institute of Mental
referral to services; (5) ongoing and innovative
Health (NIMH). At the time of the law’s passage,
research; and (6) the development of technology to
NIMH was assigned the responsibility of offering
increase access to services, resources, and informa-
states the opportunity to develop CMHCs instead
tion. As a result of the study, community health
of state psychiatric hospitals for persons with
centers are incorporating these national goals into
mental illness.
their models of care.
Most CMHCs continue to be financed by fed-
The two overarching goals of Healthy People
eral, state, and local government funding, while
2010 are to increase the quality and years of
some are funded through private organizations.
healthy life and eliminate health disparities. Mental
Currently, the Center for Mental Health Services,
health is 1 of the 28 focus areas and 1 of 10 lead-
the Center for Substance Abuse Prevention, and
ing health indicators. As a result, shifts in focus
the Center for Substance Abuse Treatment of the
have occurred regarding CMHCs and services,
including the increased attention to health dispari-
Administration (SAMHSA) administer the Mental
ties and minority populations. As a result of the
Health Services Block Grant Program and the
President’s New Freedom Commission on Mental
Substance Abuse Prevention and Treatment Block
Health, CMHCs have also been focusing more
Grant Program for CMHCs. These block grant
efforts on advocacy, outreach, and community
programs fund CMHCs to create programs that
mental health education. These changes have led
prevent mental health and substance abuse prob-
to a concern among some mental health profes-
lems as well as expand existing services for treating
sionals regarding the allocation of services pro-
mental health problems. Payments from clients,
vided for persons with severe and persistent mental
private insurance, Medicare, and Medicaid, and
illness. Since the original purpose of the Community
fund-raising efforts contribute to the financing and
Mental Health Services Act of 1963 was to address
maintenance of the centers.
the needs of persons with mental illness, a shift to
the needs of the larger community may leave the
Recent Trends
most severely mentally ill persons without needed
The First Report of the Surgeon General on Mental mental health services.
Health was published in 1999 through collabora-
tion with SAMHSA and NIMH. This report
addressed the effectiveness of mental health services Future Implications
and the range of services existing for mental ill- Community mental health centers often face the
nesses in the nation. In 2002, President George W. uncertainty of receiving ongoing financial support
Bush formed the President’s New Freedom based on current levels of federal and state fund-
Commission on Mental Health and charged a panel ing. Hence, an important need is to achieve and
of experts with conducting the first comprehensive maintain organizational sustainability. Chances of
study of the nation’s public and private mental success are increased when CMHCs collaborate
Comparing Health Systems 207
with surrounding institutions such as local com- and categorization inherited from others and
munity hospitals and universities and develop inhabited by virtue of the language we use.
partnerships with their communities. Integration Much of the rationale of comparative analysis in
of CMHCs with community-based systems and public policy rests on the claims it makes about
networks allows increased commitment and fol- learning. Ordinarily, these are of two kinds, one cast
low-up with clients and families. It also facilitates in terms of evaluation and the other as explanation.
the development of improved methods to measure Cross-national evaluation assumes that researchers
and evaluate factors related to access, cost, qual- might learn from others: If they look abroad, they
ity, and the provision of mental health services. might examine alternative ways of doing things,
alternative solutions to common problems, and new
Michelle Choi Wu ideas that might work for them. Single-pipe financ-
See also Access to Healthcare; Community Health
ing, for example, or the flow of funds from a single
Centers (CHCs); Diagnostic and Statistical Manual of source, seems to limit the growth of the cost of
Mental Disorders (DSM); Disability; Disease; Mental healthcare (simply because those standing at the
Health; Mental Health Epidemiology; Substance pipe can turn the tap on or off).
Abuse and Mental Health Services Administration Meanwhile, in seeking explanations of why
(SAMHSA) things happen as they do, comparing two or more
cases makes it possible to isolate dependent and
independent variables and then to specify relation-
Further Readings ships between them. This makes for greater (and
Ahr, Paul R. Made in Missouri: The Community Mental sometimes lesser) confidence in the understanding
Health Movement and Community Mental Health of causes and effects, inputs, outputs, and out-
Centers, 1963–2003. St. Louis, MO: Causeway, 2003. comes. Historians of health policy, for example,
Druss, Benjamin G., Steven C. Marcus, Jeannie note the role of organized labor in the introduction
Campbell, et al. “Medical Services for Clients in and expansion of public coverage for the personal
Community Mental Health Centers: Results From a costs of healthcare: In some European countries,
National Survey,” Psychiatric Services 59(8): 917–20, national systems were introduced by conservative
August 2008. regimes to meet (or at least blunt) workers’
Rosenberg, Jessica, and Samuel Rosenberg, eds. demands; in others, they were introduced by work-
Community Mental Health: Challenges for the 21st ers’ parties once in power.
Century. New York: Routledge, 2006. In both instances, evaluation and explanation,
comparison constitutes a more or less elaborate
appeal to scientific method to establish what works,
Web Sites
and why. It is encouraged by demands for evidence-
National Association of State Mental Health Program based policy and plays well to an assumption that
Directors (NASMHPD): http://www.nasmhpd.org good policy should be based on good science.
National Institute of Mental Health (NIMH): Yet there is a third function of comparison, one
http://www.nimh.nih.gov that may in fact be prior to the other two. Because
Substance Abuse and Mental Health Services it seems more ordinary, more ubiquitous, it often
Administration (SAMHSA): http://www.samhsa.gov passes unnoticed. This is comparison as a form of
exploration, of self as much as others. Researchers
figure out who they are and what they do by refer-
Comparing Health Systems ence to others, by association with them, and in
distinction from them. As the British medical soci-
Comparison is elemental and learning inevitable ologist Philip Strong described in The Ceremonial
in life as much as in health services research. We Order of the Clinic, it was only when he watched
know what something is only by reference to what clinical encounters in the United States that he
it is not, while the very process of referring and understood how those in the United Kingdom
distinguishing depends on patterns of classification really worked.
208 Comparing Health Systems
The origins of the cross-national, comparative OECD countries appear to fall into three distinct
investigation of health systems lie at least as far types: (1) the national health services of northern
back as the University of Chicago’s medical soci- and southern Europe, largely tax-financed and
ologist Odin W. Anderson’s work of the early with a salaried profession working in facilities
1960s. But they came into vogue in the 1980s that are publicly owned; (2) the compulsory
and 1990s for a number of contextual reasons. social insurance systems of continental Europe,
Some of these have to do with the increased avail- with facilities in mixed public and private owner-
ability of low-cost air travel and information ship and in which physicians’ income is in some
technology. But it has also become clear that sys- way proportionate to the amount of work they
tems of all kinds had to find some way of manag- do; and (3) systems based to a much greater
ing increasing demand in the context of fixed or extent on private insurance, such as the United
at least finite resources. At the same time, rela- States, in which hospital ownership is mixed (and
tions between countries were becoming more a higher proportion than elsewhere may be for
competitive, meaning that getting it right in profit), physicians’ income is typically from fees,
health policy—ensuring universal access to high- and there is no assumption that population cov-
quality healthcare without breaking the bank— erage should be universal. Much comparative
was to get ahead both in domestic politics and in policy research has been essentially trichotomous,
the international economy. Global trends were based on sampling representative cases of each of
creating unprecedented opportunities for com- these models.
parison and learning, as well as a pressing need WHO’s World Health Report 2000 sought to
to take them. shift the terms of cross-national policy discussion
by ranking the different national health systems of
the world according to their performance on
Survey, Case Study, and Comparison
selected indicators. It was an exercise in bench-
It was the Organization for Economic Co-operation marking, which refers broadly to the comparative
and Development (OECD) that set the terms of assessment of organizational performance, under-
international comparative debate in the late 1980s taken to inform its improvement (benchmarking
as those of efficiency and cost containment. It emerged in fast-developing areas of industry and
provided its essential currency, too, in a continu- commerce, where no objective standards of evalu-
ously updated and elaborated comparative data ation exist, or where those standards change
set, which now includes aspects of system perfor- quickly; it works not by the imposition of stan-
mance. In turn, statistical data are complemented dards but by the construction and subsequent dis-
by increasingly systematic descriptive accounts of cussion and interpretation of norms). The WHO
health systems, such as those provided by World report was met with substantial technical criticism,
Health Organization’s (WHO’s) reports on health principally for the way it used composite indica-
systems in transition. Processes of professionaliza- tors to measure performance and for its sensitivity
tion (of health services management, for example) to different definitions and measurements of effi-
and regionalization (as in the expansion of the ciency. More radical criticism was made of its
European Union) occasion conferences and meet- purpose and implications. Nevertheless, it made
ings at which these data and what they mean are for more sophisticated discussion of the principles
discussed. It is now effectively impossible for and methodology of cross-national comparison
health policymakers in one country to think and than had existed before.
act without some understanding of what their The assumption behind the data collection and
counterparts in other countries are thinking and dissemination activity of international agencies
doing. such as the OECD and the WHO seems to be one
More academic research in comparative public of essential similarity. Standardized reporting
policy has identified different types of health sys- mechanisms seem to construct a common frame of
tems and then sought to account both for those reference within which transnational assessments
differences and for the effect they have on the and initiatives can be exchanged. Case-based com-
way systems develop. The health systems of parisons of policy and politics, in contrast, tend to
Comparing Health Systems 209
emphasize the local specificity of health service Meanwhile, of course, public officials talk to
arrangements, including their determinants, func- each other, at conferences and other meetings.
tioning and effects, and a consequent need for cau- Significantly, too, the conference is not just a
tion in assessing (let alone applying) comparative means of exchanging information but also of mak-
“lessons.” ing contacts and forming relationships, of net-
For comparison and learning from it are more working. These are sometimes consolidated by
difficult than they seem in several ways. First, fact-finding trips, by going and seeing what others
cross-national comparative research is a laborious do. Government officials and their civil servants,
and protracted activity, demanding of the research- as well as political leaders and opinion formers,
ers that they mesh more than one local wisdom often make exploratory visits to other countries
with formal and generic scientific understanding. that interest them. For example, Lloyd-George
Second, the size, intricacy, and complexity of (then the British Chancellor) famously undertook
health systems, as well as the scope and scale of a formative visit to Germany in 1908, during
change to which they are subject, mean that in which his initial interest in a contributory pension
practice, policy lessons have been as frustratingly scheme developed into the broader conception of
difficult to draw as they are to apply. Third, and social insurance that underpinned the landmark
perhaps even more fundamentally, this conception Liberal Reforms. In 2002 and 2003, members of
of comparative research is predicated on a rational- the United Kingdom’s Department of Health vis-
ist model of the policy process. It casts comparative ited California’s Kaiser Permanente healthcare
analysis as a technocratic activity and its purpose, organization, interested in understanding the rela-
in the American political scientist Aaron Wildavsky’s tionship between funding mechanisms and the
phrase, as speaking truth unto power. It separates quality and productivity in service delivery.
knowing from doing: Where it is the business of the The motivation may come from the host as much
comparativist to go abroad in the world, to garner as the guest, in that international experts frequently
new knowledge and bring it home, it is that of the act as consultants to domestic programs and proj-
policymaker to take account of it. It is for research ects. In 1991, in New Zealand, reform proposals
to know and for government to act. were developed by a Health Services Task Force,
which appointed different groups of international
consultants to consider specific issues. In Sweden in
Comparison in Practice
1992–1993, the findings of a controversial parlia-
Meanwhile, of course, policymakers themselves mentary commission on healthcare, HSU 2000,
are out there in an internationalized policy world, were reviewed by an international group of health
constructing and devising truths and lessons of policy researchers and administrators.
their own. But how do they do so? What kinds of Sometimes, the meeting or visit may develop
comparison do policymakers make? into a more sustained or substantial exchange,
What policymakers know about what is going including bilateral agreements to foster partner-
on abroad they know from published material in ships between offices and organizations.
journals and reports; from attending conferences; What distinguishes these various kinds of learn-
through targeted visits to other countries, regions ing? What connects them to each other? What
or specific projects, and through various forms of policymakers know from published research is
more sustained exchange. Published research highly mediated by the process of data collection,
forms the apex of what has come to be termed the analysis, and dissemination. The conference setting
hierarchy of evidence, and policymakers fre- makes it possible for the reader or listener to inter-
quently commission reviews of such work. Its rogate the researcher and for readers and listeners
usefulness, however, is subject to familiar qualifi- to ask questions of each other. In turn, the visit
cations. The applicability of generic research find- makes it possible for information and understand-
ings to different, specific local contexts is ing to be acquired directly by the visitor, for him or
questioned, while for many issues and problems her to engage more immediately in “situated learn-
little evidence about the effectiveness of particular ing.” What this means is that a nominally scientific
interventions exists. system of knowledge (the hierarchy of evidence) is
210 Comparing Health Systems
embedded in a social one. When asked about what much of it has focused on the OECD and within that
they learn from abroad, policymakers respond in group on selected countries in Europe and North
terms of “meetings,” “study visits,” “links,” “con- America. There are similar reasons to think that
tacts,” and “networks.” What goes on in other countries might have most to learn from those like
countries is sometimes genuinely remote, read or them because they share institutional, financial, or
heard about if known at all, but it is also some- administrative arrangements or a common language
times personal, informal, and even intimate. Here, and political culture and on both counts are likely to
a disjuncture begins to emerge between the models face similar problems. Note that the United Kingdom’s
that actors consciously espouse from those they National Health Service (NHS) leaders sought to
effectively use (their theory-in-use). The difference learn not from the United States in general but from
is between the rational, clinical, or scientific episte- California’s Kaiser Permanente in particular.
mology in which public health policymakers and The policy scientist, for his or her part, would
practitioners are trained and the social, manage- note that change is always more likely to be incre-
rial, and political ways of knowing that are the mental than radical and that what policymakers
currency of their daily practice. know and think is shaped by the immediate envi-
ronment—as is the way they interpret news from
abroad and as is the news itself. The bulk of health
Understanding Comparison
services research is generated in the United States
in Research and Practice
and the United Kingdom and/or is written in
There are three ways of thinking about doing English, and is necessarily inflected in particular
comparison in health services research, and they ways. To take up the American political scientist
have corollary assumptions about the relation- Herbert Simon’s famous phrase, the “rationality”
ship between research and practice, about the of cross-national research is as “bounded” as that
ways in which comparison might be a source of of policy making.
learning. And the third way of thinking that matters here
The first is rationalist. The researcher’s commit- is to take seriously the idea that both research and
ment is science, assuming that the sensible policy- policy paradigms are social constructs. Cross-
maker will take up his or her findings and use national analysis in health policy shares many of
them to make more effective decisions. Comparative the characteristics of what the American historian
evidence of the extent of health inequality has of the history and philosophy of science Thomas
clearly informed recent public health initiatives in Kuhn’s would call “normal science”: The field is
Scotland, for example. still small enough for many of its key figures to
The policy scientist, however, will argue that have known and worked with each other and to
what is rational for the policymaker is what fits his share assumptions about what warrants investiga-
or her purposes and interests. This is why evidence tion and how.
from abroad seems so often to be used instrumen- One of those standard assumptions is that
tally, as ammunition in domestic policy warfare. In cases or units of comparative analysis are inde-
the United States, for example, both Canada and pendent of each other (while the suspicion that
the United Kingdom (very different healthcare sys- they might not be is what is known as Galton’s
tems) can be praised for their universalism, attacked problem, named after Sir Francis Galton). Yet
for their “socialism,” or both. The strength of researchers know that professionals and patients
commitment to existing arrangements is also move between systems, as do technologies, regu-
partly why research that reports uncomfortable lations, and sometimes money—and as, too, does
news is so vigorously attacked on methodological health services research. Policymakers cannot
grounds. help but have some comparative understanding
The second way of thinking about doing and of health systems, not least as a result of the work
learning from comparison is institutionalist. There they do. But they know much less about how that
are good reasons to think that comparative research matters, about how new knowledge is inter-
is most meaningful when sampling cases that are preted, adapted, and translated in specific local
similar in most important respects: This is why so contexts. Major statements and reports from the
Compensation Differentials 211
OECD, the WHO, and others, for example, seem Journal of Health Services Research and Policy 8(3):
to serve not as evidence but as opportunities for 180–82, July 2003.
interpretation. To the extent that health systems Ham, Chris, “Lost in Translation? Health Systems in the
are complex systems, researchers may need to U.S. and the U.K.,” Social Policy and Administration
begin to think of relationships between them less 39(2): 192–209, April 2005.
in terms of comparison and learning than of Jacobs, Kerry, and Pauline Barnett, “Policy Transfer and
coevolution. Policy Learning: A Study of the 1991 New Zealand
What all this might mean for the comparative Health Services Taskforce,” Governance 13(2):
185–214, April 2000.
mission of health services research is that research
Marmor, Theodore R., Richard Freeman, and Kieke
in itself will make little useful difference to policy.
Okma. “Comparative Perspectives and Policy
Its significance lies in disturbing the assumptions
Learning in the World of Health Care,” Journal of
and routines of prevailing patterns of policy
Comparative Policy Analysis 7(4): 331–48, December
making; what difference it makes depends on 2005.
the arguments, interpretations—and sometimes Strong, Philip. The Ceremonial Order of the Clinic:
decisions—that result. For what policymakers Parents, Doctors and Medical Bureaucrats.
know about what goes on abroad is often frag- Burlington, VT: Ashgate, 2001.
mented and difficult to process: The scientific World Health Organization. World Health Report 2000.
and technical knowledge they value is embedded Health Systems: Improving Performance. Geneva,
in specific social and political contexts, while the Switzerland: World Health Organization, 2000.
lessons they look for seem both essential and
elusive.
As a result, policymakers learn with others as Web Sites
much as from others, and they do so in debating
what different sets of ideas, evidence, and experi- Commonwealth Fund: http://www.commonwealthfund.org
ence might mean. They operate much closer to the Organization for Economic Co-Operation and
third, exploratory function of comparison set out Development (OECD): http://www.oecd.org
above than sometimes imagined. By the same Pan American Health Organization (PAHO):
http://www.paho.org
token, of course, conditions for such a dialogue are
World Health Organization (WHO): http://www.who.int
difficult to establish. It may well be these difficul-
ties of constructing opportunities for and making
commitments to open, sustained communication
across countries that set limits on the extent to
which learning by comparison occurs. Compensation Differentials
Richard Freeman Compensation differentials play an important role
See also Anderson, Odin W.; Health Services Research in in understanding labor economics and trends in
Canada; Health Services Research in the United employee benefits. In equilibrium labor markets,
Kingdom; International Health Systems; Pan American where the supply and demand of labor intersect,
Health Organization (PAHO); Public Policy; United people are paid what they are worth; more techni-
Kingdom’s National Health Service (NHS); World cally, individuals are compensated the value of
Health Organization (WHO) their marginal product. Compensation, however,
can take many forms, including money wages,
vacation time, pleasant working conditions, a
Further Readings pension, and/or employer-sponsored health insur-
Cylus, Jonathan, and Gerard F. Anderson. Multinational ance. Thus, if compensation in the form of pen-
Comparisons of Health Systems Data, 2006. New sion plan generosity is reduced, then some other
York: Commonwealth Fund, May 2007. element of the compensation bundle will be
Freeman, Richard, and Theodore R. Marmor. “Making increased. There will be a compensating adjust-
Sense of Health Politics Through Cross-National ment in the form of higher wages or perhaps
Comparison: Odin Anderson’s Seminal Essay,” increased job security.
212 Compensation Differentials
Compensation differentials also help illustrate theory also implies that if an employer were to
the complex nature of employer-sponsored health reduce the coverage in its health insurance plan,
coverage. A growing body of empirical evidence perhaps by raising the copays for physician visits
supports the notion that workers pay a price for and prescription drugs, the employer would have
health coverage through their jobs, which may to improve coverage in some other dimension.
be reflected in lower wages or weaker pension Employers would have to make workers whole,
packages. by raising wages, increasing pension contribu-
tions, or expanding other forms of compensa-
tion. If this is not done by the employer, many of
Theory
the employees would seek employment else-
In health services, the concept of compensation dif- where. With this theory, the price of employer-
ferentials is most commonly seen in discussions of sponsored health insurance to the worker is not
employer-sponsored health insurance. The under- just the out-of-pocket premium; it is the out-of-
lying concept is that if health insurance coverage is pocket premium plus the wages and other bene-
added to an employee’s compensation bundle, then fits given up.
some other benefit will be reduced, such as money Compensation differentials are one of the stron-
wages or pension. If this adjustment did not take gest predictions to arise from labor economics. A
place, the firm would find that it was paying more 2005 survey of health economists indicated that
than the market clearing “price” for labor. People 91% of them agreed with the statement that
would be clamoring to work for the firm, and they “workers pay for employer-sponsored health
would be willing to do so at a lower level of com- insurance in the form of lower wages or reduced
pensation. This argument is perfectly symmetrical. benefits.”
In an equilibrium labor market, if a firm decided to
drop health insurance from its compensation bun-
Empirical Evidence
dle, it would have to increase some of the remain-
ing elements in the bundle. Otherwise, current Until recently, the empirical evidence of compensa-
employees would resign to take jobs that offered tion differentials in health insurance has been
better overall compensation. sparse. The difficulty has been controlling for
Of course, the theory is based on equilibrium. If worker productivity. For example, if a person has
the demand for labor is rising, one would expect relatively few skills, education, or experience, he
an employer to add something to the compensa- or she will not be very productive in the labor
tion bundle, be it a more generous health insurance market. The worker may have a job with low
package or more wages without removing other wages and a modest health insurance plan. Someone
elements. Similarly, if the demand for labor is fall- with more skills, education, or experience may
ing, the firm can reduce wages or cut health insur- have both higher wages and a more generous
ance benefits without adjusting the compensation health insurance plan. If one ignores productivity
bundle because workers are less likely to be able to and simply compares the wages and health insur-
find other employment. ance of the two individuals, one would conclude
The upshot of this theory is that workers pay that there is no compensation differential between
for employer-sponsored health insurance in the wages and health insurance. Indeed, one may con-
form of lower wages and or reductions in other clude that higher wages and generous health insur-
forms of compensation. This model has a num- ance are positively associated with one another.
ber of implications. It implies, for example, that Employers want to hire job candidates who
if a state were to require firms to provide health are intelligent, are creative, understand the busi-
insurance for their workers, the workers would ness, are able to work well with coworkers and
pay for this coverage in the form of lower wages the public, are able to take and carry out orders,
or fewer other benefits. The theory suggests that are able to meet deadlines, and can provide lead-
there would be few unemployment effects unless ership for the tasks at hand. These are the char-
wages could not be adjusted further downward, acteristics of productive workers. Finding such
perhaps because of minimum wage laws. The employees, however, is difficult. Suppose that the
Compensation Differentials 213
only information employers had about appli- (DDD) analysis. They compared the change in wages
cants were their age, years of schooling, and before and after the enactment date of the laws
perhaps the number of years of experience in the Difference 1), in states that did and did not enact the
industry. When studying compensation differen- law (Difference 2), for people who would and would
tials, researchers face similar challenges. Because not be affected by the law (Difference 3). The idea is
only very crude measures of productivity are that the wage changes in unaffected states and for
available, the resulting comparisons are biased similar but unaffected individuals would control for
toward positive relationships between wages and other factors at work in the states and local labor
benefits. The empirical issues are compounded markets.
because a researcher would also want to control The states of New York, New Jersey, and Illinois
for the relevant household marginal tax rate enacted the maternity care mandate between July
because under current U.S. law, employer-spon- 1, 1976, and January 1, 1977. The states of
sored health insurance is not considered taxable Connecticut, Massachusetts, Ohio, Indiana, and
income, while money wages are taxed. This North Carolina were used as controls because they
design provides incentives to shift compensation did not enact such laws. The average wage for
from taxed wages to untaxed health insurance relevant workers in these states ranged from $5.59
benefits. to $6.61 in constant 1978 dollars. Affected work-
A study from 2004 provides the most straight- ers were defined as married women of childbearing
forward analysis of compensation differentials, ages, that is, between the ages of 20 and 40. The
which examined data from 1988 through 1990 unaffected group was defined as all individuals
on a panel of workers, some of whom changed between 40 and 60 and all single men. The indi-
jobs. Researchers could have taken the standard viduals excluded from the study were single
approach to studying compensation differentials women and married men aged 20 to 40. Both of
by estimating a regression equation in which these groups could have been affected by the laws,
wages were a function of having employer- but their inclusion would only complicate the
sponsored health insurance, observable job, and comparison.
worker characteristics. The problem, however, is Married women aged 20 to 40 in states that
the inability to adequately account for the unob- enacted the law had wage decreases of 3.4%. In
served differences in productivity across workers. states that did not enact the law, married women
Instead, this study estimated worker-specific aged 20 to 40 had wage increases of 2.8%. The
changes in wages in an equation as a function of difference in these two differences was −6.2%. For
the change in the presence of employer-sponsored the unaffected group, single men aged 20 to 40 and
health insurance and changes in job and observ- all people aged 40 to 60, in the states enacting the
able worker characteristics. If one can assume law, wages decreased by 1.1%, suggesting that
that worker productivity does not change much there were other wage trends going on in the exper-
from year to year, then this change equation effec- imental states besides the enactment of maternity
tively holds productivity constant. Each person benefits laws. For the unaffected group in states
serves as his or her own control. The study found that did not enact the laws, real wages declined
that workers who lost health insurance over the by 0.3%. Thus, the difference-in-differences for
period had wage increases of 10% to 11%. This the unaffected groups was a decline of 0.8%. The
finding presents good evidence of compensating estimated effect of the laws was the difference in
wage differentials. these two overall differences or 5.4%. This study
In an earlier study, researchers examined the uncovered dramatic evidence of compensating
effects of the imposition of state insurance mandates wage differentials that are borne by the affected
for maternity benefits. In 1979, the federal govern- group.
ment required that most group health insurance plans Another study from 1999 used the relationship
cover maternity care like any other covered medical between age and wage to identify compensating
condition. Before that time, only 23 states had done wage differentials. The investigator argued that
so. In this study, investigators undertook what older workers were more likely to have health
is called a differences-in-differences-in-differences insurance claims and so any compensating wage
214 Competition in Healthcare
differential for employer-sponsored health insur- Web Sites

ance should be more pronounced for older work- America’s Health Insurance Plans (AHIP):
ers. Moreover, these claims should be higher in http://www.hiaa.org
communities with higher healthcare costs. If com- American Society of Health Economics (ASHE):
pensating differentials exist, then older workers in http://healtheconomics.us
communities with higher health insurance premi- Employee Benefit Research Institute (EBRI):
ums should receive lower wages. This study found http://www.ebri.org
that wages were $113 lower for each year of age in
the high-premium markets relative to those facing
lower premiums.
Last, another study used the 1989–1999
National Longitudinal Survey of Youth to exam- Competition in Healthcare
ine the effects of obesity in the labor market. The
researchers found that obese individuals with Competition in healthcare refers to the interaction
employer-sponsored health insurance received between healthcare providers and third-party pay-
lower wages, while those without employer-spon- ers. This interaction is designed to obtain the busi-
sored coverage, those with nongroup coverage, ness of consumers in the form of the purchase of
and those with no health insurance coverage did healthcare services or insurance. This interaction
not receive lower wages. The investigators’ esti- also represents the marketplace for the purchase
mated wage reduction was roughly in line with the and distribution of healthcare services.
additional medical costs associated with obesity. From a normative perspective, an emphasis on
competition reflects a preference for private-sector
Michael A. Morrisey control and delivery of healthcare services. It also
reflects a preference for minimum government
See also Cost of Healthcare; Employee Health Benefits;
Health Economics; Health Insurance; Health Insurance
intervention and regulation of healthcare markets.
Coverage; Public Policy; Tax Subsidy of Employer- Decision making in a competitive environment is
Sponsored Health Insurance also considered to reflect rational choice based on
the best available information.
In its ideal form, when healthcare markets oper-
Further Readings ate properly, competition will determine the appro-
priate prices for medical services, the appropriate
Jensen, Gail A., and Michael A. Morrisey. 2001. organizational forms for healthcare financing and
“Endogenous Fringe Benefits, Compensating Wage delivery, and the appropriate range and availability
Differentials and Older Workers,” International for cost/quality/service trade-offs. However, there
Journal of Health Care Finance and Economics are also major tensions built into how competition
1(3–4): 203–226, September–December 2001.
operates in the healthcare system. The major ten-
Levy, Helen, and Roger Feldman. “Does the Incidence of
sion is over whether to support competitive mecha-
Group Health Insurance Fall on Individual Workers?”
nisms within a market paradigm on the one hand
International Journal of Health Care Finance and
and whether to preserve access and fairness through
Economics 1(3–4): 227–48, September–December 2001.
Miller, Richard D., Jr. “Estimating the Compensating
government intervention on the other hand.
Differential for Employer-Provided Health
Competition is thought of as determining who
Insurance,” International Journal of Health Care gets what, when, and how, and this process, in
Finance and Economics 4(1): 27–41, March 2004. turn, influences the pace and character of policy
Morrisey, Michael A. Health Insurance. Chicago: Health change. However, the American healthcare system
Administration Press, 2007. is not structured to maximize consumer choice or
Simon, Kosalli I. “Displaced Workers and Employer- sovereignty. Providers and third-party payers are
Provided Health insurance: Evidence of a Wage/ in a much more powerful position than consumers
Fringe Benefit Tradeoff?” International Journal of due to issues related to asymmetric information,
Health Care Finance and Economics 1(3–4): 249–72, economic dominance, and structural arrangements.
September–December 2001. The federal and state levels of government on the
Competition in Healthcare 215
one hand, and employers on the other, have taken of mergers and acquisitions among hospitals
on the role of an umpire whose responsibility it is increased the concentration of the hospital sector,
to resolve tensions and provide mediated or nego- and a few large national hospital chains gained a
tiated solutions. significant market share during this time period.
Competition in healthcare markets is one of the The hospital industry argued that these mergers
primary tools used in the United States as a strategy offered efficiency gains that more than offset any
to contain costs, promote efficiency, and encourage potential anticompetitive effects they may have.
innovation. Indeed, competition has been the pre- Despite concerns among federal antitrust regula-
ferred strategy for cost containment in the nation, tors, industry analysts, and the public, some
much more so than other cost containment strate- empirical evidence did emerge that these efficiency
gies that are prevalent in many European countries, gains were real. Studies of hospital competition in
such as the use of price setting, global budgets, and California and Washington suggested that increas-
rationing of access to healthcare services. In fact, ing competition across hospitals did in fact lower
some have argued that rigorous government costs. Evidence also shows that heath maintenance
enforcement of antitrust regulations and the result- organizations (HMOs) and preferred provider
ing protection of private innovation have allowed organizations (PPOs) nationally document signifi-
the healthcare industry in the nation to remain a cantly lower healthcare costs in regions with com-
predominantly private enterprise, as opposed to petitive hospitals.
one that is government run, as in most other Competition in the U.S. health insurance mar-
nations. Because of this, the United States provides ket has been primarily driven by the development
many examples of how competition can work in of managed care since the early to mid-1990s. By
the market for hospital care. Market-oriented 1996, 73% of those obtaining coverage through
health policy highlights the role of incentives in employment were in managed-care plans, com-
generating appropriate behavior on both the pared with 27% 8 years earlier. HMOs were the
demand and the supply sides of the medical mar- most popular plan type, accounting for 31% of the
ketplace, among both consumers and providers. market.
The laws of competition in the United States The benefit structure in managed-care plans
affect the way healthcare is financed and deliv- included far less in the way of financial incentives
ered, as well as its quality and affordability, for patients, which had been the norm in tradi-
through their effects on the interaction of provid- tional insurance plans. This reflected a managed-
ers and patients within the organizational and care philosophy that consumers should not be
structural framework of the healthcare industry. called on to limit their use of services because of
Competition law has traditionally focused on the their ability to pay. Instead, professionals—either
process of market interactions, not necessarily on the patient’s physician, with incentives other than
the individual actors in that process or on the fee-for-service, or clinical staff of the health plan—
outcomes—it does not concern itself with whether should take responsibility for limiting services that
the outcomes that result from the operation of an have a low value.
efficient market accord with a particular definition
of optimal social policy. However, given changing
Competitive Approaches on
market dynamics and expectations of consumers,
the Consumer Side of Markets
the framework of competition law is expanding to
take into account trade-offs between price, qual- As already indicated, competition in healthcare can
ity, innovation, and access, which are all features be characterized as reflecting the interests and inter-
of the healthcare system that consumers are actions among consumers, providers, and third-
demanding. party payers. Consumers want to maximize their
Despite this, there are a number of problems power and choice based on the best available infor-
with competition in the private insurance model in mation about their providers, about their treatment
the United States. The decade of the 1990s wit- options, and about the healthcare delivery system.
nessed profound changes in the competitive envi- However, consumers operate in a context of asym-
ronment of healthcare providers. A large number metric information. Physicians have much more
medical information and expertise than their respect to cost, access, and fairness. The impact of
patients, and patients rely on their provider to offer the balancing between competitive approaches
and prescribe the most effective treatment possible. and government regulation has been most pro-
Providers, in turn, as typified by the traditional found in the hospital sector in the United States.
physician–patient relationship, depend on the loy- An increasingly competitive hospital market, as
alty of their patients and adequate reimbursement well as changing payment policies in both the pri-
levels provided by third-party payers. Traditionally, vate and public sectors, has forced hospitals to
providers have been in a position where physicians reenvision their role in the healthcare environ-
propose and patients dispose. Under this model, ment, and a number of structural, procedural, and
patients dissatisfied with their providers may switch financial changes have occurred.
physicians, assuming a healthcare system in which Competition has a number of effects on hospi-
a consumer has free choice of providers. Third- tals, including the potential to improve quality and
party payers, and particularly managed-care pay- lower costs, but it can also undermine the hospi-
ers, play a critical role in this system because they tals’ ability to engage in cross-subsidization of the
establish rates of reimbursement and can often cost of care between profitable and nonprofitable
determine if a consumer is able to obtain the ser- services or between wealthy and poor consumers.
vices that he or she prefers. The managed-care revo- Medicare pays essentially the same price for a
lution has significantly altered these traditional given health service regardless of where it is deliv-
relationships, particularly in the era when most ered. As a result, hospitals compete for the busi-
Americans receive their health insurance coverage ness of Medicare beneficiaries on the nonprice,
through an employer who selects the benefit plans system-based features that they offer. On the other
that will be available to the consumer. Just what the hand, there are price-based and nonprice-based
consumer is able to choose in this context is unclear. competitive opportunities for hospitals in the pri-
This has, in turn, significantly affected the context vate patient/payer markets.
in which competition takes place. In the United States, hospitals operate in a regu-
Consumerism and managed competition share latory environment that has developed over time at
the market paradigm that social resources, includ- the federal and state levels. Laws and regulations
ing medical care, should be allocated based on have emerged to address many issues, including
individual rather than collective decisions. public financing, patient confidentiality, patient
Informed and price-conscious individual choices rights, risk management, medical malpractice suits,
represent the values and preferences of the patient peer review activities, withdrawal of life support,
better than do the choices of even the most advance healthcare directives, medical guardian-
benevolent third party. The performance of the ships, institutional review boards, hospital staff
delivery system is enhanced by consumer and privileges, contract and corporate law as applied
provider incentives that align the pursuit of indi- to the healthcare industry, AIDS-testing issues,
vidual self-interest with the social interest in pro- certificates of need, and others.
moting a high-quality, cost-effective system of Hospitals are experiencing a number of price-
care. Collective choice mechanisms such as regu- related pressures as a result of rising costs, insur-
latory agencies, professional associations, and ance industry trends, Medicare payment policy,
corporate organizations find their utility in sup- and regulatory mandates. Some of the factors that
porting, and their disutility in displacing, indi- affect hospital pricing and the recent rapid increases
vidual choices. in costs include the public’s demand for new and
better technology, the aging of the population,
shortages of hospital staff, including nurses,
Competition and Regulation
demands for new and broader forms of informa-
While there have been major pushes to enhance tion and reporting, patient safety initiatives, rising
the competitive environment in healthcare, gov- liability insurance premiums, higher pharmaceuti-
ernments at the federal and state levels have also cal costs, and increasing numbers of uninsured
maintained a watchdog role and intervened when patients to whom they are required to provide
there have been perceived market failures with care. Many of these factors represent new areas in
which hospitals can find competitive advantages if consolidation represents both a response to increas-
they perform well, but these pressures on hospitals ingly competitive hospital markets and an oppor-
are often augmented by the fact that they, unlike tunity to compete more efficiently by reducing
some of the newer competitors, are obligated to duplication and capitalizing on economies of scale
provide a certain amount of uncompensated care and administrative expertise. These systems and
and other services under federal regulations. networks range from comprehensively integrated
Traditionally, hospitals were where people went organizations with shared licensing and ownership
to receive a wide range of medical services, includ- arrangements to loosely organized partnerships
ing diagnostic, therapeutic, and rehabilitative care. with shared governing bodies but independently
They were the point of care for patients with operating facilities. The benefits of hospital con-
healthcare needs that ranged from relatively minor, solidation may include a reduction of excess
acute conditions to serious, life-threatening emer- capacity, increased ability to assume financial risk,
gencies. Patients would be admitted to the hospital expansion of the hospital’s delivery network, and
and would stay until they were well, which would service coordination.
be anywhere from a few days to weeks, up to sev- There has been some concern that hospital sys-
eral months. Under this model, hospitals were the tems have used consolidation as a tool to exert
recipients of the bulk of healthcare dollars. This increased market power to distort the competitive
diversification of services allowed them to cross- environment and demand increased prices from
subsidize relatively nonlucrative services with rev- payers. This argument stems from the observation
enues from the more lucrative services they that some hospital mergers have resulted in higher
provided. Since they were required to maintain a hospital prices without the concomitant increase in
certain number of beds, operating rooms, and efficiency, such as the integration of clinical ser-
emergency departments, often with residual capac- vices or reduction of duplication.
ity in case of unforeseen circumstances, they Hospital payment mechanisms are complex and
depended on these cross-subsidies to maintain varied, with some hospitals billing the patient
their financial bottom line. directly and others billing their insurance company.
Over the past two decades, however, a number Some insurance companies require the patient to
of trends have emerged in the hospital sector that pay a copayment at the time of service and then
have altered the competitive environment in which pay the hospital directly for all costs beyond that,
they operate. Almost without exception, these while other insurance plans require the patient to
trends have challenged the traditional role of hos- pay the full bill up front and reimburse the patient
pitals and have forced them to compete in new later for allowable expenses. Many Medicare plans
ways. Outpatient surgery centers, single-specialty require a copayment at the time of service but pay
hospitals, rehabilitation hospitals, and outpatient the hospital directly for the remainder of the
diagnostic imaging centers have all cut into the patient’s bill. The impact of Medicare payment
revenue sources that were previously available systems on the hospital sector has been substantial
only to general hospitals. General hospitals, in the and widespread since it introduced its prospective
meantime, continue to be required to maintain payment system (PPS) in 1983.
residual capacity in the less lucrative or more The nature of the hospitals with which private
expensive areas such as emergency care, general insurance companies contract can affect the insur-
surgery, and intensive care. This diversification in ance companies’ ability to compete with one
the healthcare market certainly increases competi- another. For example, marketability of insurance
tion among different types of providers, but it has plans to employers and employees depends not
also forced the hospital sector to evolve in impor- only on the price of the coverage they offer but also
tant and profound ways. on the number of hospitals where coverage is
While historically hospitals operated as inde- offered and on the quality, accessibility, and desir-
pendent organizations within local markets, more ability of those hospitals. Being a “must-have”
than two thirds of the nation’s hospitals are now hospital may confer a significant competitive advan-
part of mulithospital system or operate under a tage to such a hospital in contract negotiations with
network of affiliated hospitals. This hospital private insurance companies.
The Centers for Medicare and Medicaid Services shift from the emphasis on the independent,
(CMS), the federal administrative agency of the fee-for-service provider and has been a relatively
Medicare program, clearly has a profound effect recent occurrence. The U.S. Supreme Court first
on the competitive environment in which hospitals applied antitrust principles to healthcare providers
operate, but this is primarily an indirect effect in 1975, and hospitals and providers are now
through its price-setting authority. It does not, for required to comply with federal antitrust legisla-
example, have the ability to use competitive bid- tion. Previous jurisprudence had held that the
ding or selective contracting mechanisms to exert medical community was a “learned profession”
direct control of the providers, with which it nego- and therefore exempt from antitrust regulation.
tiates. And there is virtually no way for Medicare There are three main federal laws that govern
to encourage nonprice competition between pro- the competitive environment of the nation’s health-
viders. This is what recent pay-for-performance care industry: (1) the Sherman Act (1890), (2) the
initiatives would attempt to do by inserting quality Clayton Act (1914), and (3) the Federal Trade
and outcome measures into the payment policy, Commission Act (1914).
but such initiatives are in their infancy. The Sherman Act, also known as the Antitrust
Act, is the predominant law in the United States
that deals with issues of competition in financial
Legal Framework Affecting Competition and business markets. The Sherman Act is con-
The major way in which the federal and state gov- cerned with maintaining competition to ensure
ernments affects competition is through the imple- consumer welfare, and it generally prohibits uni-
mentation and enforcement of laws and regulations lateral and collective conduct that poses unaccept-
focusing on unfair competition, antitrust, and cer- able dangers to competition. Generally, the act
tificate of need. prohibits contracts, combinations, and monopoli-
zation or attempted monopolization in restraint of
trade. Section 1 (codified as 15 U.S.C. §1) of the
Unfair Competition act prohibits “every contract, combination . . . or
conspiracy in restraint of trade.” As such, competi
Competition law has traditionally focused on tion can be defined as “a dynamic process featur-
the process of market interactions, not necessarily ing voluntary transactions between, and independent
on the individual actors in that process or on the decisions by, mutually accountable buyers and sell-
outcomes—it does not concern itself with whether ers.” In the healthcare setting, potential anticom-
the outcomes that result from the operation of an petitive actions that are particularly scrutinized
efficient market accord with a particular definition under the Sherman Act are price fixing, market
of the best social policy. However, given changing division, and group boycotts. Section 2 of the act
market dynamics and expectations of consumers, (codified as 15 U.S.C. §2) deals with the develop-
the framework of competition law is expanding to ment of monopolies, particularly when they arise
take into account trade-offs between price, quality, or are maintained through wrongful or exclusion-
innovation, and access, which are all features of ary means. The existence of a monopoly in the
the healthcare system that consumers are demand- healthcare sector, such as the presence of only one
ing. Hence, under these laws, government is able hospital in a given geographic area, is not necessar-
to intervene to label a given practice by a provider ily a violation of the act, but tactics by that hospi-
or insurance company to be unfair and thus null tal’s administration to restrict the entry of a second
and void. hospital in the region may very well violate Section
2 of the Sherman Act.
The Clayton Act (and the Robinson-Patman Act
Antitrust
of 1936, which is a related piece of legislation) pro-
The application of antitrust laws, regulations, hibits commodity price discrimination; exclusive
and principles to healthcare services relies on the dealing arrangements that substantially lessen com-
assumption that hospitals are businesses that pro- petition; and mergers, acquisitions, or joint ven-
vide medical care as a service. This is a distinct tures that would substantially lessen competition or
create a monopoly. Section 7 of the Clayton Act However, other types of mergers may come
(codified as 15 U.S.C. §18) prohibits mergers and under greater scrutiny by the FTC or the USDOJ if
acquisitions where the effect “may be substantially they tend to create or enhance the merging hospi-
to lessen competition, or to tend to create monop- tals’ market power in a given region. Under the
oly.” In scrutinizing potential, or planned, arrange- 1992 Horizontal Merger Guidelines of the com-
ments that could lead to future Sherman Act mission, whether the proposed merger could pos-
violations, the Clayton Act provides an additional sibly have anticompetitive effects depends on the
safeguard against the development of anticompeti- following: whether the merger, in light of market
tive monopoly power. In the current U.S. health- concentration and other factors that characterize
care environment, in which major national the market, would be likely to have adverse com-
healthcare systems have been consolidating their petitive effects; whether entry would be timely,
market power, both the Clayton and Sherman Acts likely, and sufficient either to deter or to counter-
have been repeatedly invoked. act the competitive effects of concern; whether
The Federal Trade Commission Act prohibits there are efficiency gains from the merger that
unfair methods of competition and deceptive acts meet the commission’s criteria for examination;
or practices, including misrepresentations or false and whether, but for the merger, either party to the
and misleading advertising. Section 5 of the act transaction would be likely to fail, causing its
(codified as 15 U.S.C. §45) prohibits “unfair meth- assets to exit the market. Under these guidelines, a
ods of competition” and “unfair or deceptive acts market is defined as a product and a geographic
or practices in or affecting commerce.” area in which it is produced or sold, such that a
There is clearly an overlap between these three hypothetical profit-maximizing firm that was the
laws, as well as in the regulatory authority to pur- only present and future producer or seller of those
sue claims under the laws. The U.S. Department of products in that area would likely impose at least
Justice (USDOJ) and the Federal Trade Commission a small but significant and nontransitory increase
(FTC) are the primary enforcers of the laws, and in price.
state attorney generals as well as private parties The institutional status (for profit vs. not for
can file lawsuits under competition laws. profit) of hospitals can sometimes become an issue
There are some exceptions under the antitrust in antitrust analysis when mergers are proposed.
laws that permit certain types of hospital mergers, Being a nonprofit hospital does not per se protect
and not all such mergers are scrutinized as poten- it from scrutiny under antitrust laws although
tially anticompetitive. In fact, the FTC’s “Health some courts have been more sympathetic to non-
Care Statement,” which outlines its antitrust profits wishing to consolidate their operations with
enforcement policy, provides a safety zone for cer- other nonprofits. Even in these cases, however, the
tain types of hospital consolidation and merger underlying antitrust issue is whether such an insti-
that protects them from challenges. This safety tution would use its newly acquired market power
zone is designed to lessen the burden for merger in ways that would be harmful to consumers.
activities when the merging hospitals are not Medical antitrust law is complicated by the fact
major competitors before the merger. It specifi- that federal and state governments are a major
cally protects mergers between two general acute regulator and purchaser of healthcare services
care hospitals where one of the hospitals has an while antitrust laws are primarily designed to regu-
average of fewer than 100 licensed beds and has late the private economy. Traditional antitrust law
an average daily inpatient census of fewer than 40 is designed to shape the behavior of private busi-
patients. In general, the commission and the nesses, but there is a melding of private and public
USDOJ will also not challenge a potential merger actors in healthcare service funding, purchasing,
if there are significant, demonstrable efficiencies to and delivery. This may lead to market-distorting
be gained by the merger. To be deemed procom- effects that invite unnecessary business transac-
petitive (or at least not anticompetitive) such effi- tions, impair organizational efficiency, and hamper
ciencies should be merger-specific; be verifiable; the negotiation of mutually advantageous arrange-
and not arise from anticompetitive reductions in ment by willing buyers and sellers. Government
output or service. programs such as Medicare and Medicaid have a
substantial impact on how hospitals can conduct repealed in 1982, when it was found that such
themselves within the marketplace as competitive regulations had little impact on the rising cost of
businesses. healthcare. In fact, critics of CON argue that they
Additionally, antitrust law rests on the premise have been used by hospitals to stifle competition
of active bargaining between buyer and seller to and that the programs may actually increase
create competition. The rise of managed care and healthcare costs as supply is simply depressed
third-party payers has all but removed the active below competitive levels. Despite these criticisms
bargaining component. Managed care has changed and the repeal of the federal mandate, 36 states and
the bargaining market in two distinct ways: main- the District of Columbia have retained their CON
streaming explicit contracting for the sale of hospi- laws.
tal services, and creating a new group of purchasing
agents (third-party payers) who negotiate prices
Future Implications
for health services. The complex and changing
healthcare market, therefore, does not always fit The competitive environment in the nation’s
cleanly into the traditional antitrust regulation healthcare industry will develop in response to cost
framework, and some commentators have argued pressures and consumer demand, as well as tech-
that these regulations may actually stifle competi- nological advances. Among the greatest pressures
tion and drive up costs as opposed to stimulate for competitive reforms are consumer-driven care,
competition and moderate costs. a demand for greater choice of providers, the
changing role of the hospital sectors, and the
increasing importance of Medicare and Medicaid
Certificate of Need
in the private health insurance industry. In addi-
Certificate of need (CON) laws are state regulation, the trend toward self-insurance will also have
tions that require institutional healthcare providers an impact on the competitive environment. Finan
to seek prior approval before adding new improve- cial incentives for patients will continue to become
ments, equipment, or facilities or replacing existing more important, and refinements to the benefit
healthcare facilities. Prior approval is granted by structures that include substantial patient cost
the respective state’s Department of Health and is sharing will get more attention. More emphasis
also required for the addition of certain medical will be given to incentives to choose more efficient
services at the facility. CON laws are designed to providers.
hold down costs by preventing duplication of Concerns over the rising costs of healthcare and
medical services. Examples of facilities required to health insurance have led providers, consumers,
seek CON approval include new hospitals, psychi- and third-party payers to new attitudes toward
atric facilities, chemical-dependency treatment facil- healthcare reform. The concern is over a growing
ities, and nursing home facilities. CON requests will number of employers who cannot afford to offer
be approved if it is determined that the community health insurance as a benefit, and a growing prob-
genuinely needs the proposed service or facility. lem of lack of access to adequate healthcare.
The CON laws were developed in response to The current discussion about healthcare reform
the belief that there was wasteful duplication of is influenced by the Jackson Hole Group, which in
medical resources and facilities within the hospital the early 1990s asserted that the nation needed to
sector. The feeling was that because hospital prices adopt a strategy of managed competition. The con-
were relatively fixed in a geographic area, hospi- cept of managed competition can be characterized
tals did not compete for patients based on the price as a market-based policy of controlled or regulated
of their services but rather increased their com- competition among insurance carriers with incen-
petitive edge on the basis of perceived quality of tives for insurance carriers, physicians, and other
care, services, or facilities. As a result, competition healthcare providers to improve quality, increase
was based on quality and unnecessary, wasteful benefits, expand access, and control costs. It calls
expenditures to attract patients. for “robust competition among healthcare plans”
CON laws were initially required by federal by creating large regional healthcare cooperatives
mandate in 1974, but this mandate was later or health alliances.
Complementary and Alternative Medicine 221
In the future, competitive models will likely be Hammer, Peter J., and William M. Sage. “Critical Issues
built around consumers’ choices and some of the in Hospital Antitrust Law,” Health Affairs 22(6):
core concepts of managed competition. Increasing 88–100, November–December 2003.
amounts of information will be available to con- Sage, William D., David A. Hyman, and Warren
sumers, which will allow them to compare provid- Greenburg. “Why Competition Law Matters to
ers and financial arrangements as they make more Health Care Quality,” Health Affairs 22(2): 31–44,
careful healthcare choices. Information technology March–April 2003.
(IT) will be an important part of this new com- U.S. Federal Trade Commission and the U.S. Department
of Justice. Improving Health Care: A Dose of
petitive environment in healthcare, and consumers
Competition. Washington, DC: U.S. Federal Trade
and providers will clearly use IT in different ways.
Commission and the U.S. Department of Justice,
Providers will use IT to organize and present infor-
2004.
mation about their efforts to increase efficiency
and improve quality and to advertise to consum-
ers. Consumers, on the other hand, will use IT to
shop for the best deal from the best provider they Web Sites
can find. This will force providers to improve qual- Cato Institute: http://www.cato.org
ity and outcomes in an effort to compete for con- Center for Studying Health System Change (HSC):
sumers’ business. Of course, this will require that http://www.hschange.com
more and better information become available Heritage Foundation: http://www.heritage.org
about the various providers in the marketplace. U.S. Code: http://www.gpoaccess.gov/uscode/browse.html
Hospitals are likely to continue to consolidate, U.S. Department of Justice (USDOJ):
motivated in large part by their dwindling market http://www.usdoj.gov/atr/public/health_care/204694.htm
share as competition increases. This will create U.S. Federal Trade Commission (FTC):
new opportunities for hospitals to develop innova- http://www.ftc.gov/bc/healthcare/index.htm
tive partnerships, perhaps integrating previously
for-profit hospitals with nonprofit hospitals to
develop new types of multihospital systems.
Competition will certainly play an important
role in the U.S. healthcare system in the future, but
Complementary and
just what form it will take and with what restraints Alternative Medicine
remain to be seen. Indeed, who will have the great-
est control in shaping the future of competition in Constituted of multiple therapies that have their
healthcare in the nation—government, providers, origin in cultural practices and traditional medi-
insurers, or citizens—remains an open question. cine, some of which have a history of thousands
of years, complementary and alternative medicine
Robert F. Rich and Christopher T. Erb (CAM) encompasses a diverse group of health-
related practices and products that are viewed
See also Certificate of Need (CON); Health Economics; as existing outside mainstream medicine. The
Health Insurance; Hospitals; Managed Care; Rationing
approach to healing and the wellness construct
Healthcare; Regulation
that defines each of these modalities may, in some
respects, differ from the realm of conventional
thought as present in the West or as is taught in
Further Readings the traditional medical curriculum in the United
Gaynor, Martin S., and Deborah Haas-Wilson. “Change, States. These CAM practices are divided into four
Consolidation, and Competition in Health Care domains by the National Institutes of Health’s
Markets,” Journal of Economic Perspectives 13(1): National Center for Complementary and Alter
141–64, Winter 1999. native Medicine (NCCAM): (1) mind-body medi-
Ginsburg, Paul B. “Competition in Health Care: Its cine, (2) biologically based practices, (3) manipulative
Evolution Over the Past Decade,” Health Affairs and body-based practices, and (4) energy medi-
24(6): 1512–22, November–December 2005. cine. The effectiveness and/or safety of some of
222 Complementary and Alternative Medicine
the modalities within these groups continue to be yang, allows the proper flow of Qi, the vital
in question, while others are gathering strong sci- energy, along meridians, pathways within the
entific evidence in their favor. body. Traditional Chinese medicine uses acupunc-
Every year, an increasing number of Americans ture and moxibustion, the Chinese Materia Medica
are using CAM therapies by means of licensed (herbal reference), and massage and manipulation
practitioners as well as through the use of over- as parts of its therapeutical modalities. Ayurvedic
the-counter herbal preparations. In 1997, David medicine, with origins in India, also places an
Eisenberg estimated that 42% of the U.S. popula- emphasis on balance. This system attempts to
tion was using some form of alternative therapy, restore harmony within the body, mind, and spirit
and another study by Nancy Elder estimated that through Ayurvedic treatments such as meditation,
at least 50% of primary-care patients were using herbal therapy, massage, controlled breathing,
some form of CAM. In 2004, the NCCAM illus- and diet. Naturopathy, practiced mainly in the
trated that these numbers are rising with evidence West, originated in Europe and holds six princi-
that upward of 60% of adults in the United States ples as its basis: (1) the healing power of nature,
are using some form of CAM. According to this (2) identification and treatment of the cause of
survey, women more than men, people with higher disease, (3) first—do no harm, (4) the physician as
educational levels, and people who have recently teacher, (5) treatment of the whole person, and
been hospitalized are more likely than others to (6) prevention. Naturopathy uses many forms
use CAM. In addition, allopathic physicians are, in of modalities, including diet modification, nutri-
greater numbers, using these methods through tional supplements, herbal products, hydrother-
referral or direct recommendations. Medical apy, massage, manipulation, and lifestyle
schools are incorporating this topic into the core counseling and borrows some therapies from tra-
curriculum, and continuing medical education ditional Chinese medicine, including acupuncture.
courses are being offered in related topics. Also, Another recognized medical system is homeopa-
some third-party payers are increasingly reimburs- thy, which uses the Law of Similars, stating that a
ing for these services. As popularity continues to substance causing a particular single or set of
rise, expenditures dedicated toward this arena symptoms in a healthy person is viewed as a rem-
climb. CAM continues to grow in popularity edy in persons suffering from similar symptom(s),
within the United States and, in the process, which can be cured in these individuals. The Law
enhances the lives of many while raising concerns of Dilutions states that the more a remedy is
of safety and regulation among others. diluted, the stronger it becomes. This field was
formed primarily by a German physician, Samuel
Hahnemann, in the 1800s and has increased in
Whole Medical Systems popularity since that time.
The NCCAM classifies certain fields of CAM
under the heading of Whole Medical Systems as
Mind–Body Medicine
they are considered complete systems of theory
and practice. There is some overlap with these The NCCAM domain of mind–body medicine is
medical systems and the four domains of CAM; evolving, with more and more modalities being
however, historically these systems have devel- recognized as mainstream in recent years. Of note,
oped independently and hold their basis within an patient support groups and cognitive-behavioral
accepted theory and often use specific modalities therapy are commonly used methods of counsel-
of practice as recognized within this framework. ing. Other modalities within this domain include
Traditional Chinese medicine is one of the most meditation, prayer, mental healing, and creative
well-established and complete systems that have therapy, encompassing art, music, and dance. In
been practiced well before the first known written fact, prayer is the most common CAM practice
texts dating to 200 BCE. The maintenance of the used, with about 45% of the U.S. population
body and spirit within a balanced state through practicing prayer for health-related reasons in
the regulation of two opposing forces, yin and 2002.
The importance of the mind within healing was The NCCAM survey concluded that only about
recognized by traditional Chinese and Ayurvedic 12% of those using CAM have done so through
medicine, just as mind–body medicine recognizes seeking care from a licensed CAM practitioner:
the importance of the relationship between emo- Thus, the remaining use CAM to treat themselves.
tions and physical health. This, in part, is due to This can be alarming, as in contrast to the com-
the interrelationship between the sympathetic and mon perception of these products being completely
parasympathetic nervous systems and has been safe, there are critical dosing issues with all, as well
widely documented and often exhibited in patients as possible dangerous herb to drug, food, or illness
through symptoms such as gastrointestinal hyper- interactions. The Dietary Supplement Health and
activity, neck and shoulder pain, and headaches. Education Act of 1994 exempted herbal medica-
These clinical manifestations have a direct relations and supplements from safety and efficacy
tionship with increased levels of tension and stress requirements and regulations applied to prescrip-
in these individuals. Walter Cannon, in the 1920s, tion and over-the-counter medications. Because of
first drew the correlation between stress and the this legislation, there can often be a problem with
neuroendocrine response. Since that time, this field quality in these over-the-counter preparations.
has continued to be extensively researched, and the Variations in potency and biological, chemical, or
importance of moral and spiritual aspects, belief, pharmaceutical contamination may be present.
emotion, and positive thought within healing is Presently, the burden does not rest with the manu-
more and more recognized. Intervention strategies facturer. It is the responsibility of the U.S. Food
used within this field include relaxation, hypnosis, and Drug Administration (FDA) to prove that a
visual imagery, meditation, yoga, biofeedback, tai product is unsafe before it can be pulled from
chi, qi gong, and spirituality. shelves. Therefore, practitioners and patients must
strive to be well informed.
Practitioners and patients must also remain
Biologically Based Practices astute to avoid possible dangerous interactions.
Herbs such as Ginkgo biloba may alter glucose
The biologically based practices as recognized by
levels and can be a dangerous product in persons
NCCAM include therapies such as botanicals,
who are diabetic. Other herbs and supplements
animal-derived extracts, vitamins, minerals, fatty
such as ginger, garlic, and fish oils can inhibit
acids, amino acids, proteins, and probiotics. With
platelet aggregation and dangerously alter the
NCCAM estimating that about one fifth of the
effectiveness of pharmaceutical anticoagulants
U.S. population use natural products, this domain
commonly used in patients with arrhythmias and
encompasses a large portion of the popular usage
with a history of blood clots. There are multiple
of CAM. Herbal products are popular as they
other possible dangerous interactions, and persons
carry a perception by the general population of
using these products should heed caution. Many
being more natural than pharmaceuticals as well
products have been shown to be effective, but one
as more gentle, having fewer side effects and being
should only use them after much study and consid-
more affordable. Some of the most common herbs
eration, as well as through recommendation by a
used in the United States include Ginkgo biloba,
medical practitioner.
commonly used as an antioxidant and for the
improvement of memory; St. John’s wort, used for
mild depression; ginseng, used for fatigue and
Manipulative and Body-Based Practices
weakness; garlic, used for high cholesterol; and
Echinacea, used for the relief of common colds The manipulative and body-based practices domain
and respiratory infections. Some common supple- includes chiropractics, osteopathy, and massage.
ments include glucosamine and chondroitin sulfate Chiropractics finds its origins as a profession in
for osteoarthritis, CoQ-10 as an antioxidant to Davenport, Iowa, as developed in 1895 by
fight heart disease, melatonin for insomnia, amino D. D. Palmer, though historically, spinal manipula-
acids for body building, and omega fatty acids for tion has been a part of cultural practices for centu-
high blood pressure and high cholesterol. ries throughout the world, including in ancient
224 Complementary and Alternative Medicine
Egypt. The basis of chiropractics according to well as within hospitals, fitness centers, primary-
modern theory is based on vitalism and proffers care offices, and intensive-care units and in con-
the tenant that normal functioning will return junction with psychotherapy treatment programs
through joint structure restoration. Chiropractors and hospice.
work mostly with musculoskeletal complaints, The most common form of massage, Swedish
including spinal subluxations, low back pain, neck massage, incorporates a variety of strokes, includ-
pain, muscle strain, and tendonitis, but they may ing effleurage, petrissage, tapotement, vibration,
also incorporate therapy for other disorders such friction, and compression to aid in therapy through
as asthma, upper respiratory conditions, constipa- the relief of muscular tension. While Swedish mas-
tion, and menstrual disorders. Through mechani- sage generally focuses broadly on the full body,
cal manipulation, the chiropractor is able to inhibit neuromuscular therapy often addresses localized
and reduce the pain reflex, release connective tis- areas of trigger points within the myofascial sys-
sue, and stimulate the autonomic nervous system. tem and seeks to restore a balance with the allevia-
Chiropractics is popular in the United States, as a tion of local and referred pain. Western massage
discipline being the third largest health profession techniques may, as well, be used for specific pur-
after medicine and dentistry, and in addition, poses such as sports, pregnancy, and with infants.
many third-party payers will cover chiropractic Another classification of massage includes struc-
services. Chiropractics is regulated in all 50 states, tural and functional movement and influences the
with 16 chiropractic colleges being accredited. posture and biomechanics of the body while rees-
Osteopathy, developed in Kirksville, Missouri, tablishing a balanced relationship with gravity.
by Andrew Taylor Still in 1874, is now considered Forms within this classification include rolfing,
a part of mainstream medicine. Practitioners in Feldenkrais, zero balancing, craniosacral therapy,
this field follow a curriculum similar to that of and the Trager Approach. Asian forms are gener-
allopathic physicians, with more emphasis placed ally referred to as acupressure and attempts to
on a holistic approach with additional training in regulate Qi without the use of needles (as is used
manipulation. Doctors of osteopathy continue within acupuncture). The common forms within
with a residency appointment to become licensed this classification include Shiatsu, Jin Shin Do, Jin
practitioners in the field of their choice. Those who Shin Jytsu, and Chinese Tuina.
choose to remain within the realm of primary care
are able to better use their additional training of a
Energy Medicine
holistic approach to diagnosis and therapy.
Massage therapy is a very diverse field and The massage techniques of energetic or zone
holds its origins in cultural traditions throughout therapies are sometimes referred to as reflexology
the world. Chinese medical texts dating back 4,000 and fall within the NCCAM-defined domain of
years make reference to the benefits of therapeutic energy medicine, which includes biofield thera-
massage; the healing art of Ayurveda, originating pies such as qi gong, reiki, and therapeutic touch.
in India, includes massage as part of its practice; Modalities not based on massage also fall within
and Hippocrates, as well, advocated the use of this domain and include bioelectromagnetic-
medicinal oils for massage therapy. Today, the based therapies such as pulsed fields, magnetic
field encompasses many categories, including relax- fields, and alternating-current and direct-current
ation or Swedish massage, neuromuscular mas- fields.
sage, and craniosacral therapy, to name a few, and Acupuncture and homeopathy (described above
holds the intent of improving health through posi- as a whole medical system) are, as well, classified
tively affecting relaxation, circulation, nerve within the domain of energy medicine. Acupuncture,
responses, or energy flow through skilled manipu- an art of traditional Chinese medicine dating back
lation of soft tissues and connective tissues. Some at least 2,500 years, uses Qi, a vital energy, that
estimates state that more than $4 billion is annually circulates in the body through pathways. Fine
spent on massage by over 80 billion consumers. needles are placed at points along these pathways,
More than 200,000 massage therapists are licensed also called meridians, to restore and balance the
in the United States and practice independently as flow of energy in order to promote healing.
Licensing As concerns herbal preparations, there is some

evidence that Ginkgo biloba in recommended
Professional regulation of the CAM professions
doses can improve cognitive and social function in
differs from state to state, with the most common
patients with dementia. Garlic has been shown to
CAM professionals being licensed acupunturists
significantly lower cholesterol and lower blood
(LiAcs), doctors of chiropractic (DCs), natur-
pressure as shown in multiple studies. Saw pal-
opathic doctors (NDs), and licensed massage
metto is likely effective at reducing the symptoms
therapists (LMTs). The professionals recognized
of benign prostatic hypertrophy. Black cohosh, in
by state professional license in a smaller number
addition, significantly reduces symptoms of meno-
of states are as follows: homeopathic practitio-
pause in perimenopausal women when taken over
ners, therapeutic touch practitioners, reiki healers,
several weeks. The supplements glucosamine and
herbalists, and aromatherapists. As concerns
chondroitin sulfate have been shown to be effective
mainstream physicians, ideally all should have a
for improving joint symptoms caused by osteoar-
competent working knowledge of CAM regard-
thritis. Omega-3 fatty acid, found in fish oil prepa-
less of the extent to which they implement CAM
rations, has been shown to be cardioprotective and
into their practice. An adequate patient history
will improve blood pressure control in patients
should reveal utilization of CAM, thus giving
taking the recommended dosages. Also, probiotics
warning if a certain CAM therapy possesses a
have been shown to reduce the duration of certain
contraindication or critical interaction with a pro-
types of diarrhea in infants and children.
posed manner of treatment. Several estimates
Massage therapy continues to be limited in its
place the rates of patient disclosure to the primary-
scope of available evidence though strong support
care physician concerning use of alternative thera-
does exist through some scientific studies. Massage
pies between 35% and 40%. These low rates can
has been shown to positively affect acute and
lead to complications and endanger patient safety.
chronic pain, chronic inflammation, lymphedema,
It is critical, thus, that medical curricula and con-
anxiety, and arthritis. There is, as well, some sup-
tinuing medical education include CAM as an
port in consideration of the effect of massage on
important aspect of teaching.
depression, diabetes, fibromyalgia, chronic head-
aches, stress, and hypertension.
The aforementioned evidence in support of
Evidence
specific CAM therapies should be viewed as a
There is convincing scientific evidence supporting general overview and should not be considered to
the efficacy of many of the previously mentioned be all-inclusive. All scientific evidence should be
therapies. scrutinized, with risks and benefits of the particu-
Mind-body interventions are effective for acute lar therapy weighed on a case-by-case basis in
and chronic pain management, headaches, wound conjunction with discussions with a medical
healing, and low-back pain. It has also been practitioner.
shown to be useful in coping with chemotherapy-
induced nausea and vomiting as well as in reduc-
ing discomfort, controlling adverse effects, and Future Implications
improving hemodynamic stability as associated CAM is an extremely broad and rich field that is
with some surgical procedures. Susceptibility to gaining in popularity in the United States in recent
infection decreases with greater control of stress decades. Many of these health-related practices
through relaxation techniques, and mind-body and products were developed over the course of
techniques have even been shown to assist in con- thousands of years and often incorporate a con-
trol of coronary artery disease. Acupuncture, for struct of viewing disease and health that is viewed
example, has been shown to be effective for the as being outside mainstream thought. An increas-
treatment of postoperative and chemotherapy-ining number of research studies are being per-
duced nausea and vomiting, nausea associated formed in recent years, and results are providing
with pregnancy, postoperative dental pain, and encouraging support for some therapies. While
osteoarthritis of the knee. scientific evidence does grow in support of some
226 Computers
therapies and practices, patients and practitioners Rosenthal Center for Complementary and Alternative
should continue to strive to be well informed of Medicine: http://www.rosenthal.hs.columbia.edu
the interactions, contraindications, and side effects U.S. Food and Drug Administration (FDA):
of the modalities they choose for treatment. http://www.fda.gov
Certain professions within this field are regulated
at the state level, but many products are available
over the counter, with little regulation. If used
appropriately and judiciously, the practices and Computers
products within the realm of CAM can offer much
in relation to health and wellness. Computers play an important role in increasing
access, lowering costs, and improving the quality
J. Andrew Dykens of healthcare. Healthcare organizations use com-
See also American Osteopathic Association (AOA);
puters for a variety of purposes in a variety of
Chiropractors; National Institutes of Health (NIH); settings. For example, computers can be used to
Pharmacy; Physicians; Physicians, Osteopathic; U.S. store and retrieve electronic medical records, to
Food and Drug Administration (FDA) assist in medical decision making, and to improve
patient safety by reducing medical errors. While
many healthcare organizations use computers for
Further Readings various purposes, relative to other large industries
(e.g., financial, travel), the nation’s healthcare
Bausell, R. Barker. Snake Oil Science: The Truth About
industry lags far behind in their use and applica-
Complementary and Alternative Medicine. New
tions. For example, although some large hospitals
have electronic medical records systems, very few
Bodeker, Gerard, and Gemma Burford, eds. Traditional,
physician offices and nursing homes have such
Complementary, and Alternative Medicine: Policy
and Public Health Perspectives. London: Imperial
systems. Furthermore, most hospital electronic
College Press, 2007. medical record systems are not compatible, and
Eisenberg, David M., Roger B. Davis, Susan L. Ettner, these records cannot be transferred from one hos-
et al. “Trends in Alternative Medicine Use in the United pital to another. The Agency for Healthcare
States, 1990–1997,” Journal of the American Medical Research and Quality (AHRQ) and several private
Association 280(18): 1569–75, November 11, 1998. organizations are attempting to change this situa-
Elder, Nancy C., Amy Gillcrist, Rene Minz. “Use of tion by providing grant funds for healthcare orga-
Alternative Health Care by Family Practice Patients,” nizations to purchase and implement various
Archives of Family Medicine 6(2): 180–84, March– computer systems.
April 1997.
Kratky, Karl W. Complementary Medicine Systems:
Comparison and Integration. New York: Nova Basic Definitions
Science, 2008.
Zollman, Catherine, Janet Richardson, and Andrew
A computer is an electronic machine that manipu-
Vickers. ABC of Complementary Medicine. 2d ed. lates data in accordance with a set of predeter-
Malden, MA: Blackwell, 2008. mined instructions. Earlier versions of computers
used vacuum tubes and required a large building
to house the computer. Now, computers come in
Web Sites many different forms and sizes from a large main-
Alternative Medicine Homepage: frame to a small smart phone.
http://www.pitt.edu/~cbw/altm.html A computer contains a system board, central
Complementary-Alternative Medical Association processing unit (CPU), memory chip, system clock,
(CAMA): http://www.camaweb.org power supply, expansion slots, ports, and bus
National Institutes of Health (NIH), National Center for lines. A system board is a flat board that contains
Complementary and Alternative Medicine (NCCAM): the CPU and a memory chip. The CPU is the cen-
http://nccam.nih.gov ter of all processing. All data manipulation and
Computers 227
arithmetic/logic computations are performed and systems, and (5) knowledge work systems. Only
controlled in the CPU. A chip has many tiny cir- the latter three systems are used in the health-
cuit boards etched on small silicon wafers. The care field.
memory chip consists of registers that are located Decision support systems can be managerial or
in the control unit and arithmetic logic unit of the clinical in nature and use various analytical tools
CPU. Memory also consists of cache memory, ran- to facilitate and improve the outcomes. The deci-
dom access memory (RAM), and read-only mem- sion support systems can provide basic report
ory (ROM). Cache memory is located between the generation or sophisticated graphical or textual
RAM and the CPU for faster access. RAM is used integration from different data storages. In expert
to store temporary data or programs when the systems, the system integrates data and knowledge
computer’s power is on. ROM stores essential based on the structure and complexity of the prob-
information permanently, and the system clock lem presented by the user to suggest a feasible deci-
controls how often the operations will take place sion and/or alternatives. Management, physicians,
within the computer. The expansion slots deter- nurses, pharmacists, and researchers use decision
mine the functions that can be added to the com- support systems.
puter. Ports are where printers, keyboards, and Management information systems process raw
other devices connect to an expansion board in the data to provide useful, complete, and timely mana-
unit. The bus lines are an electrical pathway gerial information. The information is used by
through which bits are transmitted between the managers to organize daily tasks to support orga-
CPU and other devices. Bits are binary informa- nizational plans and operations. These systems
tion consisting of zeroes and ones. provide support to the information technology
The set of instructions that control how the department, financial operations, personnel depart-
computer reacts is called system software. The ment, and other auxiliary departments.
operating system is the official name for the system Knowledge work systems are systems developed
software, and it allows the computer to interact for professional and technical workers. These sys-
with the application software. Application soft- tems are more pronounced in healthcare now and
ware is the computer software that enables the are being used by nurses and physicians in the
user to perform word processing, accounting, and form of handheld computers.
other specialized functions.
The size and type of computer used depend on
the type of information the user needs to conduct Use of Laptop and Handheld Computers
business. Computers are machines that are used to
The national nursing shortage and the complexity
process data into information. Data are raw facts
of healthcare knowledge have led to a redesigning
collected during the normal daily operational func-
of existing automation used in the point-of-care
tions of an organization. In contrast, information
processes that occur between nurses and patients.
is data that have been processed to gain the intrin-
Handheld computers have been employed to
sic value useful to the operation and management
allow nurses to capture interventions or graphi-
of the organization. Computers provide the pro-
cally view changes in data values at the patient’s
cessing power to transform the raw data into infor-
bedside. System interfaces have been developed to
mation based on a set of instructions. The set of
provide nurses with decision support information
instructions differ, depending on the classification
on a personal digital assistant (PDA) within the
of the computer system and the intended user.
confines of the patient’s room or home in an effort
to increase patient safety and care management.
PDAs can be synchronized with the main hospital
Types of Computer Information Systems
information system and other team members’
There are five general types of computer infor- PDAs and can be used to browse the Internet for
mation systems: (1) executive information systems, the latest medical information. Thus, nurses can
(2) transaction processing systems, (3) decision stay current on all new findings contained in the
support systems, (4) management information medical journals through the daily use of a PDA.
228 Congressional Budget Office (CBO)
Physicians also use PDAs, and they can soon be Organization,” Journal of Nursing Administration
expected to have access to electronic medical 33(11): 557–62, November 2003.
records on them. Currently, physicians use PDAs Joos, Irene, Nancy Whitman, Marjorie J. Smith, et al.
and laptop computers to document patient find- Introduction to Computers for Healthcare
ings and to order medical tests. Information can be Professionals. 4th ed. Sudbury, MA: Jones and
synchronized to the main hospital information Bartlett, 2006.
system where wireless connections are not avail- Thompson, Brent W. “The Transforming Effect of
able for online ordering or entry into the main Handheld Computers on Nursing Practice,” Nursing
Administration Quarterly 29(4): 308–14, October–
databases. When laptop computers are used, the
December 2005.
hospital provides connections at the nurse’s sta-
tions or along the hallway for mobile connection
so that data can be updated to the main computer
system. Mobile computers and handheld devices Web Sites
allow physicians to tailor their workflow to meet
the patient workload. Thus, they can see more http://www.ahrq.gov
patients without compromising safety or care. American Medical Informatics Association (AMIA):
Case managers and pharmacists also use hand- http://www.amia.org
held computers. As more knowledge work system Leapfrog Group: http://www.leapfroggroup.org
applications are developed for healthcare, the use
of handheld computers will likely expand, thus
allowing healthcare professionals to provide closer
and more personal support to patients without Congressional Budget
having to turn their back to the patient to enter
data. However, with every advantage, a disadvan- Office (CBO)
tage also exists. The disadvantages that arise with
the increased use of laptops and handheld comput- Established by the Congressional Budget and
ers are the increase in data security and data pri- Impoundment Control Act of 1974 (PL 93–344),
vacy risks. The risks that will arise from the the Congressional Budget Office (CBO) is a non-
increased dependency on these computers as a partisan federal agency within the legislative
means to enhance medical care are that the devices branch of the U.S. government. The primary
are more susceptible to be misplaced or stolen, and responsibility of the CBO is to make budgetary
thus, data encryption and password policies will and cost projections of legislation proposed by the
need to be enforced more stringently. Therefore, U.S. Congress. It is analogous to the White House
the data contained on these devices will need to be Office of Management and Budget (OMB), which
protected to a given degree of certainty or at an makes estimates of projected spending for the
acceptable level of risk. executive branch of government. However, the
political appointment of many OMB officials by
Greer W. P. Stevenson the president tends to result in more partisan
See also Clinical Decision Support; Cost of Healthcare; spending projections that tend to favor the presi-
Data Privacy; Data Security; Healthcare Informatics dent’s policy agenda. Thus, the CBO’s estimates
Research; Health Informatics; Medical Errors; Quality are typically considered more credible and objec-
of Healthcare tive than those produced by the OMB.
Further Readings Leadership

Bardram, Jakob E., Alex Mihailidis, and Dadong Wan, The director of the CBO is jointly appointed to a
eds. Pervasive Computing in Healthcare. Boca Raton, 4-year term by the speaker of the House of
FL: CRC Press, 2007. Representatives and the president pro tempore of
Dienemann, Jacqueline, and Barbara Van de Castle. the Senate on recommendations of both the House
“The Impact of Healthcare Informatics on the and Senate budget committees. There are no term
Congressional Budget Office (CBO) 229
limits, but the U.S. Congress may pass a resolu- Cost Estimates
tion to remove the director. The director hires all
The CBO develops projections and prepares cost
other CBO staff members, and positions are filled
estimates of proposed legislation at the request of
based on professional merit, rather than political
the U.S. Congress. Nearly every bill that makes it
appointment.
to a congressional committee will be scored by the
The current director of the CBO, Peter R.
CBO. The cost estimates, designed to inform
Orszag, took office in January 2007. He is the
members of Congress about the financial implica-
seventh director of the CBO. Prior to joining the
tions of the legislation, should it be enacted,
CBO, Orszag, who is an economist by training,
broadly include the following: (a) the cost of
served on President Clinton’s Council of Economic
establishing new programs, (b) the projected cost
Advisors and was a senior fellow and the deputy
of savings from altering existing programs, and (c)
director of economic studies at the Brookings
anticipated changes in revenues, should tax laws
Institution. Orszag’s immediate predecessor was
be changed. In cases related to proposed changes
acting director Donald B. Marron, who served in
in the tax code, the CBO is legally required to use
that capacity beginning in December 2005. Alice
estimates prepared by the Joint Committee on
Rivlin, the first director of the CBO, holds the title
Taxation. All other estimates generally attempt to
of the longest tenure as head of the agency, having
project the effects of the legislation at least 5 years
served from the office’s inception from February
into the future. Ten-year and longer projections,
1975 until August 1983.
however, are not uncommon. Included with each
estimate is a narrative explaining the specific
Organization and Structure methods used and the assumptions made in calcu-
lating the final figures.
The majority of the CBO’s annual budget, which
CBO’s estimates, which are often revised as a
amounted to more than $35 million in 2007, pro-
bill moves through Congress and is amended, play
vides salaries for its more than 230 employees, the
an important role throughout the entire legislative
majority of whom have graduate degrees in fields
process, from preliminary bill drafting, through
such as economics and public policy. A mix of
the design of floor amendments, to the final bill
economists, policy analysts, budget analysts, and
that emerges from the conference committee for a
research assistants work in one of six of the
vote. Members of Congress, as well as various
office’s divisions: (1) the Budget Analysis Division,
governmental agencies, policy research organiza-
(2) Health and Human Resources Division, (3)
tions, advocates, and many others, rely heavily on
Macroeconomic Analysis Division, (4) Micro
the expert advice provided to them by the CBO’s
economic Studies Division, (5) National Security
cost estimates to determine how to allocate a lim-
Division, and (6) Tax Analysis Division.
ited amount of available funds.
The CBO also confers with the Panel of Economic
Additionally, the Unfunded Mandates Reform
Advisors and the Panel of Health Advisors. These
Act of 1995 requires the CBO’s cost estimates to
two groups of experts are responsible for reviewing
inform the U.S. Congress if a piece of proposed
the CBO’s methods and forecasts in the context of
legislation contains federal mandates to the states.
the current economic and sociopolitical landscape.
If such a mandate exists, and the estimated cost to
The panels also advise the CBO on important
the states exceeds a predetermined threshold, the
developments in their respective fields.
CBO must fully estimate these state costs in its
The Budget Analysis Division, the largest divi-
reports.
sion within the CBO, prepares spending projec-
tions of proposed legislation currently before the
U.S. Congress and the CBO’s estimate of the presi-
dent’s annual budget. The division is subdivided The Federal Budget
into four substantive units, each with expertise in a The current federal budget is more than $2.5 tril-
different area: (1) health; (2) defense, international lion. Each February, the President releases a bud-
affairs, and veterans’ affairs; (3) human resources; get proposal created by the OMB, which outlines
and (4) natural and physical resources. the administration’s priorities for the coming
230 Consumer-Directed Health Plans (CDHPs)
fiscal year. Ultimately, however, it is the U.S. Web Sites

Congress that must create and pass a budget bill. Congressional Budget Office (CBO): http://www.cbo.gov
For this reason, the CBO plays an important role
in the federal budget process.
The CBO’s first task is to reevaluate the presi-
dent’s budget and create a report to Congress that Consumer-Directed
contains objective nonpartisan estimates of the Health Plans (CDHPs)
President’s proposals. In odd-numbered years, the
CBO also provides Congress with a “budget
Consumer-directed health plans (CDHPs) are
options” report that lists literally hundreds of pos-
insurance plans that combine two major design
sible budget alternatives for the Congress to con-
features: (1) a high-deductible health plan that
sider. In the spirit of political neutrality, however,
provides catastrophic coverage, but places the con-
the report makes no policy recommendations.
sumer at risk for substantial spending, including
In January, the CBO also provides an annual
possible cost sharing on amounts above their
report to Congress titled the Budget and Economic
deductible, and (2) a tax-advantaged employer
Outlook, which includes an economic forecast
and/or self-funded individual savings account that
along with 10-year projections of federal spending
can be used to pay directly for healthcare expenses
and revenues. This report is useful to members of
and can be rolled over from year to year. A central
Congress when considering proposed legislation
claim is that by combining higher cost sharing with
(and their corresponding CBO cost estimates) as it
savings accounts, CDHPs can encourage more
provides a baseline against which comparisons can
price-conscious purchasing by consumers and help
be made. In addition to these publications, the
contain costs while mediating exposure to the risk
CBO prepares analytical papers, policy and issue
of large direct out-of-pocket payments. Other fea-
briefs, monthly budget reviews, and background
tures often associated with CDHPs include exemp-
and working papers. All the CBO’s publications
tion of certain services such as preventive care
are available on its Web site.
from deductibles and access to decision support
Brad Wright tools “empowering” consumer decision making.
Interest in CDHPs is relatively new and has cen-
See also Centers for Medicare and Medicaid Services tered on the private sector. In 2006, only 3% to
(CMS); Cost of Healthcare; Inflation in Healthcare; 4% of the privately insured population in the
Medicaid; Medicare; Public Policy; Regulation; U.S. United States were enrolled in CDHPs, but this
Government Accountability Office (GAO) represented a substantial increase over previous
years, and enrollments could grow further in the
future. Important issues raised by the growth of
Further Readings
CDHPs include their design and relationship with
Auerbach, David, and Chapin White. Geographic managed care, their potential for future growth,
Variation in Health Care Spending. Washington, DC: and the possible implications of increased enroll-
Congressional Budget Office, 2008. ments for access, costs, and quality of healthcare.
Hagan, Stuart, and Peter Richmond. Evidence on the
Costs and Benefits of Health Information
Technology. Washington, DC: Congressional Budget Background
Office, 2008.
Nexon, David. “‘Inside the Sausage Factory’: The CDHPs have emerged against a background of
Singular Case of the Congressional Budget Office,” rising insurance premiums, dissatisfaction with
Milbank Quarterly 81(1): 161–64, 2003. managed care, and changing consumer attitudes
Orszag, Peter R., and Philip Ellis. “Addressing Rising about involvement in their care. Managed-care
Health Care Costs: A View From the Congressional plans arguably played a major role in slowing
Budget Office,” New England Journal of Medicine the growth of healthcare costs in the 1990s by
357(19): 1885–87, November 8, 2007. combining selective contracting with restrictions
Consumer-Directed Health Plans (CDHPs) 231
on consumer choice, allowing them to reduce pay- insurance plan and are employer owned and
ments to hospitals and physicians. Key features administered. Along with employer contributions
included direct controls on utilization and the use to insurance premiums, expenditures made from
of financial incentives to steer consumers to net- HRA accounts are tax-exempt, subject to Internal
works of contracting providers. However, since Revenue Service (IRS) review. HRA-based plans
the late 1990s, there has been a growing consumer are usually defined as a CDHP in the literature if
backlash against these restrictions. This has been deductibles equal or exceed $1,000 for single cov-
accompanied by a shift in enrollment toward less erage and $2,000 for family coverage. HRA funds
restrictive types of managed-care organizations may be rolled over from year to year. However,
(e.g., moving away from health maintenance orga- balances are generally nontransferable and revert
nizations [HMOs] toward preferred provider to the firm if an employee leaves his or her job.
organizations [PPOs]), a relaxation of plan con- Consequently, an employer’s actual spending may
straints on choice, and a re-acceleration in the be less than the amount contributed.
growth of health insurance premiums. The combi- Based on a Henry J. Kaiser Family Foundation/
nation of rising premiums and the push back Health Research and Educational Trust survey of
against managed care has fueled interest in CDHPs employers, in 2006, the average employer contri-
as an alternative cost containment strategy or at bution to employee CDHP HRA accounts was
least as a means of shifting some of the burden of $797 for single coverage and $1,584 for family
cost increases toward consumers. At the same coverage. The average total premium for insurance
time, there has also been growing interest among associated with HRA plans, including both
consumers in greater involvement in decisions employer and employee contributions, was $3,666
about their care and in CDHPs as vehicles for tax- for single coverage and $10,482 for family cover-
advantaged saving. age, which compares with average premiums of
$4,242 and $11,480, respectively, for all types of
insurance plans combined. The average deductible
Design and Operation
for HRA CDHPs was $1,442 for single coverage
Typically, CDHP insurance plans include not and $2,985 for family coverage, and average out-
only a high deductible but also substantial con- of-pocket maximum stop-loss caps were $2,693
sumer cost sharing above this deductible until and $5,230, respectively. HRA funds may be used
the consumer reaches a maximum stop-loss cap to cover both deductibles and coinsurance.
on out-of-pocket expenditures, at which point However, because there is usually a gap between
services are usually fully covered as long as they the employer’s contribution and the maximum
are obtained in the network. Consequently, stop-loss cap in the typical HRA plan, unless a
insurance premiums will usually be lower than consumer has rolled over sufficient funds from
for coverage with a smaller deductible and less past years, they are at risk for direct out-of-pocket
cost sharing, but there is greater risk exposure. payments to bridge this gap.
In the individual insurance market, this trade-off HSAs are regulated under Title XII of the
between premiums and risk is explicit. In employer- Medicare Modernization Act of 2003. An HSA
based plans, the impact on a consumer will may be established in conjunction with either a
depend on an employer’s decision not only about qualifying employer-sponsored insurance plan or
contributions to employee spending accounts an individual purchase of qualified coverage. In
but also about premium contributions. either case, HSA accounts are personally owned
Two major types of savings account arrange- and fully portable. Typically administrated through
ments are currently in use for CDHPs: (1) employer- an outside financial institution such as a bank or an
based and funded Health Reimbursement insurance company, there are no income limits on
Accounts (HRAs) and (2) personal Health Savings who can contribute to an HSA, and they are triply
Accounts (HSAs) funded with individual and pos- tax advantaged—contributions to HSA accounts,
sibly employer contributions. HRAs are offered earnings on account balances, and withdrawals for
in conjunction with an employer-sponsored healthcare expenditures are all tax-exempt. Subject
to payment of regular federal income tax and a provide such tools, but the literature suggests con-
10% penalty, HSA funds may also be used for tinuing problems. For example, it is often difficult
other purposes. This penalty is waived at age 65, for a consumer to obtain accurate, timely data on
however, and unlike most retirement plans, there the prices that they can expect to pay for specific
are no mandatory provisions for withdrawing services and how much their plans will reimburse
funds from HSAs after age 65. for them, let alone the anticipated overall cost of
In 2007, to qualify for an HSA, a consumer had an episode of care at different providers. In this
to be enrolled in a health insurance plan with a context, developing comprehensive bundled prices
deductible of at least $1,100 for single coverage combining the costs of hospital and physician ser-
and $2,200 for family coverage and a maximum vices could be an important factor in facilitating
out-of-pocket spending limit of $5,500 or less for shopping. On the quality side, data on perfor-
single coverage and $11,000 or less for family cov- mance are often rudimentary, especially for physi-
erage, with both limits subject to adjustment for cians, while there are important issues with their
inflation. Combined contributions from individu- interpretation.
als and their employers were limited to a maxi-
mum of 100% of the deductible, but not more
Illustration of Reimbursement
than $2,850 for single coverage and $5,650 for
family coverage, also subject to adjustment for Consider a consumer enrolled in an employer
inflation. Again, a substantial gap may exist HRA plan with a deductible of $1,500 and a 20%
between the maximum allowed contribution and coinsurance rate for expenses above this deduct-
the maximum cap on out-of-pocket spending, ible up to a maximum cap of $3,900 for total
placing a consumer at risk for large potential out- eligible expenditures. Suppose the employer’s
of-pocket payments, where by law, purchase of annual HRA contribution is $800 and that the
first-dollar supplemental coverage is prohibited. employer’s insurance plan includes a managed-
One widely expressed concern with CDHPs is care organization network and restrictions on
that cost sharing may lead consumers to reduce reimbursement for out-of-network providers. In
spending on “necessary” as well as “unnecessary” Year 1, suppose the consumer has no major health
services, resulting in higher costs and/or poorer problems and spends a total of $600 on health-
outcomes. At least in part, this concern may be care, including $300 for preventive services. In
addressed by exemptions permitting reimburse- this case, the consumer will be at risk for 20% of
ment for services even if a consumer has not the cost of eligible preventive services (20% ×
reached their deductible. By law, HSAs must $300 = $60) and the full cost of the remaining
exempt preventive services such as screening tests, services ($300), a total of $360. Deducting $360
while many HRAs do so as well. Some CDHPs from his or her HRA, no out-of-pocket payments
also exempt expenses related to the management will be required, and a balance of $800 − $360 =
of chronic medical conditions such as diabetes and $440 will be rolled over to the next year.
may offer consumers incentives to enroll in disease In Year 2, if the employer again contributes
management and wellness programs. However, $800, the total HRA balance will be $1,240, but
beyond this, deductibles, coinsurance, and copay- suppose that the consumer has major health prob-
ments are typically applied using a one-size-fits-all lems leading to total expenditures of $19,000.
approach. Possible refinements include further Suppose all these services are purchased from net-
adjustments in cost sharing based on individual work providers and are fully eligible for reim-
clinical characteristics and possibly income. bursement. The consumer will owe the first $1,500
Another important concern is that even if con- of the cost of his or her care (the deductible). He
sumers are motivated to shop for care, they are ill or she will also be required to pay 20% of the cost
equipped to do so. Proponents of CDHPs argue of care above the deductible up to the point where
that this can be addressed by empowering enroll- the total out-of-pocket spending (the deductible
ees with decision support tools, for example, plus coinsurance payments) equals $3,900. The
Web-based tools enabling consumers to com- HRA will cover $1,240, but he or she will still
pare prices and quality information. Many plans have to pay $2,660 ($3,900 − $1,240) directly out
Consumer-Directed Health Plans (CDHPs) 233
of pocket. Assume again that in Year 3, they have as a cost containment mechanism. However, for
large expenses ($14,000), in which case, with no expenditures below the deductible, the issue of
funds to roll over and an employer contribution of consumer choice is typically reframed in terms of
$800, they will spend $3,100 out of pocket how consumers want to spend their own money.
($3,900 − $800). Note, however, that as long as Plan rules on what expenditures are eligible for
the consumer uses network providers, this amount reimbursement do not explicitly become an issue
($3,100) will represent his or her maximum risk until a consumer exceeds the deductible. Plan net-
exposure since expenditures above the stop-loss works may still be important in determining pro-
cap will be fully covered. (Note, out-of-pocket vider choices even for low dollar expenditures
spending could be substantially higher if a con- because of the price discounts they offer. Further
sumer goes out-of-network for services and incurs more, the network a CDHP offers may be a major
expenses not eligible for reimbursement. However, factor in consumers’ enrollment decisions. But
this situation could also occur with conventional high deductibles effectively eliminate direct issues
managed care and is not unique to CDHPs.) with the reimbursement eligibility of providers for
From this example, it is evident that a CDHP the majority of consumers.
can potentially expose a consumer to substantial CDHPs also typically eliminate direct con-
financial risk and that he or she may face consid- trols on utilization of low dollar services, a fre-
erable complexity in navigating a plan’s provi- quent source of conflict with consumers under
sions. In addition, this example highlights an managed care. Instead, efforts to affect con-
important limitation of typical CDHP cost-sharing sumer behavior are usually framed in terms of
strategies: Once a consumer reaches his or her incentives (e.g., eliminating deductibles for pre-
maximum out-of-pocket stop-loss limit (or antici- ventive services and use of incentive payments to
pates he or she will), there is no further incentive encourage participation in disease management
to control costs for services eligible for reimburse- and wellness programs). The literature suggests
ment. This issue is irrelevant for the vast majority that plans may complement low dollar cost shar-
of enrollees because their spending is below maxi- ing with the use of case management to directly
mum caps. Nonetheless, it is an important design control utilization of high dollar services. The
issue because of the high concentration of health- extent and stringency of case management by
care spending (e.g., the top 10% of patients CDHPs is not well documented. But in any case,
account for nearly 70% of total expenditures). A it is likely to involve only small numbers of con-
key challenge for CDHPs is to find ways to consumers and to be a less visible source of conflict,
trol high dollar expenditures either through although issues may still arise, for example,
restructuring of cost sharing or through alterna- high-profile cases regarding access to experi-
tive mechanisms. mental services.
Relation to Managed Care Enrollment Trends

It is possible to envision a system in which con- Currently, CDHPs cover only a very small per-
sumers individually enroll in CDHPs and indepen- centage of Americans with private health insur-
dently shop for their care, and the primary ance, but between 2005 and 2006 estimated
function of plans is to pay claims and supply deci- enrollments grew sharply, rising from about 3 mil-
sion support tools. However, proponents of this lion to about 5 or 6 million enrollees. In 2006, an
kind of approach usually link it to major restruc- estimated 3 million of these enrollees were in
turing of healthcare markets. Currently, consumer employer-sponsored HRA plans, and 2 to 3 mil-
cost sharing in CDHPs is usually complemented lion were in HSA plans, including plans purchased
by continued reliance on major features of man- individually.
aged care, albeit repackaged in ways that may In the employer group market, a 2006 Henry J.
reduce sources of tension with consumers. Kaiser Family Foundation survey found that 7%
Thus, CDHPs typically continue to rely on of firms offering health benefits provided a CDHP
selective contracting and use of provider networks as an option and that 4% of covered workers were
enrolled in such plans. However, among firms not savings compared with other plans. Even if they
offering CDHPs, 24% indicated that they were cannot, CDHPs may still be attractive to employ-
either somewhat or very likely to offer such a plan ers (and possibly the public sector) as a framework
next year. Large firms were more likely to offer a for shifting costs toward consumers through
CDHP, while when small firms offered a CDHP, it greater financial risk bearing. Greater familiarity
was more likely to be the only option. with CDHPs could increase consumer acceptance,
Studies of enrollment patterns for CDHPs find especially with more consumer education. But
evidence of moderately favorable selection. substantial numbers of consumers may remain
Enrollees tend to be more educated and have reluctant to assume the financial risks involved
lower levels of prior healthcare utilization. The and/or greater responsibility for shopping for their
evidence on age is mixed. Retirement savings care. Other potential barriers to future growth
opportunities are hypothesized to be an important include the lack of adequate decision support tools
consideration for enrollees in HSA-qualified plans, and issues with federal and state regulations gov-
especially for higher-income individuals. The lit- erning HSAs.
erature indicates that when consumers have a An immediate public policy concern is the effect
choice, they are more likely to enroll if CDHPs CDHP growth could have on insurance markets.
actively seek to educate consumers about the The evidence so far suggests only modest favorable
plan’s features. selection. However, a large-scale shift of more
healthy, lower-cost individuals to CDHPs could
leave other types of plans with a disproportionate
Cost and Quality share of more costly enrollees, potentially driving
up premiums in those plans serving individuals
The RAND Health Insurance Experiment (HIE)
with the greatest need for care. In addition, to the
provides strong evidence that high-deductible
extent CDHPs redistribute financial burdens, there
plans can reduce utilization, primarily through
are concerns that risk could be disproportionately
effects on a consumer’s decision to seek care.
shifted to those enrollees least able to bear them,
Simulation studies using HIE data suggest that
for example, individuals with severe chronic ill-
combining high deductibles with savings accounts
nesses. In the longer run, a central question is the
would mediate the effects on utilization but that
ability of consumer-directed strategies to generate
reductions could still be substantial. However,
sustained cost savings while ensuring the quality of
findings from the HIE raise concerns that consum-
healthcare.
ers may reduce the use of “necessary” as well as
“unnecessary” care, especially in the case of poor, William D. White
sick consumers, while in real terms, deductibles in
the HIE were much greater than those currently in See also Coinsurance, Copays, and Deductibles; Cost of
use by CDHPs. Studies based on actual experi- Healthcare; Forces Changing Healthcare; Healthcare
ences with CDHPs remain limited, and issues exist Financial Management; Health Insurance; Health
with controlling for favorable selection and track- Insurance Coverage; Health Savings Accounts (HSAs);
Managed Care
ing out-of-pocket spending. However, the avail-
able evidence is generally consistent with at least
onetime savings. The evidence on the effects on Further Readings
quality is mixed, with at least some evidence that
consumers may adopt behavior that could have Bonney, Robert S. Consumer-Driven Healthcare and Its
adverse health consequences. Implications for Providers. Chicago: Health
Administration Press, 2005.
Dixon, Anna, Jessica Greene, and Judith Hibbard. “Do
Consumer-Directed Health Plans Drive Change in
Future Implications
Enrollees’ Health Care Behavior?” Health Affairs
Continued increases in private health insurance 27(4): 1120–21, July–August 2008.
premiums could spur growth in CDHPs, especially Feldman, Roger, Stephen T. Parente, and Jon B.
if CDHPs can successfully realize even modest cost Christianson. “Consumer-Directed Health Plans: New
Continuity of Health Service Operations During Pandemics 235
Evidence on Spending and Utilization,” Inquiry 44(1): little warning, and the novel flu virus may be
26–40, Spring 2007. identified in any region of the world. Experts
Herzlinger, Regina. Who Killed Health Care? America’s believe that there will be 1 to 6 months’ time
$2 Trillion Medical Problems—And the Consumer- between the identification of the novel influenza
Driven Cure. New York: McGraw-Hill, 2007. virus and the time that widespread outbreaks
Jost, Timothy Stoltzfus. Health Care at Risk: A Critique begin to occur in the United States. Simultaneous
of the Consumer-Driven Movement. Durham, NC: clusters of disease are expected to occur through-
Duke University Press, 2007. out much of the nation, preventing the relocation
Newhouse, Joseph P. “Consumer-Directed Health Plans
of human and material resources. Multiple waves
and the RAND Health Insurance Experiment,”
of infection are anticipated. The effects of an
Health Affairs 23(6): 107–13, November–December
influenza pandemic will be relatively prolonged,
2004.
occurring in estimated waves of 8 to 20 weeks’
Rowe, John W., Tina Brown-Stevenson, Roberta L.
Downey, et al. “The Effect of Consumer-Directed
duration.
Health Plans on the Use of Preventive and Chronic
Illness Services,” Health Affairs 27(1): 113–20, Continuity of Operation Plans
January–February 2008.
With a possible influenza pandemic, governments
at all levels must be prepared for the health crisis.
Web Sites The plans for the maintenance of services and the
recovery of public health departmental capability
America’s Health Insurance Plans (AHIP): after the crisis have been referred to as continuity
http://www.ahip.org of operations planning. Such plans describe the
Center for Studying Health System Change (HSC): organization with its operational framework for
http://www.hschange.com
continuing essential public health functions when
Employee Benefit Research Institute (EBRI):
normal operations are disrupted or otherwise can-
http://www.ebri.org
not be conducted. At a minimum, the continuity
Henry J. Kaiser Family Foundation (KFF):
of operation plans should meet several key objec-
http://www.kff.org
U.S. Government Accountability Office (GAO):
tives. The plans should identify prioritized essen-
http://www.gao.gov
tial functions and determine necessary resources
to maintain these functions. They should also
establish a command and control structure related
to the management of personnel to maintain these
Continuity of Health Service services during the crisis. Other objectives of the
plans should be to identify the triggers that would
Operations During Pandemics initiate the sequential phases of the continuity of
operations and to list the necessary resources,
The emergence of hazards related to the global such as people, equipment, and materials, to per-
transmission of pandemics presents challenges to form essential functions. Finally, the plans must
local public health departments. It requires the establish procedures to acquire necessary supplies
planning of responses, not only with respect to and support services to continue essential public
the crisis itself but also with respect to the conti- health functions, as well as the capabilities to
nuity of essential public health services during the restore or reconstitute agency activities to their
crisis. Influenza pandemics have occurred several pre-event status.
times during the 20th century, and there is a high The structure of the plans should be driven by
probability that an influenza pandemic will occur the types of problems arising from the occurrence of
again in this century. Such a pandemic will pandemics and the necessity of maintaining certain
directly and indirectly affect the operations of services during a crisis. A public health department
public health departments, critical infrastructures, has to effectively reorganize its lines of authority,
and private and nonprofit organizations. When operations, and service provision to reflect a vastly
the pandemic does occur, it will likely be with different set of public health priorities. Plans must
236 Continuity of Health Service Operations During Pandemics
be in place prior to the crisis, which define essential These trigger points will initiate pandemic
versus nonessential services so that nonessential response actions, which will in all likelihood
services can be curtailed during the crisis. The dis- require the shifting of personnel in the public health
tinction between an essential and nonessential pub- department from nonessential services to the imple-
lic health service needs to be clearly understood. mentation of pandemic response activities.
The designation of a nonessential service does not Therefore, for each of these trigger points, a paral-
mean that such a service is not of vital importance lel continuity-of-operation trigger point involving
to the public health of citizens. Nonessential, in this the termination of nonessential services exists.
context, means that a service can be delayed for the The shifting of personnel raises a number of
period of 1 to 3 months without causing significant managerial problems within public health depart-
or immediate public health problems. ments trying to respond to the pandemic. Due to
Beyond the definition of essential and nones- the illness of key personnel, adjustments will have
sential services, other issues must be addressed in to be made in personnel assignments during the
continuity of operation plans. The issues include pandemic in order to ensure the continuity of essen-
the appropriate preparations to be made before tial services. It is likely that alternative work prac-
the occurrence of a pandemic, such as the preor- tices such as telecommuting will be employed more
dering of pharmaceuticals for patients who may be heavily during the pandemic influenza response.
unable to obtain them during the crisis. The train- Such work practice changes require preparation
ing needs of temporarily reassigned personnel and operational guidance to work effectively. If
should also be considered. When preparing the schools are closed, the rate of absenteeism at the
plans, leaders also need to determine which changes department could increase significantly.
should be made to departmental reporting and It is assumed that there will be at least a 2- to
communication to allow management to create a 3-week period of time prior to the diagnosis of the
unified situational awareness during the rapidly first case of pandemic influenza locally, when a city
shifting conditions of the crisis. Finally, since a will have warning of the impending crisis.
public health department depends on a network of Preparatory action for the large-scale reassignment
services provided to it to function, the interactions of personnel needs to take place. Other necessary
between the department and service providers dur- preparatory actions may include the following: (a)
ing the crisis must be addressed as changes in these pre-ordering medications for patients in anticipa-
interactions are expected. For example, emergen- tion of difficulties in filling prescriptions during a
cy-contracting provisions may need to be created citywide pandemic influenza response, (b) just-in-
to allow the rapid ordering of urgently needed time training for voluntary staff, (c) ensuring that
supplies. computer network capacity for an increase in the
use of home-based work practices exists, and (d)
editing of public information alerts to be issued as
Managerial Organization and Coordination
nonessential services are curtailed.
Continuity of operation plans need to be speci- The curtailment of nonessential services will
fied so that they are coordinated with pandemic require a coordinated public information program
response plans. Pandemic response plans are so that a coherent and consistent message is pro-
phased in using a number of specific trigger vided to the general public. Information on the
points. Such points may include the following: damage due to the curtailment of nonessential ser-
(a) activation of the Public Health Incident vices, such as patients not seen and health inspec-
Command System (PHICS); (b) enhanced public tions postponed, will need to reside in a central
health surveillance activity; (c) community con- location in order to assist in developing an effec-
tainment, including quarantine and isolation, tive postpandemic influenza recovery plan.
and the enactment of social distancing measures; The maintenance of essential services during the
(d) epidemiological investigation; (e) administra- influenza pandemic response will require an inte-
tion of prepandemic vaccines, and antiviral dis- grated command structure capable of responding
tribution; and (f) mass vaccination of the entire to program-level problems and issues. Program
population. managers will need to respond in a timely manner
Continuity of Health Service Operations During Pandemics 237
so that specific resources cannot be made available In making an assessment of essential versus
for nonessential services during the pandemic nonessential services, regardless of the approach
response. This is just as important as responding used, certain information should be collected to
positively to a program request for additional create continuity of operation plans. First, normal
resources. Due to rapidly changing conditions, the service and staffing levels should be examined.
continuity of operation management structure This information establishes the baseline from
must be capable of significantly faster response which the plans are developed and allows an esti-
than required in nonemergency conditions. mate of the personnel resources released due to the
cessation of nonessential services, which can be
used to respond to the pandemic crisis. Next,
Defining Essential Services and
information on the extent and severity of the
Departmental Service Support
impact of service cessation over different planning
The process of defining essential services may take horizons should be considered. The number of
place by either a top-down approach or a bot- people affected and the severity of impact will vary
tom-up one. The advantage of creating a single based on the service under consideration. The
criterion by which essential services can be defined impact may also vary greatly with the length of
based on interviews with upper management is time of the curtailment. Some services can be cur-
that this approach will create a designation of tailed for short periods of time with little impact
essential services based on criteria that presum- but may have significant impacts for longer peri-
ably will relate to some form of benefit cost con- ods, such as the provision of prescription drugs for
siderations and could be easily communicated. chronic ailments.
A bottom-up programmatic level–initiated defi- Required staffing levels for essential services
nition of essential services will seek the views of must also be determined. The designation of staff
each program manager. When each manager has levels devoted to the provision of essential services
input into classifying and determining essential during the crisis involves more than just defining
and nonessential services during the response, the the number of staff remaining in their program
result is complex, and the process is more compli- during the crisis. The continuance of essential ser-
cated than a single-criterion definition. A signifi- vices at a program may require a specific talent
cant advantage to this approach, however, is the mix to function even at minimal service levels.
increased level of participation in the plan’s forma- Next, leaders must consider policy and practice
tion by middle management and an increased level alterations. A number of employment-related poli-
of acceptance of the plan once it is developed. cies may have to be suspended or altered during
Regardless of the approach employed, the the crisis. Personnel will be assigned to areas or
basic consideration in defining essential services is jobs that do not appear in their job descriptions or
the implication for stakeholders of the damages to tasks for which they have not received extensive
resulting from the temporary cessation of nones- training. Different work practices may also be ini-
sential services. The stakeholders in this case are tiated to provide lower-quality or less resource-in-
the general public. Such damage assessments must tensive service. The documentation of such policy
consider not only the immediate damages due to and practice alterations is an integral part of defin-
the services postponed but also a potential diffi- ing essential services in a continuity of operation
culty in reestablishing the service after the crisis. plan. Finally, information on external service
In the assessments of essential and nonessential requirements should be detailed. Public health
services, the potential development of resource departments are dependent on a variety of services
constraints ultimately resulting in the curtailment from organizations within and outside the city,
of even some essential services must be consid- county, and state agencies to function under ordi-
ered. For this reason, even those services initially nary circumstances. Pharmaceutical companies,
considered essential should be ranked so that laboratory services, and information technology
adjustments to essential service levels may be firms are among such support service organiza-
made in response to shifting priorities and conditions. During a crisis, this dependence continues,
tions during the crisis. but it will be altered. The level of some outside
238 Continuity of Health Service Operations During Pandemics
support services may decline due to the curtail- postpandemic recovery resources. The assessment
ment of nonessential services, while other support will also help leaders estimate how long the pro-
becomes more critical. cess of recovery will take. The information
During this process, the pattern of dependence required to make such decisions must come from
on agencies and organizations outside the public program-level personnel as part of the damage
health department must be made explicit. Potential report. At a minimum, the damage report should
difficulties in maintaining support services from contain program-specific information regarding
these organizations should be identified. Infor an assessment of the backlogged services created
mation regarding these organizations needs to be during the pandemic, a judgment regarding the
gathered as part of the continuity of operation priority of eliminating different types of back-
plans. Such information may include the follow- logged services, and an estimate of the level of
ing: (a) the type and level of support services dur- additional resources and time needed to eliminate
ing noncrises conditions, (b) the impact of the the backlogged services.
pandemic on the organizations’ capacity to con-
tinue to provide these services to support essential
public health services, (c) the level of continuity Testing and Exercises
planning that the organization has carried out to
ensure continued support to the public health To be effective, the procedures developed in the
department, (d) the point of contact at the organi- continuity of operation plans will require the
zation in the event of a pandemic, (e) the level and training of public health personnel. A testing,
type of prepandemic preparatory plans, (f) con- training, and exercise program includes activities
tract or procurement issues that may arise during to ensure that the public health organization is
a crisis, and (g) preferred communication methods capable of supporting the continued execution of
during the crisis. its essential mission and critical functions through-
out the emergency response. The most effective
method of training for emergency response proce-
Damage Assessment dures is in the form of exercises in which the per-
The continuity of operation plans should not sonnel to be trained are presented with realistic
only be designed for the continuance of essential scenarios that simulate pandemic management
services during a pandemic, they should also lay conditions. These exercises will also serve as a
the groundwork for the postpandemic recovery. guide in the important process of maintaining the
A damage assessment at the end of the crisis will plans over time in light of changing conditions
be required to determine the impact of the cur- and personnel reassignments.
tailment of nonessential services. Such an assess-
ment requires that program managers maintain
records during the crisis related to the impacts of Future Implications
reduced service. Some of the curtailed services Deadly influenza pandemics have occurred in the
will never be able to be provided after the pan- past, and they will indeed occur in the future. To
demic. An extreme example of this would be a save lives and minimize economic and social dis-
patient who died due to the reduction in normal ruptions, local public health departments must be
services. A more typical case would be nonessen- prepared and ready to meet the challenge. During
tial services that are capable of being backlogged the pandemic, resources will have to be redirected,
until after the crisis, such as restaurant inspec- some services will have to be temporarily elimi-
tions. At the end of the crisis, each program will nated, and special attention will have to be given
have to face the need both to resume normal ser- to essential services. To achieve the continuity of
vices and to develop plans to dispose of back- health services, public health departments will
logged services. need to systematically organize, prioritize, and
A damage assessment report should be mobilize their efforts.
developed that will allow upper management
to make decisions regarding the allocation of Kevin Croke and Dennis Cesarotti
Continuum of Care 239
See also Centers for Disease Control and Prevention person may need over the course of time to deal
(CDC); Community Health; Disease; Emergency and with his or her health condition. This includes the
Disaster Preparedness; Epidemiology; Hospitals; Public coordination of complex care and multiple ser-
Health; World Health Organization (WHO) vices that a patient may need to improve his or her
health outcome. Continuum of care is defined as a
client-oriented system of care that comprises both
Further Readings services and integrated mechanisms that guides
Committee on Implementation of Antiviral Medication and tracks patients over time through a vast array
Strategies for an Influenza Pandemic, Institute of of health, mental health, and social services that
Medicine. Antivirals for Pandemic Influenza: span all levels and intensity of care.
Guidance on Developing a Distributions and Client-oriented refers to the healthcare system
Dispensing Program. Washington, DC: National being designed around a client’s or patient’s need
Academies Press, 2008. and not the insurance company’s authorization for
Devlin, Roni. Influenza. Westport, CT: Greenwood services or the provider’s convenience. This concept
Press, 2008. makes every continuum potentially unique as each
Ryan, Jeffrey, ed. Pandemic Influenza: Emergency client has individual needs. The continuum of care
Planning and Community Preparedness. Boca Raton, concept is particularly relevant for clients with
FL: CRC Press, 2009. chronic disease conditions and with multiple comor-
Stewart, William. How to Prepare for a Pandemic: And bidities, whose clinical condition requires the coor-
Other Extended Disasters. Charleston, SC: Book dination of many diverse healthcare services.
Surge, 2006.
Healthcare must be approached in a holistic
Swayne, David E., ed. Avian Influenza. Ames, IA:
manner, particularly for those with complex and
Blackwell, 2008.
chronic illnesses. A person’s physical environment,
U.S. Congressional Budget Office. A Potential Influenza
financial status, social support, and emotional
Pandemic: An Update on Possible Macroeconomic
Effects and Policy Issues. Washington, DC: U.S.
well-being all affect health status. Therefore, the
Congressional Budget Office, 2006.
intertwining of health, mental health, housing, and
U.S. Government Accountability Office. Influenza social services should be considered to achieve pre-
Pandemic Challenges Remain in Preparedness. Report vention, cure, or disease management.
No. GAO-05-760T. Washington, DC: U.S. The aspect of the continuum of care model that
Government Accountability Office, 2005. guides and tracks a person over time assumes that
Woodson, Grattan. Flu Preparedness Planner: What It the client needs assistance to navigate the many
Is, How It Spreads, What You Can Do. Deerfield services available and to optimize the match of
Beach, FL: Health Communications, 2005. services to the client’s needs. Additionally, the con-
tinuum maintains an ongoing record of the client’s
condition and care. Baseline information, service
Web Sites intervention information, and service use data, as
Centers for Disease Control and Prevention (CDC): well as costs and charges and outcomes data, are
http://www.cdc.gov all evolving as integral to the prevention and treat-
National Association of County and City Health ment of individuals and populations.
Officials (NACCHO): http://www.naccho.org Last, all levels of care refer to the potential need
National Institutes of Health (NIH): http://www.nih.gov of a client for more or less intensity of care as the
PandemicFlu.gov: http://www.pandemicflu.gov client’s condition changes over time. For example, a
World Health Organization (WHO): http://www.who.int person with a hip fracture may need surgery in an
acute-care hospital and may then move to rehabilita-
tion for a period of several weeks. Following this, the
person may be discharged to his or her residence
Continuum of Care with home care or be discharged to a nursing home
for further recovery. As the client’s condition pro-
Continuum of care is a conceptual framework to gresses, the services that are needed change, and ide-
organize all the health and related services that a ally, the continuum of care facilitates this change.
240 Continuum of Care
Although quality, efficiency, and cost-effective- Interentity Integrated

ness are not explicitly stated in the definition of the Structure and Care Information Integrated
continuum of care, it is inherent in the model. Management Coordination Systems Financing
When a full range of services is available to a client
and matched to a client’s need, essential informa- Extended Care
tion should be shared across providers, quality of Acute Care
care should be maximized, transitions should be Ambulatory
efficient, and cost-effectiveness should be achieved. Care Home Care
Outreach
Client outcomes under a model of continuum of Programs
care should be better than under a fragmented sys- Wellness
Housing
tem of care. Programs
Overview
The concept of continuum of care started in the Figure 1 Services and Integrating Mechanisms of
United States in the early 2000s. The notion was Continuum of Care
to create an organized and seamless healthcare Source: Evashwick, C. Definition of continuum of care. In
delivery system to use limited resources most Managing the Continuum of Care, edited by C. Evashwick
effectively. Despite this, comparative outcomes and L. Weiss. Gaithersburg, MD: Aspen, 1987.
data that document the value of the ideal contin- Note: The services of the continuum are coordinated by
uum form of organization remain a challenge. deliberate integrating mechanisms.
Nonetheless, they will become increasingly avail-
able as electronic health records and comprehen- Nursing facilities are the dominant providers of
sive patient information systems provide this level of care. However, others that might pro-
opportunities to evaluate clinical outcomes and vide extended care for any given individual include
cost-effectiveness. The continuum is shown graph- rehabilitation hospitals, long-term care hospitals,
ically in Figure 1. assisted living in a state that allows a high health-
care component, and intermediate care facilities
for the mentally disabled in a state that allows a
Services
strong medical component. As federal and state
A partial list of more than 60 services of the con- regulations and nomenclature have changed, the
tinuum of care is presented in Table 1. These ser- providers in this category have varied.
vices are grouped into seven categories: (1)
extended care, (2) acute care, (3) ambulatory care,
(4) home care, (5) outreach services, (6) wellness Acute Care
activities, and (7) housing. The categories do not Acute care refers to acute medical or surgical
have a fixed order. An individual client will use a services provided by a licensed hospital. Acute care
unique combination of services in a sequential or implies a short period of time. However, the major-
simultaneous order appropriate for the person’s ity of patients in today’s hospitals have underlying
condition. Thus, categories of services could be diagnoses of chronic disease conditions. Thus, the
arranged by location (as they are in the diagram), acute inpatient stay is often just one episode in
by type of provider personnel, by the patient’s ongoing care. Many acute-care hospitals have ser-
functional status, or by any of a number of other vices for those with chronic conditions, as well as
variables. the services designed for episodic care.
Extended Care Ambulatory Care

Extended care refers to inpatient medical or Ambulatory care refers to medical and other
nursing care over an extended period of time. health services provided on an outpatient basis
Table 1 Services of the Continuum of Care
Extended Care Hospice

Nursing facilities Durable medical equipment
Sub-acute units
Outreach Programs
Intermediate care facilities
Mobile vans
Long-term–care hospitals
Telephone reassurance
Rehabilitation hospitals
Senior services
Psychiatric hospitals
Friendly visitors
Other chronic-care hospitals
Parish nurses
Acute Care Nurses in schools
Emergency rooms Nurses in housing complexes
General hospitals
Specialty hospitals Wellness Programs
Health education
Ambulatory Care Health fairs
Physicians’ offices Exercise programs
Multi-specialty group practices Workplace wellness
Outpatient clinics Disease management
Ambulatory-care centers
Urgent-care centers Housing
Community clinics Independent housing
Adult day care Assisted living
Continuing-care retirement
Home Care
Medicare-certified home health Communities
Private home health Board and care
High-tech home therapy Group homes
Note: The full continuum includes more than 60 services, grouped into seven major categories for convenience.
to persons who are not bedridden. Hospital Outreach Programs

outpatient clinics, ambulatory-care centers, phy-
Outreach services represent efforts by formal pro-
sicians’ offices, urgent-care centers, nurse practi-
viders and informal support services to reach people
tioner clinics in rural areas, physical therapy
in their homes and communities. These services are
clinics, and pharmacies offering consultation by
typically less medically intense than those available
licensed pharmacists are all examples of ambula-
in facilities with sophisticated equipment and a
tory care.
cadre of highly trained professionals. Examples of
services provided by formal healthcare organiza-
Home Care tions include mobile vans operated by hospitals,
health fairs conducted in community venues, and
Home, or the place of residence, is placed in the
telephone monitoring offered by for-profit compa-
center of the continuum of care schematic because
nies. Informal or volunteer services include programs
most people prefer to be at home, with care orga-
such as Friendly Visitor, sponsored by Area Agencies
nized under the assumption that they reside and
on Aging, home-delivered meals organized by church
function as independently as possible in their
volunteers, and telephone reassurance calls by vol-
home. Home care ranges from informal assistance
unteers organized by local community agencies.
provided by friends and families to care provided
by formal, government-regulated organizations
Wellness Programs
such as Medicare-certified home health agencies
and hospices. The majority of care in the home is These services are designed to help people stay
provided and paid for by families. healthy. They may occur at any location, from a
formal institution to a person’s home. They Care Coordination

encompass primary, secondary, and tertiary
This refers to coordination of clinical care. As is
prevention, with goals that range from initial
evident from the long list of services, clients may use
prevention of an acute condition to disease main-
many services over the years. Particularly for those
tenance for a chronic condition. Examples of
with complex and/or chronic disease conditions,
wellness activities include free fitness centers
services change over time as conditions change.
offered on-site by employers for employees,
Ideally, clinical information would be shared across
health education lectures held at hospitals, and
providers over time. For example, having a baseline
pharmaceutical management programs that mon-
assessment of a person’s functionality prior to a
itor potential drug interactions provided by mail-
stroke gives providers a basis on which to set goals
order pharmacies.
for recovery.
Clinical care may be coordinated in any of sev-
Housing eral ways. Rehabilitation uses the model of an
interdisciplinary team. Primary-care physicians
The home environment has a critical effect on often view themselves as the coordinator of medi-
a person’s health. A child living in a house with cal care and are officially designated by managed-
lead paint is at risk for lead poisoning; an elderly care organizations as the single person with the
person with a broken hip cannot return home as authority to authorize care by other providers,
quickly to a residence in a three-story walk-up particularly specialists.
apartment as can a person residing in a one- The role of the case manager, care coordinator,
story, easy-access ranch house. Assisted-living or service coordinator has evolved over the past
facilities have emerged during the latter part of three decades as a means for dealing with the frag-
the 20th century as the intersection between pro- mentation of services in the nation’s healthcare
moting independence and providing an environ- delivery system. Case managers are often regis-
ment rich in physical accessibility, service tered nurses, social workers, or even people with
availability, and cost affordability. Many assist- no specific professional degree or license but
ed-living facilities border on extended care, and people who have taken formal training by their
they are distinguished only by state regulations organization to coordinate the care of clients. The
on the amount of formal care allowed under each profession of case management has evolved to the
licensing category. extent that there are now nationwide professional
associations of care managers, and insurance
Integrating Mechanisms companies pay for case management functions
just as they do for the services of other healthcare
The services of the continuum of care do not fit
professionals.
easily together in the nation’s healthcare system.
These services arose at different times to serve
populations that might have been distinct at the
Integrated Information Systems
time. State licenses, federal regulations, payment
systems, and accreditation differ for each service. The sharing of client information across service
Thus, the rationale for fragmentation is historic. providers is still in its infancy. According to the
From the client’s perspective, the need to integrate ideal framework of the continuum of care, provid-
services is essential to obtain comprehensive care. ers of all services will be able to access client infor-
Four basic integrating mechanisms are incorpo- mation to understand disease state, environmental/
rated into the continuum of care definition. These social/financial dimensions that might affect health,
mechanisms include (1) care coordination, (2) prior treatments, service utilization patterns, and
integrated information systems, (3) integrated health outcomes. Ultimately, such record sharing is
financing, and (4) interentity management and essential to achieve efficiency and cost-effectiveness
structure. Other integrating mechanisms, such as of care for the tens of millions of people suffering
physician management and state policy, could also from multifaceted chronic disease conditions.
apply to specific situations. However, presently, information is held by each
individual provider, with only a minimum of infor- leading the main push toward enrollment in capi-
mation shared between providers on individual tated systems, each with its own variation of pay-
request. This puts clients at risk of duplicating ment and service organization parameters. Thus,
medical tests and ineffective services, not matching payment for the continuum of care services remains
services to the comprehensive state of the person’s highly fragmented, with a fragmentation in the
condition, and becoming ensnarled in complicated provision of services as well.
financial accounting and payment processes. There
are several examples of integrated information Interentity Management and Structure
systems that demonstrate both the value of such
management information systems (MIS) and the A full continuum of care need not be owned by
cost and complexity of implementation. For exam- a single entity, and it will most likely draw on sev-
ple, the Veterans Health Administration (VHA), eral organizations that are linked through a vari-
the largest multihospital system in the world, has ety of formal and informal mechanisms. To pull
implemented a comprehensive networked elec- all the services and integrating mechanisms
tronic patient clinical record system. The U.S. together, an integrated organizational structure
military has a patient clinical record system that must be present. This carries the inherent author-
enables a soldier in Hawaii to get blood drawn for ity to ensure that the various components of the
a test; fly to Los Angeles and get the test results system work as effectively and efficiently as
and start necessary medication; and then fly on to intended. Within a multiservice organization, this
Frankfurt, Germany, and be tested to see if the might take the structure of a service line, such as
medication is working—all within 24 hours. In the Cardiac Care, or a center of excellence, such as a
private sector, Kaiser Permanente has one of the Women’s Center. Across providers, this might take
best large-scale integrated patient clinical record the form of a preferred provider network or a
systems in the nation. multispecialty group practice that has its own hos-
pital, home-care agency, and nursing facility.
Formal transfer agreements articulate patient
Integrated Financing transfer terms in detail; informal relationships
For services to be provided according to a per- between two professionals who work together
son’s clinical need, financing must not be a barrier frequently may be equally effective at transferring
to care. In the United States, however, fragmented client information but must be bolstered by for-
services, differing coverage by insurance compa- mal agreements pertaining to legal and financial
nies, and many people without any health insur- issues.
ance coverage at all make integrated financing of
healthcare a major challenge. Managed care, origi-
Clients
nally begun as health maintenance organizations
(HMOs), is the conceptual model that makes Although the continuum of care is client-oriented,
financing of care on a service-by-service basis the terms used to refer to clients reflect the multi-
unnecessary. Under a capitated system, a person ple services encompassed in the continuum and
pays a monthly fee and is entitled to the full range the current lack of coordination among services.
of services covered by the insurance. With the Table 2 shows select services and the terms by
HMO model, a broad scope of services is available which they refer to the users of their services.
from a single, organized multiservice provider. The clients of the continuum represent a mosaic
Thus, single financing matches the single provider. of subsets of the population. Anyone might benefit
Kaiser Permanente and the VHA are, once again, from being part of an organized system of care. A
good models of this type of system. healthy individual might access preventive services,
Over the past two decades, however, the move wellness programs, and health monitoring. The
toward single source providers accepting capitated greatest benefit of the continuum is to those who
financing has dissipated as the nation’s consumers have complex, multifaceted illnesses requiring care
have insisted on an unlimited choice of providers. from several service providers either simultane-
At the present time, state Medicaid programs are ously or over time. Segments of the population
Table 2 Terminology Used for Clients of rather than physicians or case managers.
Continuum Services Healthcare is likely to be more coordinated for
those facing traumatic, disease-specific illnesses
Service Name Used for Clients
requiring multiple services over a relatively short
Hospitals Patient period of time, such as cancer treatment or hos-
Nursing facilities Resident pices for the terminally ill.
Hospice Patient The VHA and the U.S. Armed Forces medical
Home care Client systems have demonstrated that a fully integrated
Adult day services Participant continuum of care is feasible, and Kaiser Permanente
Assisted-living facilities Resident has demonstrated that the continuum of care can
Physicians’ offices Patient be cost-effective. However, integrating financial
Pharmacies Customers streams remains a challenge. Furthermore, inte-
grated information systems are increasingly sophis-
Note: Each of the services of the continuum establishes its
ticated and expensive, organizational structures
own terminology for the people it serves. that match clients with services run counter to the
American insistence on unrestricted choice, and
state and federal policies pertaining to the contin-
who are likely to benefit the most from an orga-
uum of care remain conspicuous in their absence.
nized continuum of care include (a) the very
As the nation’s population gets older and the pro-
elderly, 85 years of age or older, who are likely to
portion of individuals with multiple chronic dis-
have multiple chronic disease conditions; (b) peo-
ease conditions increases, the demand for
ple with severe chronic mental health problems; (c)
coordinated care may outstrip the social prefer-
children with special healthcare needs who require
ence for independence.
attention from health, welfare, and educational
Until future demand creates change, the contin-
systems; (d) those suffering from debilitating
uum of care model remains an ideal concept that
strokes and other neurological conditions; (e) vic-
helps structure individuals’ thinking about how
tims of Alzheimer’s disease; (f) people with major
healthcare services should fit together and what
functional disabilities; and (g) people with HIV/
must be done to accomplish the goal of having a
AIDS, chronic obstructive pulmonary disease
comprehensive, coordinated system of care that pro-
(COPD), congestive heart failure, and other sys-
vides high-quality care efficiently and effectively.
temic chronic disease conditions that require con-
stant and complex care. In short, the users of the Connie J. Evashwick
continuum might have a physiological or mental
condition as the primary diagnosis, suffer a perma- See also Acute and Chronic Diseases; Case Management;
nent condition or curable illness, and be experienc- Disease Management; Equity, Efficiency, and
ing an acute episode of need. The commonalities Effectiveness in Healthcare; Health Maintenance
include the use of multiple services offered by dif- Organizations (HMOs); Long-Term Care; U.S.
Department of Veterans Affairs (VA)
ferent providers, and thus the need to coordinate
the services for clinical, financial, and patient well-
being purposes is paramount. Further Readings
Evashwick, Connie J., ed. The Continuum of Long-Term
Future Implications Care. 3d ed. Albany, NY: DelMar, 2005.
Haggerty, Jeannie L., Robert J. Reid, George K.
In the early 2000s, healthcare that was organized Freeman, et al. “Continuity of Care: A
as a comprehensive and coordinated continuum Multidisciplinary Review,” British Medical Journal
of care was the exception rather than the rule. 327(7425): 1219–21, November 22, 2003.
Although large healthcare systems may have Joint Commission Resources. Assessing Cognitive and
many of the services that make up the continuum, Emotional Functioning Across the Continuum of
the majority of routine healthcare continues to be Care. Oakbrook Terrace, IL: Joint Commission
coordinated by individuals and their families Resources, 2003.
Cost-Benefit and Cost-Effectiveness Analyses 245
Kerber, Kate J., Joseph E. de Graft-Johnson, Zulfiqar A. various health interventions. This concept has
Bhutta, et al. “Continuum of Care for Maternal, become more important as health-related costs
Newborn, and Child Health: From Slogan to Service continue to rise. The federal government reported
Delivery,” Lancet 370(9595): 1058–1169, October that national health expenditures in the United
13, 2007. States amounted to $2.3 trillion in 2007, with per
McBryde-Foster, Merry, and Toni Allen. “The capita health spending estimated at $7,600. These
Continuum of Care: A Concept Development Study,” sums have been projected to rise to more than $4
Journal of Advanced Nursing 50(6): 624–32, June trillion and $12,320 per capita in 2015. Better use
2005.
of cost-benefit and cost-effectiveness analyses can
Mueller, Keith J., and A. Clinton MacKinney. “Care
help reduce these projections or at least help
Across the Continuum: Access to Health Care
ensure that resources allocated to the healthcare
Services in Rural America,” Journal of Rural Health
sector are justified by important health benefits.
22(1): 43–49, Winter 2005.
Shih, Anthony, Karen Davis, Stephen Schoenbaum, et al.
Organizing the U.S. Health Care Delivery System for
High Performance. New York: Commonwealth Fund, Overview
2008. A substantial part of healthcare expenditures is
financed through insurance or a third-party payer.
This renders many consumers insensitive to the
Web Sites actual price of healthcare, and they often shop on
the basis of perceived quality. Healthcare provid-
Commonwealth Fund: http://www.commonwealthfund.org ers, in turn, want to be regarded as “top quality”
Kaiser Permanente: http://www.kaiserpermanente.org
and often seek the latest technology to signal
National Quality Forum (NQF):
excellence to the consuming public. The pharma-
http://www.qualityforum.org
ceutical industry, medical equipment manufactur-
U.S. Department of Veterans Affairs (VA):
ers, and medical electronics producers, to name a
http://www.va.gov
few, actively seek to meet this demand with new
or at least differentiated products. Some have
called this a medical arms race. At the root of it is
a lack of cost-saving health technologies and a
Cost-Benefit and lack of confidence that money is being well spent.
Cost-Effectiveness Analyses Money may be squandered with productive inef-
ficiency, where inputs are not producing as much
Cost-benefit and cost-effectiveness analyses are output as possible, or money may be squandered
widely used tools in health services research to by producing output that is not sufficiently val-
control health spending and efficiently allocate ued to cover the costs, were it not for insurance
limited resources. The purpose of cost-benefit and contributions.
cost-effectiveness analysis is to compare the cost Cost-benefit and cost-effectiveness analysis are
and value of different health interventions and used to address these problems of inefficiency by
technologies and to evaluate whether this leads to comparing two or more interventions. The analy-
improved health and extension of life. The term sis can be seen as a four-part procedure.
cost-benefit analysis is used when the impact of the
health intervention is measured in monetary terms.
However, cost-effectiveness analysis does not use The Procedure
money to measure effects. Instead, cost-effective- First, costs must be identified and measured.
ness analysis typically uses health outcomes. Generally, all relevant costs are measured, includ-
Both cost-benefit and cost-effectiveness analy- ing those for the provision of health services and
ses help manage the efficient provision of health indirect patient costs, such as transportation costs
services and resource allocation while providing and the value of lost labor output due to illness.
an understanding of the cost and outcomes of Health service costs include direct costs, those that
246 Cost-Benefit and Cost-Effectiveness Analyses
vary with output, and indirect production costs, controversy about cost-utility analysis. One concern
such as overheads, which do not vary with output. is that the relative weights used to generate QALYs
Allocations may be included for fixed costs such implicitly use social values and subjectively impose
as buildings and equipment. Fixed and variable interpersonal utility comparisons. This contravenes a
costs overlap with direct and indirect costs. For fundamental tenet of neoclassical economic theory.
example, fixed costs may be direct or indirect Cost-benefit studies discount both costs and ben-
costs. The same is true for variable costs. efits. The discounting of nonmonetary effects in
Allocations for indirect production costs need to cost-effectiveness analyses is more controversial.
be linked to the output of health services in an This is sometimes done to reflect a social rate of time
efficient and fair manner. For example, custodial preference. But in other cases, it is not done because
or heating and cooling support costs can be allo- there is no opportunity cost of capital at issue.
cated by the proportion of square footage used to The third step is to combine the costs and ben-
provide the relevant health services. efits/effects. This is done by generating an inte-
Costs that are spread out over multiple years grated measure such as a benefit-cost ratio in
should also be discounted. Discounting accounts cost-benefit studies or cost per QALY in cost-effec-
for the opportunity cost of capital, which is theo- tiveness studies. A single stand-alone measure is of
retically given by the marginal product of capital. relatively little use. Far more useful is a comparison
The discount rate is also driven by an optimal rate of how one intervention compares with another.
of time preference. Under certain conditions, the This allows one to compare the relative efficiency
marginal product of capital and the rate of time of two or more interventions. For cost-benefit
preference are driven to equilibrium. In practice, analyses, policymakers may choose the interven-
however, determination of appropriate discount tion with the highest benefit to cost ratio. Cost-
rates is problematic. In applied settings, the oppor- effectiveness results differ somewhat. Table 1
tunity cost of capital is given by interest rates, and illustrates the possibilities when comparing the
these are sometimes used as discount rates even relative cost-effectiveness of the status quo with a
though they vary widely with inflation and risk. new technology. The most favorable result is the
Some economists have questioned whether market lower left box, where a new technology lowers
interest rates can be used to appropriately measure costs and improves outcomes. The least favorable
time preference, especially for a social rate of time result is the upper-right box, where the new tech-
preference. Many economists have called for the nology is associated with higher costs and worse
use of discount rates that are lower than prevailing outcomes. Such results are unambiguous, and
interest rates. In the 1990s, a consensus panel on medical decision makers can easily decide if the
cost-benefit and cost-effectiveness analyses in the new technology is cost-effective. More problematic
healthcare sector recommended the use of a real are results along the principal diagonal, where, for
(inflation-adjusted) discount rate of 3%. example in the lower right box, costs increase and
The second step in the process is to identify and outcomes improve. This is common in the health
measure the impact of health interventions. sector since this is the purpose of much technical
Sometimes, these are intermediate outcomes, such innovation. But even here, cost-effectiveness analy-
as diagnostic accuracy, timeliness of intervention, sis can be quite helpful. It can yield measures that
or a physiological response. Many of these mea- provide information about how much additional
sures are generated in clinical settings, especially cost is incurred for a given improvement in health.
from medical research. More general health out- This might be in the form of a cost per QALY. A
comes are also used. One approach is to use qual- low cost per QALY is commonly regarded as a
ity-adjusted life years (QALYs), which weight justified expense, while a very high one is often not
years of life for relative health impairment. A seen to be economically prudent. A clear-cut
greater level of disability leads to a lower weight- threshold does not exist, but numbers such as
ing given to a year of life. $100,000 per QALY have been put forward for
Sometimes studies that use QALYs or similar advanced economies such as the United States.
tools to measure effects of health interventions are The fourth step that is typical of cost-benefit
called cost-utility analyses. There has been some and cost-effectiveness studies is sensitivity analysis.
Cost-Benefit and Cost-Effectiveness Analyses 247
Uncertainty is endemic in most such studies. There politically weak elements in society and the costs
may be questions about the medical effectiveness fall primarily on influential groups, the new tech-
of new drugs or procedures, and there may also be nology may never be integrated into the fabric of
doubt about the exact cost of workers or of labor medical or public health practice. Political forces
productivity. Frequently, there is uncertainty about are very important in the healthcare sector, and it
the appropriate discount rate. A robust conclusion is often the case that good policy is trumped by
about cost-effectiveness should stand up to a wide what leaders regard as good politics.
range of estimates for key variables. Therefore,
sensitivity analysis tests for this and shows how
Application to Health Policy
different values for key variables affect the result.
Sensitivity analysis should be done for a reason- Experience with cost-effectiveness analysis in the
able range of values for all variables that might policy arena has shown that the policy processes by
drive the conclusion. which health resources are allocated are generally
It should be pointed out that cost-benefit and not amenable to the strict use of benefit-cost ratios
cost-effectiveness analyses do not necessarily pro- or cost per QALY as the only means to allocate
vide information about the improved efficiency health service resources. For example, a society
from a general equilibrium standpoint. That is to may put a higher value on treating one person with
say, while cost-effectiveness analysis can show how a severe illness associated with a high cost per
a different approach compares with the status quo, QALY compared with a widespread screening or
it does not account for implications beyond the nar- treatment of a larger group of people for a less
row confines of the healthcare interventions under severe problem associated with a lower cost per
study. A shift to a new technology, for example, QALY. Health risks are not always viewed in a
might have implications elsewhere in healthcare or linear or consistent fashion in society. We may bear
outside healthcare altogether that are very profound a much higher health risk for some activities, per-
and can skew the net welfare gains one way or the haps operating a motor vehicle, than we do for
other. However, this is rarely considered. other activities such as the use of common over-
In reporting cost-benefit and cost-effectiveness the-counter medications. This lack of consistency
studies, it is important to identify how costs and undermines the strict use of such economic meth-
benefits/effects are distributed. Most economists odologies. On the other hand, cost-benefit and
are first and foremost concerned about net gains in cost-effectiveness studies are important tools for
welfare. But political scientists and others often policymakers to decide how best to allocate scarce
emphasize distributive issues. A new intervention resources.
may be relatively cost-effective, but if the benefits It is also common in reporting the results of cost-
fall primarily on the disenfranchised or otherwise benefit and cost-effectiveness studies to identify key
Table 1 Cost-Effectiveness Matrix
Lower Cost Same Cost Higher Cost
Worse Outcome Ambiguous Less efficient Less efficient
Same Outcome More efficient Ambiguous Less efficient
Better Outcome More efficient More efficient Ambiguous

248 Cost Containment Strategies
limitations of the study. Perhaps there are doubts Neumann, Peter J., Allison B. Rosen, and Milton C.
about the data and how it can be generalized for Weinstein. “Medicare and Cost-Effectiveness
wider applications. The population studied may Analysis,” New England Journal of Medicine
limit the study, and results may not be relevant in 353(14): 1516–22, October 6, 2005.
other settings, or perhaps technical change is so Nordman, Alain J., Murray Krahn, Alexander G. Logan,
rapid that the study results may no longer be valid. et al. “The Cost Effectiveness of ACE Inhibitors as
A wide variety of limitations may exist, and impor- First-Line Antihypertensive Therapy,”
tant ones should continue to be identified. Pharmacoeconomics 21(8): 573–85, 2003.
Future Implications
Web Sites
As healthcare costs continue to rise, cost-benefit
Agency for Healthcare Research and Quality (AHRQ),
and cost-effectiveness analyses will continue to
Focus on Cost-Effectiveness Analysis:
play an important role in controlling healthcare
http://www.ahrq.gov/research/costeff.htm
spending and the use of scarce resources more effi-
National Institute for Health and Clinical Excellence
ciently and prudently. As healthcare costs and the
(NICE): http://www.nice.org.uk
benefits of health interventions are increasingly Tufts-New England Medical Center Cost-
scrutinized, cost-effectiveness and cost-benefit Effectiveness Analysis Registry:
analyses will be central to evaluating new tech- https://research.tufts-nemc.org/cear/default.aspx
nologies to examine if they lead to improved health
outcomes and are justified compared with the rela-
tive expenditures and other available options.
Peter Hilsenrath Cost Containment Strategies
See also Cost Containment Strategies; Cost of Healthcare;
Equity, Efficiency, and Effectiveness in Healthcare; Cost containment can be defined as reducing the
Health Economics; Pharmacoeconomics; Quality- level or rate of increase in healthcare costs.
Adjusted Life Years (QALYs); Technology Assessment; During the past decades, healthcare spending in
United Kingdom’s National Institute for Health and the United States has grown at a much faster
Clinical Excellence (NICE) rate than has the general economy. Total health-
care spending increased at rates well in excess of
Further Readings the nation’s gross domestic product (GDP). In
2006, total healthcare spending was $2.1 tril-
Brauer, Carmen A., Allison B. Rosen, Dan Greenberg, lion, representing 16% of the nation’s GDP.
et al. “Trends in the Measurement of Health Utilities These figures are expected to greatly increase in
in Published Cost-Utility Analyses,” Value in Health
the future. By 2016, with a projected average
9(4): 213–18, July–August 2006.
annual percentage growth of 6.9%, the nation
Edejer, T. Tan-Torres, A. Baltussen, T. Adam, et al.
will spend a total of $4.2 trillion, or 20% of its
Making Choices in Health: WHO Guide to Cost-
GDP, on healthcare.
Effectiveness Analysis. Geneva, Switzerland: World
There are many factors increasing healthcare
Health Organization, 2003.
Fredrick, Shane, George Loewenstein, and Ted
costs, including general inflation within the econ-
O’Donoghue. “Time Discounting and Time omy, inflation specific to the healthcare industry,
Preference: A Critical Review,” Journal of Economic overall population growth, the growth of the
Literature 40(2): 351–401, June 2002. elderly, health insurance, and new medical tech-
Muennig, Peter. Cost-Effectiveness Analysis in Health: A nology. Although there is debate over which spe-
Practical Approach. 2d ed. San Francisco: Jossey- cific factor contributes the most to rising healthcare
Bass, 2007. costs, it is clear that these costs must be contained
Neumann, Peter J. Using Cost-Effectiveness Analysis to in some way. And a number of different strategies
Improve Health Care: Opportunities and Barriers. have been developed and proposed to contain the
New York: Oxford University Press, 2005. costs.
Cost Containment Strategies 249
Efforts to Control Healthcare Costs Medicaid

The primary method of controlling rising health- State efforts to control the costs of healthcare
care costs is giving incentives for providers to have focused on Medicaid, which is jointly funded
operate with reduced or controlled financial by the states and the federal government. In their
resources. Supply factors, particularly increased efforts to control costs, states have used their dis-
national medical capacity, are believed to be more cretion to determine who is eligible for Medicaid,
important than demand factors in explaining the what optional benefits to provide, and how much
high use and costs of the nation’s healthcare. to reimburse providers. The various state efforts at
Efforts by the public sector to contain healthcare cost containment have found the following: (a) one
costs have focused mainly on controlling the levels of the most effective means of managing costs is to
of and increases in payments to providers. In con- limit access to the program; (b) states that set
trast, the private sector has focused on managing broad eligibility levels often accompany them with
and controlling access to healthcare. tightly regulated provider payment rates; and (c)
states that include all payers in their cost contain-
ment strategies appear more effective than states
Public-Sector Efforts with more limited (Medicaid-only) interventions in
controlling costs.
In the public sector, the most important cost con-
tainment strategies have focused on the Medicare
and Medicaid programs and on healthcare capital Certificate of Need
spending through state Certificate of Need (CON) The CON program is a regulatory process that
programs. requires hospitals, nursing homes, and other health-
care providers to obtain state approval for the
expansion of their facilities or for major capital
Medicare’s Prospective Payment System equipment purchases. The CON program intends to
prevent unnecessary duplication of services by
To control community hospital costs, Medicare
selecting the best proposal among competing appli-
implemented the prospective payment system
cants that wish to provide a particular health service.
(PPS). The PPS sets hospital payments rates prior
CON may have a significant effect on the capital
to when care is given. By setting a fixed reim-
spending of providers. However, empirical results on
bursement level based on diagnosis, prospective
the effectiveness of CON programs on controlling
payment provides economic incentives for hospi-
the costs of healthcare have been mixed.
tals to conserve the use of their input resources.
Hospitals that use more resources than covered by
the flat rate lose the difference, while those with Private-Sector Initiatives
costs below the rate retain the difference.
Employers have attempted to limit the rise in
healthcare costs by increasing the share of costs
paid by workers; managing the supply of care; and
Medicare’s Resource-Based Relative Value Scale self-insuring their companies. Efforts by employ-
To control physician fees, Medicare imple- ers to control costs have also focused on the man-
mented the Resource-Based Relative Value Scale agement of specific health benefit programs. These
(RBRVS), which pays physicians for the various efforts have relied on innovative designs to reduce
services they provide based on the amount of unnecessary use of medical care services and to
expertise needed, how much time they spend with negotiate lower provider payment rates.
the patient, and other factors. By using the RBRVS
and changing the level of payment, certain high-
Cost Sharing
growth, highly profitable services, such as endos-
copy and ambulatory cardiac monitoring, may be Insurance coverage may lead to the overuse of
slowed and not be overused. healthcare by the insured. Cost sharing (e.g.,
250 Cost Containment Strategies
coinsurance or deductibles) can be used to reduce treat conditions, education to persuade physicians
the demand for healthcare services and thus to to use more effective care, and precertification or
reduce spending. When consumers are paying utilization review to prevent unnecessary care.
some or all the charges for healthcare services, However, there is much controversy surrounding
they tend to use fewer services. The famous estimates of how many procedures are medically
RAND Health Insurance Experiment (HIE) dem- unnecessary, and there is no evidence as to whether
onstrated that cost sharing can be an effective the proportion of unnecessary procedures has
means of reducing healthcare utilization levels. grown with time or whether medical services that
are growing in frequency are more likely than oth-
ers to be performed inappropriately.
Managed Care
Managed care, typically provided by health
maintenance organizations (HMOs) and preferred Limit Coverage of Services
provider organizations (PPOs), has been viewed as Private insurers limit the services they cover
a means of controlling healthcare costs. These through specific exclusions, financial limits, or
organized delivery systems provide or arrange to limits on coverage according to circumstances. In
provide a coordinated continuum of care to a addition, many insurers exclude specific services
defined population. These systems are both clini- that they deem to be experimental or ineffective.
cally and fiscally accountable for the outcomes and
health status of the population they serve. By com-
bining the clinical and fiscal accountability, man- Healthcare Reforms
aged care creates incentives for keeping people
Some health services researchers and policy ana-
well by emphasizing prevention and health promo-
lysts argue that the only effective way to control
tion practices. When their members become ill,
the nation’s healthcare costs is through some form
they treat them in the most cost-effective manner,
of major healthcare reform. These reform efforts
which often limits their hospitalization.
may include the following: establishing a single
payer system, the use of expenditure targets,
Consumer-Directed Health Plans global budgets, and rationing healthcare.
Consumer-Directed Health Plans (CDHPs) are
a recent attempt at cost containment. The plans Single-Payer System
have three elements: (1) medical saving accounts
(MSAs), (2) high-deductible health insurance plans, Cost savings and greater cost control may be
and (3) detailed information on healthcare provid- achieved by having a single payer or a single set of
ers. Individuals and companies make tax-free con- rules applying to all payers. Canada and the United
tributions, up to a certain amount, into a special Kingdom both use a single-payer system. Uniformity
savings account, which can be used to pay for enables the system to control costs and minimizes
medical expenses. Unused funds are carried over to cost shifting and reduces the administrative costs
the next year. To protect against the costs of a of dealing with multiple payers. However, there is
major illness or accident, the individual must also concern that a single-payer system would discour-
have a high-deductible health insurance plan. Last, age innovation, decrease consumer choice, and
for individuals to be wise consumers, they must limit market forces.
have access to information on provider’s costs,
quality, and outcomes enabling them to “shop
Expenditure Targets
around” for the best services.
This strategy relies on creating a target level for
total healthcare expenditures. The target is enforced
Increased Use of Appropriate Care
by rules that any expenditure above the target will
This strategy generally envisions some combina- trigger future reductions in payments per service
tion of research to identify more effective ways to or coverage. Such targets can be applied across all
Cost Containment Strategies 251
providers or to groups or individual providers. The rising health insurance premium costs sug-
Expenditure targets differ from global budgets in that gest that managed care has largely failed. And
they are a policy goal rather than an absolute limit on the effects of cost sharing on health expenditure
spending, and they trigger payment reductions that growth over time are less clear. In addition, there
apply to future years rather than to the current year. are growing concerns about the possible negative
effects of healthcare cost containment strategies
on access to care and the quality of care. Further
Global Budgets more, cost containment may decrease innova-
Global budgeting approaches are common in tions in medical technology. Nevertheless, healthcare
countries where their healthcare systems operate cost containment remains one of the most sig-
within a national budget. Global budgets differ nificant issues facing the nation.
from expenditure targets because they contain a
formal management process to ensure staying Tae Hyun Kim
within the budget. The Clinton administration’s
national healthcare plan proposed using global See also Consumer-Directed Health Plans (CDHPs); Cost
budget caps to limit healthcare spending. The proof Healthcare; Healthcare Financial Management;
posed plan specified that beginning in FY1999, Healthcare Reform; Health Economics; Payment
premium amounts for regional health alliances Mechanisms; Prospective Payment; Rationing
would not be allowed to increase faster than the Healthcare
sum of population growth and the projected
increase in the Consumer Price Index (CPI). In
later years, total healthcare expenditures would be Further Readings
allowed to rise at the growth rate of the GDP. It
was believed that managed competition alone, Gold, Marthe R., Shoshanna Sofaer, and Taryn
without global budgets, would not slow the rate of Siegelberg. “Medicare and Cost-Effectiveness
increase in healthcare costs. Analysis: Time to Ask the Taxpayer,” Health
Affairs 26(5): 1399–1406, September–October
2007.
Rationing Healthcare Greifer, Nicholas. Health Care Cost Containment.
Chicago: Government Finance Officers Association of
Rationing healthcare involves planning deci- the United States and Canada, 2005.
sions to not create or to eliminate the capacity to Keating, Nancy L., Mary Beth Landrum, Bruce E.
produce healthcare services that are currently used Landon, et al. “The Influence of Cost Containment
or demanded but are judged to be “unnecessary.” Strategies and Physicians’ Financial Arrangements on
This process means that patients will be denied Patients’ Trust and Satisfaction,” Journal of
care that either they or their physicians want. Ambulatory Care Management 30(2): 92–104,
Many plans for controlling healthcare costs limit April–June 2007.
supply by restricting the funding available per per- Rivers, Patrick A., Nina German Hall, and Jemima
son and then decentralize decision making and Frimpong. “Prescription Drug Spending: Contribution
financial responsibility to levels such as the state to Health Care Spending and Cost Containment
(for Medicaid), and HMOs, or a health authority Strategies,” Journal of Health Care Finance 32(8):
(United Kingdom). These strategies are intended 8–19, Spring 2006.
both to provide incentives for greater efficiency Schiff, Maria, Maxine Schuster, Sara Bachman, et al.
and more appropriate care and to allow some local “Employee Input and Health Care Cost-Containment
flexibility in living within a fixed budget. Strategies,” Managed Care Interface 16(10): 20–24,
October 2003.
Stanton, Mark W. Reducing Costs in the Health Care
System: Learning From What Has Been Done.
Future Implications
Research in Action, Issue No. 9. AHRQ Pub. No.
Despite much effort, there is little evidence that 02-0046. Rockville, MD: Agency for Healthcare
cost containment strategies have been successful. Research and Quality, 2002.
252 Cost of Healthcare
Web Sites Healthcare Costs and Prices

Centers for Medicare and Medicaid Services (CMS): The cost of anything is generally the price at which
http://www.cms.hhs.gov it is bought. In a competitive market, the price
Healthcare Financial Management Association (HFMA): equals the marginal cost of producing the good or
http://www.hfma.org service. The cost in turn depends on the prices of
Leapfrog Group: http://www.leapfroggroup.org the raw materials and labor and the production
National Coalition on Health Care (NCHC): process that is used to create the product.
http://www.nchc.org In the case of healthcare, the link between the
marginal cost of producing a service and its price
is loose at best. Markets for healthcare services are
not competitive, in large part because information
Cost of Healthcare problems are significant in these markets. Most
people do not have the medical knowledge neces-
sary to diagnose what various symptoms mean;
In 2006, the latest year for which data are avail-
most physicians cannot keep track of all the new
able, the United States spent $2.1 trillion on
pharmaceuticals that are available; and health
healthcare. This is equivalent to just over $7,000
insurance shields people from asking and knowing
per person and accounted for 16% of the nation’s
the prices of alternative services and healthcare
gross domestic product (GDP). National health-
providers. The result is that the standard economic
care expenditures are the sum of many different
model of how prices are set and how they relate to
types of healthcare spending, but chief among the
costs of production is not a realistic portrayal of
types are hospital care ($648.2 billion, accounting
price setting in healthcare markets.
for 30.8% of the total), physical and clinical ser-
Healthcare prices are set primarily by negotia-
vices ($447.6 billion, 21.3%), prescription drugs
tions between insurers and healthcare providers
($216.7 billion, 10.3%), and home health and
and by administrative decisions by insurers. Politics
nursing home care ($177.6 billion, 8.4%).
also affects Medicare and Medicaid decisions
Total healthcare spending equals the prices that
about how much they will pay for specific medical
people pay for specific types of medical services—
services. Representatives of hospitals, specialty
the costs of healthcare—multiplied by the quantities
groups of physicians, nursing home operators, and
of each specific type of care they received. Thus,
pharmaceutical manufacturers all lobby the U.S.
while the costs of healthcare and healthcare spend-
Congress and state legislators about the Medicare
ing are often used interchangeably, they are not the
and Medicaid reimbursement rates.
same. The common substitution of spending for
costs in this context occurs in large part because
total spending is a cost to individuals and to society.
Setting Prices for Healthcare Services
How much individuals spend on healthcare involves
resource allocation decisions; spending on health- Prices for healthcare services are set in a number
care has an opportunity cost in terms of income of ways. Providers can be paid a fee for each ser-
that cannot be spent on other goods and services. vice provided—what is often called fee-for-service
This entry begins by examining the tenuous link pricing. Prices may be set as fixed amounts that
between healthcare costs and prices, and how will be paid for providing any necessary services
prices for healthcare services are set. The discus- for treating a person’s specific disease or condition.
sion then shifts to why healthcare spending has This predetermined or prospective fee method can
been growing at rates exceeding population growth be expanded and a fee may be set to cover all
and income growth, and why that difference is medically necessary services for a person for a
viewed by many analysts and policymakers as a specified period of time, usually a year. This is usu-
looming problem for the United States as well as ally referred to as a capitated payment (a payment
other nations. per capita). Another method of setting prices is
Cost of Healthcare 253
known as cost-based reimbursement—this is often unexpected number of patients became very sick.
used when a medical service is new and so there is Nonetheless, prospective payments are still used
little information on the costs of providing the by many managed-care plans to price payments to
service and there is an expectation that the costs physicians to take care of patients’ predictable
will decline over time. Finally, lump-sum payments medical care during a year. In 1983, Medicare
or block grants can be used to pay providers. In implemented the prospective payment system (PPS)
this case, physicians are paid a salary, and hospi- to pay hospitals. The PPS is based on the average
tals, nursing homes, and other institutional provid- costs of caring for a person with a diagnosis that
ers are given a budget for operating costs related to fits within approximately 500 Diagnosis Related
an expected number of people needing their ser- Groups (DRGs). The costs are adjusted for each
vices during a year. hospital, and adjustments are also made for the
Fee-for-service pricing has its roots in how phy- costs of labor in the geographic area where the
sicians set prices for hundreds of years: They hospital is located. Medicare has also developed a
charged a fee for each service provided. In the days similar prospective payment pricing system for
when physicians did not have many options for skilled-nursing facility services.
how to diagnose or treat symptoms, the fees were It may seem odd to discuss cost-based pricing of
generally in proportion to the length of time a visit some medical services when the costs are so diffi-
lasted—a brief visit or a longer visit. Similarly, cult to determine in healthcare markets. However,
when hospitals began to proliferate in the late even cost-based pricing is not determined by com-
1800s, they set prices as per diem prices. As Blue petition; rather, the cost basis is arrived at through
Cross and Blue Shield health insurance plans and negotiations between providers and payers. As
commercial insurance grew in the 1930s, they ini- noted earlier, cost-based prices are generally used
tially sold indemnity policies that reimbursed to set reimbursement fees for new medical or surgi-
enrollees a set amount per day in the hospital or cal procedures and new diagnostic equipment
for a surgery or physician visit. The indemnity pay- when there is an expectation that within a period
ments were tied to norms of physician and hospital of time the costs will be lower. They will decline
fee-for-service pricing. When Medicare began pay- because after a learning period, physicians will be
ing providers in 1966, the payments were inten- able to perform the procedures with less time and
tionally set to follow the lead of the Blues and the effort, and the new machinery will become less
commercial insurers. Medicaid and its predecessor expensive per unit as more are produced. The pay-
state programs also based their payments to pro- ments for about 40% of the Medicare DRGs are
viders on the basis of fee-for-service pricing, but cost based rather than set prospectively.
Medicaid has always discounted the fees and paid Pricing physician time and effort is viewed by
between 50% and 60% of the fees. many as both problematic and unseemly. This can
Prospective pricing has its roots in the managed- be particularly true when it is difficult to judge the
care movement in the nation and the original quality of individual physicians or when a society is
health maintenance organizations (HMOs). The trying to create greater income equality. Paying
initial version of prospective pricing paid groups of physicians a salary is another way in which a price
physicians capitated payments for taking responsi- for physician expertise and time has been set. The
bility for all the healthcare needs of a group of U.S. Department of Veterans Affairs (VA), the
people during the year. During the late 1980s, as United Kingdom’s National Health Service (NHS),
more forms of managed-care plans proliferated, and a large number of countries’ public health ser-
many physicians were enthusiastic about being vices pay physicians a salary. The salary is compen-
paid prospectively. They thought that they could sation either to take care of a number of people
make more money under this pricing system than who live near the physician or to see patients during
with fee-for-service payment schedules. Support specified hours during a week. Similarly, operating
for it soon faded, however, as physicians realized budgets for hospitals often are determined as part
they could be at risk for large sums of money if an of the budget determination process of countries,
counties, and municipalities. Such fixed budgets are expenditures per person rose from $960 in 1960
related to the expected number of people from (in 2006 dollars) to $7,026 in 2006. The share of
the surrounding area who will be hospitalized. GDP spent on healthcare more than tripled, rising
Prospective payments, salaries, and set budgets are from 5.1% to 16.0%. The growth in healthcare
quite similar, but each has slightly different incen- spending as a fraction of GDP is not without
tives for how care is provided and how underlying costs—it influences the allocation of the nation’s
costs are minimized. resources and drives up the cost of health insur-
ance, which affects individuals’ incomes and deci-
sions about how they spend their incomes as well
Prices Paid by Private Insurance, as employers’ decisions about sponsoring health
Medicare, Medicaid, and the Uninsured insurance for employees.
Since the early 1980s, Medicare and commer-
cial insurers have become more aggressive about Effects of Various Factors on the
setting the prices they will pay for a wide variety of Growth in Healthcare Spending
hospital, physician, and other providers’ services.
The growth in healthcare spending per person is
The Medicare reimbursement rates have become
due to a number of factors. Although the aging of
progressively more formulaic for physician ser-
the nation’s population is often raised as a factor,
vices, and prospective, fixed rates are used for
the best estimates are that it was responsible for
most hospital and skilled-nursing facility care. The
only a small share (7%) of the increased spending
Medicare reimbursement rates take into account
between the 1950s and late 1980s. Since 1960,
geographical differences in the costs of labor and
health insurance policies have covered more ser-
other factors such as electricity and rent of offices.
vices, and the fraction of the population covered
Commercial insurers, including nonprofit plans,
by insurance has increased, especially because
have negotiated reimbursement rates that often
Medicare and Medicaid were implemented. Greater
follow the fee schedules and rates set by Medicare.
insurance coverage increases the demand for
Managed-care plans have experimented with vari-
healthcare, since people do not face the full cost of
ous forms of prospective and capitated payments
such care. But the best estimate is that the greater
to physicians and physician groups. Starting in the
insurance coverage is responsible for only as much
early 1990s, when a majority of states started to
as 10% of the growth in per capita healthcare
move Medicaid recipients into managed care, the
spending through the late 1980s. Rising incomes
rates paid to managed-care plans have been negoti-
can also contribute to increased demand for care,
ated or administratively set by the states.
and incomes have risen since the 1960s, especially
For people with private health insurance or
for the top half of the income distribution. It is dif-
those who are covered by Medicare and Medicaid,
ficult to disentangle the effects of increased indi-
these different reimbursement mechanisms effec-
vidual incomes from the effect of greater overall
tively set the prices for healthcare services. The
national wealth, which contributes to growth in
only people who pay healthcare providers’ “usual
medical technology. Nonetheless, the best estimate
and customary” stated charges, which can be set
is that increased income accounted for something
however the providers want, are the uninsured—
between 5% and 25% of the growth in per capita
they do not have an insurance plan administra-
healthcare spending through the late 1980s.
tively setting the prices or negotiating discounts off
Between 1960 and 1990, the federal government
the charges.
increased funding for medical schools and encour-
aged foreign physicians to emigrate to the United
States so as to increase the number of physicians
Growth in Healthcare Spending and Its Costs
per capita. Some analysts believe that the increased
Since the 1960s, national healthcare expenditures in number of physicians per capita contributed to
nominal dollars have grown from $26.9 billion to increased spending. This explanation is often tied
$2.1 trillion in 2006. If general price inflation and to a belief that physicians induce demand for their
population growth are accounted for, healthcare services—either to gain more income or to avoid
Cost of Healthcare 255
malpractice lawsuits. But the evidence does not increased, and the average length of stay in hospi-
support these explanations for the rate of growth in tals has declined over the past five decades. Thus
healthcare spending per person between 1960 and the 10-fold increase in inflation-adjusted total hos-
2005. At most, the increase in physicians per capita pital spending strongly implies increased intensity
accounts for a 1% increase in such spending. and amounts of care being provided to those who
Other explanations for the growth in spending are hospitalized. Hospital staffing and wages have
include the consumer price index and the fact that not increased enough to explain this large an
productivity gains in medical care treatment are increase in spending per hospital stay; technologi-
very difficult to measure. The result of the mea- cal changes seem far more plausible. Moreover,
surement problem is that it is empirically difficult more types of surgeries and diagnostic tests have
to decompose the increase in medical expenditures become outpatient procedures that do not require
into the share due to increases in prices and the an overnight stay in a hospital—and much of this
share due to increases in quantity of services pro- shift has been made possible because of techno-
vided. In sum, all these factors appear to explain logical changes. The shifting of surgeries and diag-
no more than half, and more likely only a quarter, nostic procedures to outpatient care has had the
of the growth in healthcare spending per person effect of increasing the degree of medical difficulty
since 1960. (the case-mix) of hospital inpatients. In spite of
this, however, the average length of a hospital stay
has declined, which is consistent with the hypoth-
Technological Change and
esis that technological change is responsible for the
Increased Capabilities in Medicine
majority of the increase in healthcare spending.
What then explains the remaining 50% to 75% Finally, the rate of increase in healthcare spend-
of the increased healthcare spending per person? ing for managed-care plans, especially those with
The explanation that most healthcare economists tighter controls on patient access to specialists, has
favor is technological change in medicine that has been the same as that of health plans that paid
increased the capabilities of medical care. Proving providers on a fee-for-service basis. Similarly, the
that technological change is the primary source of rate of increase in healthcare spending in the United
the enormous growth in per capita healthcare States has been about the same as that of most
spending is difficult; the evidence for it is primarily industrialized countries, especially since the 1980s.
circumstantial. First, medicine has changed dra- This is in spite of very different levels of spending
matically since 1960. People now survive diseases per capita, ratios of healthcare personnel per cap-
such as cancer, congestive heart failure, and renal ita, and financing mechanisms. The similarity in
disease that they would have died from quickly in rates of growth for both of these comparisons sug-
the 1960s. The quality of life for people with a gests that a common factor is the explanation—
variety of non-life-threatening conditions, such as and improvements in medical technologies affect
orthopedic problems, arthritis, and eye conditions, all these different health plans and countries.
is enormously better today, with a wide variety of
pharmaceuticals and joint replacement surgeries
Skewed Distributions of Healthcare
that have been developed within the past three
Spending and Technological Change
decades. Some of these medical advancements
have reduced the cost of treating some diseases The distribution of annual healthcare expendi-
(e.g., laser cataract surgery), but most have high tures per person is very skewed—a relatively small
costs. Spending has increased because the new fraction of the population is responsible for most of
technologies have been covered by health insur- the spending in a year. Half of the population
ance and most people are insured. spends less than $500 per year on healthcare,
Second, hospital care accounts for the largest including one fifth who have no healthcare expen-
share of healthcare spending—since 1960, it has ditures either because they do not get sick enough to
accounted for between 30% and 40% of national seek care or they simply do not seek medical care.
healthcare expenditures. But the fraction of people Altogether, this half accounts for only 3% of all
being admitted as inpatients to hospitals has not spending. People with annual expenditures that put
them in the top 10% of the expenditure distribution cycle, advances in neonatology are enabling babies
are responsible for about 70% of all healthcare to live who more than 30 years ago would have
spending. To be in the top 10% of the population died before they were a year old. Similarly,
in terms of healthcare spending, a person would advances in medicine’s understanding of immunol-
have had expenditures above $15,000 in 2005. The ogy, genetics, and a wide range of diseases and new
threshold for the top 2% was $30,000, and the engineered drugs have allowed people to be long-
threshold for the very top 1% was $50,000. term survivors of diseases that were untreatable
People in the top 1% or 2% of the medical just two decades ago.
spending distribution are very sick—and new In spite of these benefits, it is not clear that the
medical technologies that allow them to live are increases in spending have improved most people’s
driving the expenses. The group includes people lives. Americans do not have higher life expectan-
who need very costly pharmaceutical treatments to cies than citizens of other industrialized countries.
stay alive (e.g., people with rare forms of hemo- Moreover, within the United States, regions that
philia), premature babies, people with spinal cord have higher per capita spending do not have sig-
injuries, and people who have had organ trans- nificantly better health as measured by a variety of
plants or cardiac events, including strokes. Until health outcomes.
two or three decades ago, there was very little that Furthermore, the pace of per capita healthcare
medical providers could do for people with these spending has been faster than the growth in
conditions. Among the 15 most costly medical median income, general price inflation, and pro-
conditions in 1997, the three with the largest ductivity of the average worker. The result is a fact
shares of total spending were heart disease (10%), noted earlier—national healthcare expenditures
cancer (8%), and trauma (8%). An analysis of the have grown faster than the GDP since 1960 and
same 15 most costly diseases and conditions found accounted for 16% of the GDP in 2006. The fed-
that when the increased expenses for them between eral and state governments were responsible for
1987 and 2000 were decomposed into spending about 45% of the total spending on healthcare
versus treated prevalence (i.e., the number of peo- (with Medicare, Medicaid, and the State Children’s
ple per 10,000 who were treated for the condition), Health Insurance Program (SCHIP) being the larg-
seven had higher spending because of increased est of the public programs), and Medicaid now
costs and not greater prevalence of treated people. accounts for the largest share of many states’ bud-
The seven include the three most costly conditions gets. The Congressional Budget Office (CBO) esti-
(heart disease, cancer, and trauma) and pneumo- mates that federal spending on just Medicare and
nia, skin disorders, hypertension, and infectious Medicaid will equal 4.6% of the GDP in 2007 (or
diseases. The fact that spending on these condi- almost a quarter of the entire federal budget). The
tions increased because of significant medical CBO also estimates that federal spending on these
advancements in treating these conditions rather programs will grow to 5.9% of the GDP in
than an increased prevalence of people being 2017—a nearly 30% increase in just a decade.
treated provides further support for the hypothesis These increases in the shares of the economy
that technological change is driving the increases and the budgets of the federal and state govern-
in spending. It also contributes to the skewed dis- ments that go to healthcare are imposing a cost
tribution of healthcare spending. on the nation. They are preventing the nation
from spending more on education, national
defense, construction of mass transit and infra-
Benefits and Costs of the
structure, environmental cleanup, investment in
Growth in Healthcare Spending
alternative energy sources, and a host of other
Technological changes and expanded medical priorities.
care capabilities have improved many millions of
people’s lives. Improvements in many older
Future Implications
Americans’ quality of life have meant that they are
not only living longer lives but they are also enjoy- New medical technologies and improvements in
ing those years more. At the other end of the life medical capabilities are the primary forces behind
Cost Shifting 257
the growth in healthcare spending. Efforts to slow See also Competition in Healthcare; Cost-Benefit and
the growth in healthcare spending therefore must Cost-Effectiveness Analyses; Cost Containment
involve incentives to innovators to create new Strategies; Healthcare Markets; Healthcare Reform;
medical technologies that reduce the cost of care Health Economics; Health Insurance; U.S. National
Health Expenditures
and restrictions on which future medical technolo-
gies advances will be paid for by private insurance,
Medicare, and Medicaid. Prestigious prizes and
Further Readings
honors could be used as incentives for inventors to
create cost-reducing technologies. Ultimately, how- Anderson, Gerard F., Bianca K. Frogner, and Uwe E.
ever, restrictions on access to new technologies may Reinhardt. “Health Spending in OECD Countries in
be the most effective way to encourage the develop- 2004: An Update,” Health Affairs 26(5): 1481–89,
ment of cost-saving new medical technologies. September–October 2007.
One mechanism for restricting access to new Catlin, Aaron, Cathy Cowan, Micah Hartman, et al.
technologies involves cost-effectiveness analysis “National Health Spending in 2006: A Year of
(CEA). CEA is a method for estimating the addi- Change for Prescription Drugs,” Health Affairs 27(1):
tional cost per quality of life-year provided by a 14–29, January–February 2008.
new drug or new procedure relative to the status Cohen, Joel W., and Nancy A. Krauss. “Spending and
quo way of treating a particular disease. If the Service Use Among People With the Fifteen Most
additional cost is estimated to be below a thresh- Costly Medical Conditions, 1997,” Health Affairs
22(2): 129–38, March–April 2003.
old (often $50,000), it is generally viewed as cost-
Congressional Budget Office. The Long-Term Outlook
effective; otherwise, the new treatment is usually
for Health Care Spending: Sources of Growth in
not approved. One advantage of using CEA to
Projected Federal Spending on Medicare and
determine if a new technology or drug will be cov-
Medicaid. Publication No. 3085. Washington, DC:
ered by insurance is that it may force inventors to Congressional Budget Office, November 2007.
focus on the costs of the new technology relative to Druss, Benjamin G., Steven C. Marus, Mark Olfson, et al.
the existing treatment method. “The Most Expensive Medical Conditions in America,”
A number of industrialized nations use CEA as Health Affairs 21(4): 105–11, July–August 2002.
part of their process for determining if new tech- Schoen, Cathy, Stuart Guterman, Anthony Shih, et al.
nologies and pharmaceuticals will be covered by Bending the Curve: Options for Achieving Savings
insurance. For example, Canada, Australia, and and Improving Value in U.S. Health Spending. New
the Netherlands use CEA in deciding whether a York: Commonwealth Fund, 2007.
new drug will be covered by insurance. New
Zealand and the United Kingdom use it in making
not just drug coverage decisions but whether new Web Sites
technologies will be covered as well.
An alternative to using CEA is simply to Centers for Medicare and Medicaid Services (CMS),
announce that access to cost-increasing new tech- National Health Expenditure Accounts:
nologies will be rationed. Rationing makes most http://www.cms.hhs.gov/NationalHealthExpendData
people extremely uneasy, and therefore it could Commonwealth Fund: http://www.commonwealthfund.org
Congressional Budget Office (CBO): http://www.cbo.gov
pressure inventors to search for ways to reduce the
Medicare Board of Trustees Report:
costs of new technologies. Similarly, returning to
http://www.cms.hhs.gov/reportstrustfunds
the distinction between how prices are set in
healthcare markets and in competitive markets, if
Medicare and private health insurers were to use
their market power to set reimbursement rates for
new technologies, pressure would be on innova- Cost Shifting
tors to find production methods that reduce the
costs of the new technologies. Cost shifting exists when a hospital, physician
group, or other provider raises prices to one set
Katherine Swartz of buyers because it has lowered prices to some
258 Cost Shifting
other group. The term has also been applied to Cost shifting is different. Not only must the
managed-care firms that are similarly said to provider charge different prices to different payers,
have raised premiums to one set of purchasers it must also raise prices to one group in response
because it had to lower premiums to some other to lower prices from another group. To be able to
set. Cost shifting is often confused with price dis- do this, two things are critical. First, the provider
crimination. Health services providers commonly must have market power (i.e., it must have the
price discriminate; that is, they charge different ability to set prices above costs). Second, and most
prices to different payers. However, such differ- importantly, the provider must not have already
ential pricing strategies are not evidence of cost fully exercised its market power.
shifting. The first condition is straightforward. Suppose
a hospital had no market power. When it attempted
to raise its prices to a local preferred provider
Overview
organization (PPO), the PPO would simply drop
The term cost shifting has been commonly used in the hospital from its network and channel its sub-
debates over healthcare reform. Some have argued, scribers to other nearby hospitals. Thus, if there is
for example, that efforts to reduce Medicare substantial hospital competition in the local mar-
expenditures by lowering payments to hospitals ket, a hospital is unable to shift its costs.
under its prospective payment system (PPS) or The second condition is somewhat more subtle. A
through the encouragement of managed-care plans profit-maximizing provider with market power
may save money for the Medicare program, but it takes advantage of its power. The hospital will
will increase the costs to private payers. This is said charge Medicare according to the fixed payment
to occur because hospitals will simply raise their schedule that the government has adopted. It sets the
prices to private insurers to make up the difference price to the PPO based on the marginal revenue and
for the money that is being lost from Medicare marginal costs of the PPO’s patients. Note that the
beneficiaries. Private insurers, facing higher hospi- marginal cost of providing care to the PPO may not
tal prices, will then tell employers that they have to be simply the medical costs of providing the care.
raise health insurance premiums because they are The true marginal costs may be the payment that
being cost shifted against by hospitals. Medicare would have paid for one of its patients.
Two policy prescriptions emerge from this argu- Now suppose that the U.S. Congress changed
ment. First, private insurers should support cover- the Medicare payment formula and lowered the
age for the uninsured; the costs of the subsidy will prices it paid to hospitals. The profit-maximizing
be less than they appear because the hidden cost hospital cannot raise its price to the PPO and get
shift will be eliminated. Second, it is sometimes any more money. If it could do so, it was not
argued that cost shifting requires the systemic profit-maximizing to start with. What the econom-
reform of healthcare. Any piecemeal effort to con- ics imply is that the hospital will lower, not raise,
trol costs will ultimately be eroded by increases in its price to the PPO. The reason is that when
costs to some other payer, with the result that costs Medicare lowers its price, the profit-maximizing
are not controlled. While subsidizing care for the hospital tries to shift some of its capacity away
uninsured and reforming the healthcare system are from the now less-profitable Medicare market and
important goals, however, cost shifting is unlikely toward the PPO market. However, the only way it
to be a serious component of the rationale. can get the PPO to use more hospital days is to
Simply charging one group a higher price than lower its price. The effect of a reduction in Medi
another does not constitute cost shifting. Firms in care prices is a reduction in the prices faced by
many industries routinely do this. For example, private insurers. Similarly, if Medicare were to raise
airlines routinely charge different prices to people its payment levels, the hospital would raise its prices
on the same airplane. Movie theaters routinely to private insurers. Thus, a profit-maximizing pro-
charge different prices to adults and children. vider does not engage in cost shifting.
Restaurants and banks give senior citizen dis- A non-profit-maximizing provider does not nec-
counts. Hotels offer convention rates. This is essarily cost shift either. It all depends on the objec-
known as price discrimination. tives of the nonprofit hospital or provider. If the
Cost Shifting 259
objectives are to provide care to a third group of Empirical Evidence

patients, say, the indigent, then even this hospital
will not cost shift. Instead, it will set its prices at The empirical evidence with respect to cost shift-
the profit-maximizing level, and instead of giving ing has been mixed. Much of the work simply
the profits to the shareholders, it will use those misses the point because it seeks to show that dif-
profits to care for the indigent. If it did not set ferent payers pay different prices for essentially
those same higher prices, it would be providing the same services. This is true, but price discrimi-
less indigent care than it could have. If this hospital nation is not cost shifting. Other work tries to use
were now faced with reductions in Medicare pay- cross-sectional comparisons to test for the pres-
ment levels, it would do exactly what the profit- ence of cost shifting. This is difficult to achieve
maximizing hospital did, accept the lower Medicare because cost shifting is a dynamic phenomenon.
payments and shift capacity to the PPO. This There have been three studies that shed light on
allows it to continue to provide as much charity the presence and extent of cost shifting in health-
care as possible, given the new lower Medicare care. Hadley, Zuckerman, and Iezzoni used a
payment level. Thus, there is no cost shifting in this national sample of hospitals from 1987 to 1989 to
example either. examine the effects of financial pressure and com-
The only way in theory to obtain the cost shift- petition on the change in hospital revenues, costs,
ing result is to have a hospital (or other provider) and profitability. They found that hospitals with
that has market power but that also “likes” lower base-year profits increased costs less and
insured patients in the special sense that it charges increased their efficiency. With respect to cost
them less than it profitably could. In this sense, it shifting, the authors did not find any evidence that
has unexploited market power. Now, when cost shifting strategies that might protect hospital
Medicare reduces its payment level, the hospital revenues in the wake of financial pressure were
finds that it has fewer revenues from Medicare successfully undertaken.
with which to subsidize privately insured patients Dranove and White used 1983 and 1992
and is then forced to raise its price to them. This is California hospital data to examine the effects of
cost shifting. Thus, the ability to cost shift happens reductions in Medicaid and Medicare volume on
when hospitals still have the ability to maximize changes in price-cost margins (net price minus
the revenues from the remaining private payers. average costs all divided by net price) of privately
Cost shifting occurs because there is a growing insured patients in Medicaid-dependent hospitals.
gap between the payments from government pro- The authors did not find any evidence that
grams (Medicare and Medicaid) that pay only for Medicaid-dependent hospitals raised their prices
the direct cost of care for patients in these pro- to private patients in response to Medicaid (or
grams and not for the full economic costs of care. Medicare) cutbacks. If there was any change, hos-
Because of this, a shortfall is created and hospitals pitals likely lowered their prices. The researchers
then shift the unreimbursed costs by charging a also found that service levels fell for Medicaid (and
higher price to privately insured patients. In Medicare) patients relative to privately insured
effect, cost shifting results in the privately insured patients, and they fell by more in Medicaid-
patients subsidizing the cost of care for the pub- dependent hospitals.
licly insured patients. Because of the need to cost Zwanziger, Melnick, and Bamezai used
shift, hospitals may work to reduce their costs; California hospital data from the same source over
that can lead to greater efficiency or affect quality the full time period of 1983 to 1991 and reached
of care. decidedly different conclusions. They computed
The ability to cost shift varies in different geo- the average price per discharge for Medicare,
graphic regions based on the market power of the Medicaid, and non-Medicare or -Medicaid (i.e.,
provider, the level of payment from the public privately insured) patients. Controlling for average
payer (Medicare and Medicaid), and the level of costs in a two-stage model, they found that lower
uncompensated care. If cost shifting were not Medicare and Medicaid prices were associated
done, providers would not be able to maintain with higher private prices. A 1% point decrease in
their physical plants and equipment. the Medicare average price was estimated to
260 Credentialing
increase private prices at nonprofit hospitals by operate? Such models may more explicitly incor-
0.23% to 0.59%. The larger price increases were porate both price and quality competition and
found in markets with less hospital competition. In account for the roles of private and public-sector
addition, Zwanziger and associates also found evi- payment systems in driving providers individually
dence that for-profit-owned hospitals also engaged and as a group toward one or another type of
in cost shifting. Similar analysis by Zwanziger and competition.
Bamezai for 1993 to 2001 concluded that the cost
shifting that occurred from 1997 to 2001 of Michael A. Morrisey
Medicare and Medicaid to private payers was See also Competition in Healthcare; Cost of Healthcare;
responsible for a 12.3% increase in private payers’ Health Economics; Health Insurance; Hospitals;
prices. Medicaid; Medicare; Safety Net
It is difficult to reconcile the disparate studies.
Both Dranove and White and Zwanziger and
associates used the same data over essentially the Further Readings
same time period. Some of the differences
undoubtedly have to do with Dranove and White’s Dranove, David, and William D. White. “Medicaid-
use of beginning and end-point observations in a Dependent Hospitals and Their Patients: How Have
They Fared?” Health Services Research 33(2 pt. 1):
change model while the latter used essentially a
163–86, June 1998.
panel of hospitals. The studies used different
Hadley, Jack, Stephen Zuckerman, and Lisa I. Iezzoni.
methodologies. The former examined profit mar-
“Financial Pressure and Competition: Changes in
gins, and the latter, price per discharge (although
Hospital Efficiency and Cost-Shifting Behavior,”
not price per day, which may be less subject to Medical Care 34(3): 205–19, March 1996.
endogenous changes in length of stay). The for- Zwanziger, Jack, and Anil Bamezai. “Evidence of Cost
mer looked at changes in Medicare and Medicaid Shifting in California Hospitals,” Health Affairs
volume, while the latter looked at average price 25(1): 197–203, January–February 2006.
changes directly. Both of the studies tried to Zwanziger, Jack, Glen A. Melnick, and Anil Bamezai.
account for service or cost differences, but did so “Can Cost Shifting Continue in a Price Competitive
in very different ways. Environment?” Health Economics 9(3): 211–25,
2000.
Future Implications
One must conclude that the empirical evidence is Web Sites
mixed and that more work reconciling existing
approaches and using alternative data would be American Hospital Association (AHA):
desirable. The empirical question is compounded http://www.aha.org
by the variety of other factors that must be consid-
http://www.ahip.org
ered. What are the relevant prices? How are they
Healthcare Financial Management Association (HFMA):
to be measured, and to what extent do the inher-
http://www.hfma.org
ent compromises in their construction inadver-
tently bias the findings? How does one account
for volume, service, and quality changes that are
almost certainly endogenous (arise from within
the model)? How does one approximate the rele- Credentialing
vant marginal cost by payer group? And how does
one address the extent of competition? Credentialing is the process of assessing and con-
Finally, as Zwanziger and his associates ask, do firming the qualifications of a licensed, registered,
we need a more sophisticated hospital (or pro- or certified healthcare professional. The main goal
vider) model that not only incorporates individual of the credentialing process is to ensure that
hospital elements but more adequately accounts health professionals such as physicians, dentists,
for the market environment in which providers registered nurses, and others are skilled and
Credentialing 261
knowledgeable about the current best practices of educator, was hired to conduct on-site visits to
appropriate and effective care. To be responsible assess all medical schools in North America.
to the public and to meet legal obligations, health- Flexner compiled his findings in a landmark
care organizations must verify the competency of report, Medical Education in the United States and
their staff members. Credentialing should be con- Canada, which was published in 1910. The Flexner
ducted by an independent third party to ensure Report, as it would become known, criticized the
the accuracy of the information obtained on the state of medical education and the training pro-
staff members. Some of the elements that are nor- cess, and Flexner made a number of recommenda-
mally verified in the credentialing process include tions. Specifically, he recommended that medical
the individual’s current licensure; relevant educa- schools be integrated with colleges or universities,
tion, training, or experience; current competence; that the length of education be extended to at least
and health fitness or the ability to perform the 4 years, and that the curriculum content be agreed
required tasks. Requirements of credentialing, on and standardized by a reputable body. The
however, vary depending on specialty or area of report’s findings led to significant changes in the
practice. For example, an internship or residency nation’s medical education, including more stan-
may not be deemed necessary to ensure that a dardized curricula for medical students. Its find-
laboratory technician has the appropriate knowl- ings also carried over to the areas of accreditation
edge and experience to perform his or her job; and credentialing.
surgeons, on the other hand, are required to com-
plete lengthy and ongoing training activities.
Areas of Credentialing
Because medical knowledge is increasing daily, all
Background
health professionals need to keep abreast of new
The general public’s knowledge about the impor- developments that affect their practices, and they
tance of credentialing has grown over the years. In must also make sure that they have adequately
the past, a large variation existed in what health retained the knowledge they learned in the past, as
practitioners learned in different specialty areas or demonstrated by the recertification requirements.
schools, especially in the field of medicine. In the All types of health professions require credential-
19th century, the majority of medical schools in ing that matches the variety of specialties and
the United States were run with the focus on mak- subspecialties in medicine and healthcare.
ing a profit; they were not associated with a uni- Professionals, including critical care nurses, man-
versity or college, and curricula lacked extensive aged-care physicians, and healthcare administra-
hands-on learning opportunities such as labora- tors, seek out credentialing from a specialized
tory work or dissection. As a result, many poorly third-party agency. These agencies provide the
trained physicians entered the profession, patients professional with codes of conduct in addition to
suffered high mortality rates, and the public’s faith current information regarding their role or spe-
in the medical field was low. Communities discov- cialty, upholding the goals and furthering the mis-
ered that it was difficult to certify physicians sion of the credentialing body and the field. There
because there were no established guidelines are many credentialing organizations in health-
according to which what they had learned could care, including the American Nurses Credentialing
be assessed. Center (ANCC), the National Commission for
In the early 1900s, a number of professional Health Education Credentialing (NCHEC), and
medical organizations advocated for the establish- the National Register of Health Service Providers
ment of stricter, science-based, national require- in Psychology. Advances in technology have also
ments for medical education. As part of this effort, allowed the growth of Web-based credentialing
the American Medical Association (AMA) and the services.
Council on Medical Education (CME) wanted an Hospitals and clinics, like individual health pro-
assessment of the current status of medical train- fessionals, can also be credentialed. Facilities want
ing. With funding from the Carnegie Foundation, their staff to be credentialed and up-to-date because
Abraham Flexner (1866–1959), a professional credentialed individuals tend to be more efficient
262 Critical Access Hospitals (CAHs)
and productive as compared with noncredentialed

staff members. Hospitals also want their staff to be Critical Access
credentialed to meet various legal and regulatory Hospitals (CAHs)
requirements.
Critical Access Hospitals (CAHs) are small, limited-
service hospitals that act as safety net providers of
Future Implications
essential healthcare services for rural Americans.
The goal of credentialing is to ensure that patients These hospitals apply to become CAH-designated
receive high-quality and safe medical care by mak- under a program established by the U.S. Congress
ing sure every health professional providing care through the Balanced Budget Act of 1997.
has appropriate certification and licensing. Specifically, the program was established to
Credentialing not only ensures high standards of address the closure of a large number of rural
care and the increased quality of services but also hospitals due to increasing financial stress. The
enables patients to trust the health professionals 1980s saw a high hospital closure rate nation-
and organizations from which they receive care. In wide, with a considerably higher rate in rural
the future, as the healthcare field continues to areas. By 2000, many states had fewer than 90%
grow and incorporate a wider variety of workers, of the rural hospitals they had in the 1990s. With
such as allied health professionals and comple- the CAH program, closure rates have slowed sig-
mentary and alternative medicine professionals, nificantly in rural areas, and many hospitals that
the credentialing process will need to expand to had closed or reduced services have reopened.
address them. The number of CAHs in the nation has increased
from 41 in 1999 to 1,283 in 2007. To date, only
Paul J. Erikson New Jersey and Rhode Island have not applied for
the program. The number of CAHs varies from
See also Health Workforce; Licensing; National
year to year as some hospitals become ineligible
Practitioner Data Bank (NPDB); Nurses; Pharmacy;
for designation, either by losing rural status or
Physicians; Quality of Healthcare; Regulation
through nonadherence to requirements. At the
same time, new facilities are added. Currently,
Further Readings CAHs account for about 3% of the nation’s total
hospital beds and about 1% of Medicare’s total
Cox, Jack L. Assessing New Procedures and Technologies: payments for inpatient care.
A Guide to Credentialing, Privileging, and Dispute
Resolution. Marblehead, MA: HCPro, 2006.
Matzka, Kathy, ed. 2008 Credentials Verification Desk
Reference. Marblehead, MA: HCPro, 2008. Characteristics of the Program
Pybus, Beverly E., and Carol S. Cairns. A Guide to AHP The Medicare Rural Hospital Flexibility Grant
Credentialing: Challenges and Opportunities to Program, more commonly known as the Flex
Credentialing Allied Health Professionals. 2d ed. Program, established a new hospital category, the
Marblehead, MA: HCPro, 2004. CAH, designed to provide financial stability to
Styles, Margretta M., Mary Jean Schuman, Carol small, rural hospitals that were losing money after
Bickford, et al. Specialization and Credentialing in changes in the prospective payment system (PPS)
Nursing Revisited: Understanding the Issues,
implemented by Medicare in 1983. The program
Advancing the Profession. Silver Spring, MD:
permits designated CAHs to function as limited-
American Nurses Association, 2008.
service facilities with flexible staffing and service
requirements not permissible in larger hospitals. It
also allows simplified billing methods and offers
Web Sites incentives to develop local, integrated health-deliv-
Bureau of Health Professions (BHPr): http://bhpr.hrsa.gov ery systems, including acute, primary, emergency,
Joint Commission: http://www.jointcommission.org and long-term care. Although targeted at very
U.S. Bureau of Labor Statistics (BLS): http://www.bls.gov small hospitals, the program covers healthcare
Critical Access Hospitals (CAHs) 263
facilities and issues at the national, state, and local infrastructure support for continued CAH opera-
levels. tions is likely to continue for years to come as
The Flex Program consists of two components: states continue to build their capacity for strength-
cost-based Medicare reimbursement for designated ening rural health infrastructure.
CAHs; and a state Flex Grant Program adminis-
tered by the federal Office of Rural Health Policy
Requirements and Certification Process
(ORHP) to strengthen rural healthcare systems.
The ORHP, which is within the Health Resources Eligible rural hospitals must meet conditions of
and Services Administration (HRSA) of the certification to obtain CHA designation from
Department of Health and Human Services (HHS), state and federal agencies. About two thirds of the
manages the program nationally, making funds state Flex Programs require that hospitals apply-
available to state Flex Programs and providing ing for CAH status conduct a community needs
program oversight. assessment and submit the results of that assess-
CAHs, which are designated to act as nuclei of ment with their CAH application. Specifically, to
organized, local systems of care in rural areas, be included in the CAH program, hospitals must
work to encourage the growth of collaborative meet specific criteria. First, the hospital must be a
rural delivery systems across the continuum of care rural public, nonprofit or for-profit hospital, or a
at the community level with appropriate external hospital that was closed within the past 10 years,
relationships for referral and support. In addition or a rural health clinic that was downsized from a
to designating and supporting the conversion of hospital. The facility must be located in a state
hospitals to CAHs, the statutory and regulatory that has established a state plan with the federal
provisions of the national program require states Centers for Medicare and Medicaid Services
to develop and maintain a State Rural Health Plan, (CMS) for the Medicare Rural Hospital Flexibility
create a CAH network that is complementary to Program. Additionally, it must be located more
providing a wide range of services, fostering local than a 35-mile drive from any other hospital or
Emergency Medical Services (EMS) linkages with CAH (in mountainous terrain or in areas with
CAH networks, supporting quality improvement only secondary roads available, the mileage crite-
initiatives, and evaluating their programs within rion is 15 miles), or it must be certified by the state
the framework of national program goals. in its plan as being a necessary provider of health-
The Flex Program contains explicit expectations care services to area residents. The hospital must
and financial incentives up to $700,000 to encour- provide 24-hour emergency care services 7 days a
age CAHs to engage with their communities to week, have a maximum of 25 acute-care and
access community health and health system needs, swing hospital beds, and provide no more than 15
as well as to develop collaborative delivery sys- hospital beds for acute, hospital-level inpatient
tems. Most states are now engaged in quality and/ care. Finally, to be considered for the CAH pro-
or performance improvement activities with CAHs. gram, the hospital must provide an annual aver-
Using local, state-to-state, regional, and national age length of stay of 96 hours per patient for
collaborations, states and CAHs are sharing and acute-care patients. CAHs are required to be in
advancing knowledge on critical issues such as compliance with the federal requirements set forth
performance and quality of care improvement, in the Medicare Conditions of Participation (CoP)
health information technology development, and to receive Medicare and Medicaid payment.
capital planning and acquisition. All states con- Surveys are conducted to determine if the CAH is
tinue to streamline the CAH designation and con- in compliance, and certification is accomplished
version process, and they have now directed their through observations, interviews, and document
efforts to providing direct assistance to support and record reviews.
and improve CAH operations. Recent changes in Federal law does not require all CAHs to be
the Medicare Modernization Act of 2003, such as open 24 hours a day, 7 days a week. Twenty-four-
increasing the acute-care hospital bed capacity hour nursing is mandatory when an inpatient is
of CAHs to 25 beds, may increase CAH present in the hospital. It is also required for a phy-
conversion rates in some states. The emphasis on sician, physician assistant, or nurse practitioner to
264 Cross-Sectional Studies
be available within 30 minutes. These exceptions Dalton, Kathleen, Rebecca Slifkin, Stephanie Poley, et al.
allow considerable reductions in the cost of hospi- “Choosing to Convert to Critical Access Hospital
tal operations. Medicare pays CAHs on a basis of Status,” Health Care Financing Review 25(1):
101% of inpatient reasonable costs, as well as most 115–32, Fall 2003.
outpatient costs, while the state Medicaid program Li, Pengxiang, John E. Schneider, and Marcia M. Ward.
covers 100% of allowable inpatient and outpatient “Effect of Critical Access Hospital Conversion on
costs. Required services are inpatient and emer- Patient Safety,” Health Services Research 42(6 pt. 1):
gency care; laboratory and radiology services; and 2089–2108, December 2007.
Liu, Jiexin, Gail R. Bellamy, and Melissa McCormick.
pharmacy and some ancillary and support services,
“Patient Bypass Behavior and Critical Access
which may be provided part-time or off site. For
Hospitals: Implications for Patient Retention,”
licensure, a CAH must be in compliance with
Journal of Rural Health 23(1): 17–24, Winter 2007.
Medicare standards of participation. Individual
Scalise, Dagmara. “Critical Access Hospitals,”
states can set their own criteria for levels of care Hospitals and Health Networks 78(8): 51, 53–56,
that are higher than stipulated federal levels. August 2004.
Future Implications Web Sites
The CAH program helps fulfill a long-standing American Hospital Association (AHA): http://www.aha.org
national need of ensuring hospital services for Centers for Medicare and Medicaid Services (CMS):
rural Americans. It facilitates the financial viabil- http://www.cms.hhs.gov/center/cah.asp
ity of small, low-volume rural hospitals and has Office of Rural Health Policy (ORHP):
nearly halted hospital closures. Being designated a http://ruralhealth.hrsa.gov
CAH helps these facilities receive loans and funds Office of Rural Health Policy (ORHP), Rural Health
from diverse sources, which in turn helps them Research Gateway: http://www.ruralhealthresearch.org
Rural Health Resource Center (RHRC):
modernize and expand the services they offer. The
http://www.ruralcenter.org
availability of additional CAH services has likely
reduced the number of rural residents who bypass
these facilities to seek care at other, more-distant
hospitals. ORHP has funded studies of perfor-
mance quality, best practices, and community Cross-Sectional Studies
impact of CAHs. The results of these studies will
indicate how the CAH program may continue Cross-sectional health studies present a snapshot
to improve the quality of healthcare in rural of a disease, exposure, or health outcome at a
communities. specific point in time for a specific population.
This snapshot often provides useful information
Karen E. Peters, Sunanda Gupta, for health services researchers and other health-
and Benjamin C. Mueller care professionals. Researchers may glean useful
information from conducting cross-sectional stud-
See also Access to Healthcare; Geographic Barriers to ies or by using information obtained from them.
Healthcare; Health Resources and Services Often, the findings from cross-sectional studies
Administration (HRSA); Hospital Closures; Hospitals; help researchers identify which specific topic to
Medicare; Rural Health; Vulnerable Populations pursue for more detailed investigation.
Nomenclature and Categorization

Further Readings The purpose of many cross-sectional health studies
Becker, Cinda. “Critical Conditions: The Number of is to describe the prevalence of a disease (e.g., the
Critical-Access Hospitals Has Surged, but the number of individuals with lung cancer in a com-
Program Hasn’t Always Been a Financial Lifesaver,” munity), the exposure to a particular risk factor
Modern Healthcare 36(20): 26–29, May 15, 2006. (e.g., the number of individuals who smoke), or the
Cross-Sectional Studies 265
health outcome (e.g., changes in death, disease, (e.g., the total number of people with HIV/
disability, discomfort, or dissatisfaction) for a spe- AIDS). They are often used to establish baseline
cific population; hence cross-sectional studies are information, which can be used for health ser-
also commonly referred to as prevalence studies. vices planning purposes and to make public pol-
Cross-sectional or prevalence studies are also icy decisions.
referred to as surveys, which emphasizes the fact A large number of government agencies and
that they are conducted at one time. Beyond this private organizations conduct cross-sectional
nomenclature is the categorization and classifica- health studies. The federal agency that conducts
tion of cross-sectional studies, which often differs the largest number of such studies is the National
by author. The various classification schemes are Center for Health Statistics (NCHS), which is part
summarized below. of the National Centers for Disease Control and
Most of the healthcare literature classifies cross- Prevention (CDC). The NCHS conducts, for exam-
sectional studies as descriptive studies, along with ple, the National Ambulatory Medical Care Survey
case reports, case-series reports, and surveillance (NAMES), the National Health Interview Survey
studies. Descriptive studies in general collect infor- (NHIS), the National Health and Nutrition Exami
mation from individuals (except ecological studies, nation Survey (NHANES), the National Hospital
which are sometimes placed in this category), and Discharge Survey (NHDS), the National Home and
they attempt to describe the characteristics of Hospice Care Survey (NHHCS), and the National
people or a population. Nursing Home Survey (NNHS).
Other classification schemes divide all studies Health services researchers and public health
into either experimental studies (where the ran- workers often review information from cross-
domized controlled clinical trial is the gold stan- sectional studies to understand what risk factors
dard) or observational studies (which include are most common in a population for the purpose
cross-sectional, case-control, cohort, and eco- of choosing appropriate interventions. For exam-
logical studies). Occasionally observational stud- ple, when trying to prevent coronary artery disease
ies are subclassified into descriptive studies (i.e., in a population, if that population exercises and
case reports, case-series reports) and analytical has little obesity but has a high prevalence of
studies (i.e., ecological, cross-sectional, case- hypertension, an appropriate intervention may be
control, and cohort studies)—where the criterion establishing a public health program encouraging
for classification is whether or not the informa- the population to lower stress and limit the use of
tion collected requires data analysis to develop salt. Similarly, cross-sectional studies can be used
conclusions. to estimate the hospital bed needs and clinic staff
Yet other classification schemes simply divide training needs for a population.
all studies into either cross-sectional studies or Clinicians also rely on information from preva-
longitudinal studies—one point in time measure- lence or cross-sectional studies. Information from
ments (i.e., cross-sectional) versus repeated mea- them is part of the diagnostic decision making in
sures or time series measurements over a length of almost all the patient contacts a clinician makes.
time (i.e., longitudinal, such as a cohort study). Prevalence studies help determine the likelihood
However, when serial cross-sectional studies of the that a patient with a given presentation may have
same population are linked, such as the U.S. a specific disease and hence the temporal order of
Census of Population for several different years, a the diagnostic work-up conducted by the clinician.
modified form of longitudinal study is created (i.e., For example, when carrying out an examination
modified because the same people are not studied and tests to diagnose the cause of dyspnea (short-
each year of the census due to migration, immigra- ness of breath) in a normally healthy teenager, the
tion, and births and deaths). clinician will consider bronchitis, pneumonia, and
asthma before lung cancer, congestive heart fail-
ure, and sarcoid. Knowing the prevalence of these
Uses of Cross-Sectional Studies
diseases among teenagers helps the clinician choose
Cross-sectional studies are often used to deter- which diagnostic tests are needed for the dyspnic
mine the current health status of a population teenager.
266 Cross-Sectional Studies
Conducting and Analyzing cross-sectional data. Often, the descriptive data

Cross-Sectional Studies from these studies are analyzed to express preva-
lence, such as the rate of a disease, or the propor-
Most descriptive studies address basic questions tion of the population at risk, or who had a certain
such as who, what, when, where, and why, with exposure (the number with the disease, risk, or
an implicit question of “so what?” In many cross- exposure divided by the number responding to the
sectional health studies, researchers often start survey) in a population.
with a specific question (e.g., what is the relation- Besides being used for the presentation of preva-
ship between smoking and lung cancer?) and then lence and disease rates, cross-sectional studies are
choose a population as well as which variables to often used to develop inferences (i.e., inferring cau-
study. The people in the study are chosen without sation) or identify associations. The basic tool for
regard to their exposure (e.g., smokers and non- analyzing cross-sectional data is a 2 × 2 table,
smokers). Cross-sectional studies collect exposure where the four cells of the table are as follows:
information either from all members of a popula- a = exposure factor and disease present, b = expo-
tion or from a sample of a population, at a single sure factor and disease not present, c = no expo-
point in time. Typically, cross-sectional studies use sure factor, but disease present, and d = no
a survey instrument or study questionnaire (either exposure factor or disease present.
written or conducted by direct interview) and may Often, as in the case of determining the source
include measurements and/or obtain biologic sam- of a food-borne epidemic, several 2 × 2 tables are
ples. Cross-sectional studies collect information made to determine which food was most highly
on both the health outcome (e.g., number of indi- associated with the illness. From each table the
viduals with lung cancer) and the exposure (e.g., prevalence odds ratios (POR), an estimate of
smoker or nonsmoker) at the same time. the incident rate ratio, can be calculated. Using the
Cross-sectional studies should document and cells of the table, the POR is calculated as ad/bc.
report in detail their study designs so other The higher the POR, the stronger is the exposure
researchers can judge the quality of their results. or risk factor associated with the outcome or dis-
The results of cross-sectional studies should pro- ease. In the case of the food-borne epidemic exam-
vide the following: (a) a detailed description of the ple, the highest PORs are inferred to be the foods
population studied, or if a sample of the popula- most likely harboring the bacteria that caused the
tion was used, a description of how the sampling illness. To put it another way, the POR is the num-
was done, and if any weighting was used in draw- ber of times having a specific exposure increases
ing the sample; (b) when (i.e., date and time) and the risk of a disease above that of someone who
where (i.e., specific geographic location) the study has not been exposed to the risk factor. Chi-square
was conducted; (c) how the comparison popula- analysis can then be used to determine if the differ-
tion was chosen, assuming the data are being ana- ence between the exposure and the nonexposure is
lyzed for an association); (d) the source of the statistically significant.
information used (i.e., questionnaire or biological Cross-sectional studies are sometimes repeated
sample—giving specific questions, or method of to estimate change over time in a population,
biological analysis) and how it was ascertained but unlike cohort studies, the repeated study
(i.e., home visit, worksite, or clinic), which includes does not follow exactly the same population.
how the exposures were ascertained (i.e., blood This is called a repeated measures design, and
samples, work history, self-reporting by recall); (e) generally repeated measures analysis of variance
overall and specific response rates of people invited (ANOVA) is used to analyze data from this type
to participate in the study; (f) information on how of study.
the analysis of the study results were done; (g)
what prevalence was found; (h) what associations
Advantages and Limitations
were found; and (i) what qualification on infer-
ences and associations need to be made. Often, study methodologies are classified in terms
General descriptive statistics using means and of their ability to shed light on causality. Generally,
standard errors should be used in the analysis of cross-sectional studies are more useful in helping
Cross-Sectional Studies 267
identify possible causality than case studies, case- (effect), which at best relies on memory (which
series, and ecological studies. However, evidence may be influenced by outcome).
from case-control and cohort studies is considered Cross-sectional studies also have other limita-
stronger than that from cross-sectional studies, tions. For example, although a hospital cross-sec-
with randomized controlled clinical trials being tional, single-point-in-time survey may be used to
the best or gold standard. Nevertheless, for deter- estimate the needs of long-term care patients, the
mining the prevalence of a disease or exposure, cross-sectional survey technique will likely underes-
cross-sectional studies remain an important tool timate the prevalence of short-term hospitalizations.
for researchers. Another problem is using cross-sectional sur-
Cross-sectional studies are useful to a wide vari- veys to determine the effects of workers exposure.
ety of health professionals needing information for If a cross-sectional study is used in the workplace,
quick decisions on a low budget. Of all study workers are apt to be healthier, while others who
methodologies, cross-sectional studies are among are sick at home will not be included in the study.
the most useful in acquiring information in a short This is called the healthy worker effect. Therefore,
time, and they are relatively inexpensive to con- other methodological tools may be better suited
duct. Hence, cross-sectional studies are often for measuring employee health.
referred to as “quick and dirty” assessments. They Unless cross-sectional studies include very large
are often used to predict health service needs and populations, they are not suited for studying rare
the health impacts of disasters and disease out- events. On the other hand, several researchers
breaks. Individuals are not deliberately exposed, working on methodological issues in community-
treated, or left untreated, and therefore these stud- based health intervention trials conclude that serial
ies rarely present ethical dilemmas. Cross-sectional cross-sectional studies, using repeated measures
studies are often used to garner the first under- analysis, may be an optimal study methodology
standing of a variety of exposures and risk factors. for health services research and other health
And they are often used to make hypotheses for research that proposes to affect the health of an
further research, as seen with many large health entire population.
surveys.
Although associations may be found between Capri Mara Fillmore
exposures or risk factors and health outcomes See also Epidemiology; Health Surveys; Measurement in
using cross-sectional studies, these studies fail in Health Services Research; National Center for Health
their ability to establish causality because they lack Statistics (NCHS); Randomized Controlled Trials (RCTs)
temporal information. Inferences may be made on
possible causality, but they must be qualified
because information gleaned from cross-sectional Further Readings
studies cannot clearly establish whether the out-
Atienza, Audie A., and Abby C. King. “Community-
come precedes the exposure or risk. For example,
Based Health Intervention Trials: An Overview of
if obesity is found to be associated with lack of
Methodological Issues,” Epidemiologic Review 24(1):
exercise in a cross-sectional study, it is unclear if
72–79, 2002.
obesity made it impossible or too painful to exer-
Gordis, Leon. Epidemiology. 3d ed. Philadelphia:
cise or if obesity was caused by lack of exercise. Elsevier Saunders, 2004.
This is an example of the antecedent-consequence Grimes, David A., and Kenneth F. Schulz. “Descriptive
bias common to all cross-sectional studies. Other Studies: What They Can and Cannot Do,” The
studies might be developed to try to ascertain this Lancet 359(9301): 145–49, 2002.
temporal association (i.e., which comes first). Katz, Mitchell H. Study Design and Statistical Analysis:
However, such studies will never be as strong a A Practical Guide to Clinicians. New York:
support of causality as a prospective study. A clear Cambridge University Press, 2006.
association can be shown between exposure and a Mann, C. J. “Observational Research Methods. Research
health outcome, but cross-sectional studies cannot Design II: Cohort, Cross Sectional, and Case-Control
establish causality because of loss of the temporal Studies,” Emergency Medicine Journal 20(1): 54–60,
association between exposure (cause) and outcome 2003.
268 Crowd-Out
Stephenson, J. M., and A. Babiker. “Overview of Study There have been many carefully conducted stud-
Design in Clinical Epidemiology,” Sexually ies of crowd-out. In some cases, the studies defined
Transmitted Infections 76: 244–47, 2000. crowd-out in different ways, reflecting both the
various perspectives of the researchers conducting
them and the various databases they used. Few
Web Sites studies have sought to identify the mechanism
AcademyHealth: http://www.academyhealth.org through which crowd-out is operating. As a result,
American Statistical Association, Section on Statistics in the estimates on the extent of crowd-out can vary
Epidemiology (ASA-SIE): http://www.amstat.org/ greatly across studies. Some studies suggest that it
Sections/epi/SIE_Home.htm accounts for a very small percentage of changes in
National Center for Health Statistics (NCHS): a population’s health insurance coverage, while
http://www.cdc.gov/nchs other studies put the figure as high as 60%, depend-
Society for Epidemiologic Research (SER): ing on the public program. The 2007 U.S.
http://www.epiresearch.org Congressional Budget Office’s (CBO’s) study of the
SCHIP estimated the extent of crowd-out at 25%
to 50%. In other words, for every 100 children
who enrolled as a result of the program, there was
Crowd-Out a corresponding reduction in private health insur-
ance coverage of between 25 and 50 children.
The concept of crowd-out in the case of Medicaid
and the State Children’s Health Insurance Program
(SCHIP) refers to the substitution of public for Policy Issues
private health insurance coverage. This substitu- For many state and national policymakers, one of
tion is an important public policy concern because the most challenging aspects of creating or expand-
it may create unintended perverse incentives. ing public insurance programs is how to provide a
Crowd-out may result from employers no longer public health insurance option to individuals who
offering health insurance once the public insur- are truly in need without distorting private behav-
ance expansion is implemented, from employees ior (crowd-out). On one hand, their goal is to
declining offered coverage because they opt for increase the number of individuals covered by
public coverage for which they are newly eligible, health insurance. On the other hand, they do not
or from workers who are more inclined to take want to waste scarce public money, which merely
jobs with companies that do not offer health shifts the source of funding from private to public
insurance coverage because they can take advan- insurance and does not result in improved access
tage of the publicly available alternative. to healthcare or health status. An additional con-
cern is that when healthy individuals shift from
private to public insurance, those remaining with
Background
private insurance may be adversely affected. Risk
A number of economic studies have investigated may have to be spread over a smaller group and
crowd-out in various public programs. Studies may trigger higher premiums.
have examined crowd-out associated with the Several factors appear to increase the likelihood
expansion of the Medicaid program in the late of crowd-out. Expanding the eligibility of public
1980s and early 1990s, in various state-initiated programs to include higher income levels increases
health insurance programs and in the State the potential for crowd-out because many individu-
Children’s Health Insurance Program (SCHIP), als and families with higher incomes have private
which was enacted in 1997 and initially autho- health insurance. Another factor is family eligibility:
rized for a 10-year period. The public policy Parents are much more likely to enroll their children
debate on whether the SCHIP should be reautho- in a public program if they can also join it.
rized in 2007 focused national attention on the State public programs currently use a number of
issue of crowd-out. strategies to discourage crowd-out. They have
Cultural Competency 269
established eligibility restrictions based on current LoSasso, Anthony T., and Thomas C. Buchmueller.
insurance states; imposed cost-sharing require- “The Effect of the State Children’s Health Insurance
ments such as monthly premiums, copayments and Program on Health Insurance Coverage,” Journal of
deductibles, and annual enrollment fees; and Health Economics 23(5): 1059–82, September
required a waiting period before allowing individ- 2004.
uals to enroll in public programs. Shone, Laura P., Paula M. Lantz, Andrew W. Dick, et al.
States have also encouraged employers to begin “Crowd-Out in the State Children’s Health Insurance
and to continue offering health insurance to their Program (SCHIP): Incidence, Enrollee Characteristics
and Experiences, and Potential Impact on New York’s
workers’ states by (a) reimbursing employers for
SCHIP,” Health Services Research 43(1 pt. 2):
their purchase of employer-sponsored coverage, (b)
419–34, February 2008.
establishing purchasing cooperatives for small
U.S. Congressional Budget Office. The State Children’s
employers, and (c) establishing employer tax credit.
Health Insurance Program. Washington, DC: U.S.
Congressional Budget Office, May 2007.
Future Implications
Much more research is needed to understand bet-
Web Sites
ter the mechanisms, the extent, and the health
impact of crowd-out. It is clear that crowd-out AcademyHealth: http://www.academyhealth.org
will occur with the creation of any new public American Society of Health Economics (ASHE):
insurance program or the expansion of an existing http://healtheconomics.us
program. In the future, health economists will National Bureau of Economic Research (NBER):
need to measure more precisely the extent of http://www.nber.org
crowd-out, public health experts will need to
identify the specific health impacts of crowd-out,
and society will need to make a value judgment of
whether and how much crowd-out in public pro- Cultural Competency
grams is acceptable.
Cultural competency is an evolving concept in
Anthony T. LoSasso
health services research, with no universally
See also Access to Healthcare; Child Care; Health agreed-on definition. Although not a new concept,
Economics; Health Insurance; Medicaid; State-Based the term first became widely used in public health
Health Insurance Initiatives; State Children’s Health and health services in the 1990s. It remains prom-
Insurance Program (SCHIP); Uninsured Individuals inent in current considerations of addressing
racial/ethnic disparities in health status and access
to care. With a focus on the increasing population
Further Readings diversity of the United States and the persistence
of racial/ethnic disparities in health, public health,
Blewett, Lynn A., and Kathleen T. Call. Revisiting
medicine, nursing, social work, and other health
Crowd-Out. Princeton, NJ: Robert Wood Johnson
science disciplines are adapting the concept to
Foundation, 2007.
Davidson, Gestur, Lynn A. Blewett, and Kathleen T. Call.
address current issues in working with diverse
Public Program Crowd-Out of Private Coverage: population groups. The inference is that there are
What Are the Issues? Research Synthesis Report No. identifiable organizational, community, and policy
5. Princeton, NJ: Robert Wood Johnson Foundation, strategies that facilitate or impede the delivery of
2004. services to specific cultural groups or communi-
Gruber, Jonathan, and Kosali Simon. “Crowd-Out 10 ties. The federal Health Resources and Services
Years Later: Have Recent Public Insurance Administration’s (HRSA) Bureau of Health
Expansions Crowded Out Private Health Insurance?” Professions (BHPr) Web site offers several inter-
Journal of Health Economics 27(2): 201–17, March related definitions of cultural competency across
2008. various federal agencies. An element common to
270 Cultural Competency
all definitions is the ability to function effectively performance literature, implies skills or abilities
(in healthcare or other settings) with people who to perform role requirements in a specific context.
are culturally different. A less widely endorsed Burgoyne refers to “being competent” as meeting
strategy as a condition to the above is some degree the job demands, while “possessing competen-
of self-reflection or awareness of one’s (provider, cies” means having the knowledge, skills, and
researcher, policymaker) social position, relative attitudes to perform the job. Typical applications
power status, cultural values and practices, and of the concept may be found in health services
even worldview. Many definitions of cultural delivery, community, intervention development
competency across federal agencies and provider and evaluation, provider education, and studies
groups recognize culturally competent skills as of patient-consumer experiences with services.
encompassing the ability to incorporate culturally However, there is a continuum of activities
defined health beliefs and practices, language and beyond the provision of healthcare services
communication patterns, and health-seeking where cultural competency is concerned. In addi-
behaviors of specific groups into practice, research, tion to healthcare services, the loci of concerns
and policy. include research (including needs assessment,
In furthering the understanding of cultural program planning and evaluation, and health
competency, it is helpful to consider the meanings services research) and policy development. While
of the constituent terms, culture and competency. population diversity has implications for all
Culture refers to a unique configuration of behav- these activities, health services research can be
ioral norms, beliefs, and shared understanding of most useful in identifying how personal health-
the world that guides everyday life and is com- care services, population-based interventions,
mon to a particular population subgroup. In and public health policies are affecting the health
every cultural subgroup, there are prescriptive status of population subgroups and their access
means to transmit culture to new group members to care. For example, discrepancies between
and intuitional practices to ensure its continuity population groups in receipt of recommended
and utility in attaining individual and collective preventive services can be examined in terms of
goals in life. A common language or dialect is provider, patient, and community characteristics
typical of many but not all cultural groups, and as well as outcomes of population-based health
although shared historical, migratory, and ances- education and outreach, and policy initiatives.
tral roots are important markers in defining group Examples of how cultural competency can be
membership, there is increasing diversity within addressed across a range of public health activi-
groups due to globalization (social and economic ties, including the role of health services research,
forces’ contribution to population migration and are provided in Table 1. Here, cultural compe-
bringing cultural groups into regular contact with tency is broken down into the related concepts:
one another) and transnationalism (cultural cultural sensitivity, cultural proficiency, and cul-
groups maintaining ongoing contact with the tural humility.
homeland of origin through media, commerce, In Table 1, “Healthcare Services” refers to
and transportation systems). All cultural groups, clinical interventions with individuals and families
(including dominant Western White groups), pos- in ambulatory care settings such as outpatient clin-
sess locally adapted patterns or codes of conduct ics, physician’s offices, and community health cen-
or performances of daily life that are unapparent ters. “Community Level Interventions” refers to
to casual observers or outsiders, making it inap- health promotion practices in community settings
propriate for practitioners or researchers to such as churches, schools, and community-based
impose rigid interpretations or categorization of organizations. “Health Services Research” refers
beliefs and behaviors on any one group. to scientific inquiry designed to capture trends in
Importantly, culture provides a lens for group healthcare services access and use, identify causal
members to interpret illness symptoms and engage and contributing factors to access and use, and
in preventive and health-seeking behaviors. evaluate the effectiveness of clinical and community-
Competency, an ill-defined term in the human level interventions. “Public Health Policy” refers
to the function of ensuring access to clinical and practices of the populations of interest and iden-
community-level services through policy initia- tify cultural and community resources (ethnic
tives, particularly for vulnerable populations. grocery stores and indigenous support groups)
Public health policy can also address environmen- that can be used to complement services. At the
tal conditions (air and water quality, community community level, interventions are tailored to
safety, affordable and safe housing) that foster reflect local culture, often deploying cultural sym-
healthful living. bols of strength and persistence in the face of
adversity (e.g., Taino petroglyphs or other sym-
bols of ancestral heritage). Here linguistic compe-
Cultural Sensitivity tence is of utmost importance, and so personnel
In terms of the range of cultural competency and are proficient in the language. Hours and
approaches, cultural sensitivity is perhaps the locations of services take into account how time
normative or most prevalent approach. It is and space are structured in the community (e.g.,
concerned with an awareness of cultural differ- shift hours, safety and convenience of locations).
ences between the providers of services, the Health services research includes cultural vari-
culture of the supporting institution (clinic or ables such as acculturative status, health beliefs
organizational setting), and cultures of consum- and practices, identification of ethnic and cultural
ers or service recipients. Awareness may not subgroups (e.g., Puerto Rican and Mexican, not
necessarily lead to effective interventions, but it just Hispanic), and characteristic of services and
is a first step in recognizing potential limitations programs that reflect cultural competency (board
of the manner in which care is delivered and members and staff reflect community of interest,
how cultural differences can translate into a and linguistic competence). Research results are
“barrier” that impedes the use of health services shared with the community for feedback and for
or ability of consumers to adhere to recommen- quality improvement. The effect of policies on
dations for personal health improvement. The access and use of healthcare as well as services
same can be said for awareness in community- effectiveness is an important role of health services
level interventions, with little or no community research. Policies are developed with some input
control over the intervention. Health services from cultural groups affected by the issues, and
research in this phase of cultural competency is such input is facilitated by removal of language
mostly descriptive, and data and methods are barriers to understanding and discussion (e.g.,
not designed to capture complex cultural fac- printed materials in native languages).
tors such as acculturative processes, cultural
resources, beliefs, and practices. Likewise, poli-
Cultural Humility
cies are not tailored for specific subgroups and
have little meaningful input of affected commu- Cultural humility can be viewed as the highest
nities or subgroups. level of attainment of cultural skills because it
not only builds on cultural proficiency but also
focuses on self-reflection, a critical skill in cross-
Cultural Proficiency
cultural work, and the consequent awareness of
Although no one can be truly “culturally profi- power differences between practitioners, research-
cient” in a culture outside one’s own, this concept ers, policymakers, and the community of interest.
refers to actively valuing and embracing cultural Moreover, there is a commitment to address
differences such that ongoing efforts are made to these power differences across the spectrum of
enhance the understanding of cultures encoun- public health modalities. Cultural humility recog-
tered in practice. In healthcare services as well as nizes the privileged status and social positions
in community-level interventions, the concept of that practitioners, researchers, and policymakers
community-oriented primary care is relevant here. occupy, regardless of their own ancestral heri-
This means that the organization or program has tage. In practice, it actively seeks to understand
means to assess the health-related beliefs and and appreciate the local historical and social
272 Cultural Competency
Table 1 Cultural Competency Approaches by Public Health Modality
Public Health Modality

Cultural
Competency Health Services Public Health
Approaches Healthcare Services Community-Level Interventions Research Policy
Locus of Delivering services to Delivering interventions to Describing or Ensuring access

Change or individuals and family populations, social networks and analyzing trends in to services
Interest members subgroups, and community-based access to through policy
organizations healthcare and initiatives
services utilization
Cultural Awareness of cultural Awareness of cultural differences Presenting results Developing

Sensitivity differences between between those designing or with awareness of policies with
providers and service funding the intervention and the major cultural awareness of the
recipients those implementing and receiving subgroups in the cultural
the intervention study differences in
the population
Cultural Valuing cultural Valuing cultural differences; Valuing cultural Valuing cultural
Proficiency differences; having tailoring interventions to local differences; differences in
knowledge of group-level cultural practices and using collaborative appreciating
cultural practices while indigenous institutions and enquiry with how policies
acknowledging individual personnel for delivery of services; members of may
differences; linguistic linguistic proficiency evident in population differentially
proficiency evident in health education materials and subgroups affected affect cultural
health education materials written policies by the health subgroups;
and written policies; issue(s) under seeking input
professional and consideration; from the
organizational linguistic cultural groups
development encouraged; proficiency evident most affected by
recruitment of staff in research the health
reflecting community instruments and issue(s) under
composition recruitment of consideration;
participants linguistic
proficiency
evident
Cultural Awareness of power issues Awareness of power issues; Awareness of Awareness of
Humility in delivery of care; taking inclusion of community as an power issues; power issues;
action to reduce social equal partner in the intervention, coproduction of actively
distancing and encourage sharing of intervention fiscal knowledge with fostering
participation in care; resources; conducting training community inclusion of
encouraging culturally and skill building for members, sharing youth and
appropriate self-care and interventions; learning and research resources; community
use of community and appreciating the social-historical building members in
cultural resources; context of community; fostering community policy changes
professional and cultural revitalization; addressing capacity for
organizational the broader social determinants research; fostering
development required that affect health cultural
revitalization; using
research results to
foster change
context or worldview of communities of interest. Limitations of Culturally

One of the hallmarks of cultural humility is Competency Approaches
meaningful inclusion of cultural groups affected
Because cultural competency has not been well
by the issue. In healthcare and community inter-
defined or operationalized, it has been challenging
ventions, this means bringing local cultural
to evaluate its effectiveness. It is important to keep
resources into partnerships, a fair distribution of
in mind that cultural competency is also value-
fiscal and other resources, shared decision-mak-
based, and as such it is significant in its own right
ing about services, and conducting training and
in the absence of evidence. Additionally, cultural
fostering community capacity for taking more
competency in and of itself cannot address all the
initiative and control of intervention develop-
social determinants of health that exert influence
ment and research. Services research employs
from the broader social structure that limits oppor-
principles of collaborative inquiry such as in
tunities for equality and health in vulnerable popu-
community-based participatory research (CBPR).
lations. Nevertheless, there are calls for a research
As indicated in the literature, this means commu-
agenda to critically examine the role of the cultural
nity involvement in all phases of the research
factors identified above in healthcare delivery sys-
process from inquiry questions and instruments
tems. The evidence to date shows promise for cul-
to data analysis, interpretations, and actions that
turally congruent services (e.g., services that take
follow from the research findings. Such processes
into account cultural strengths, local resources, and
can improve the utility of research efforts because
way of life as well as population risk and protective
new understandings can emerge from the cocon-
factors). Health services research can play a vital
struction of knowledge from joint community
role through the use of mixed methods (qualitative
and academic partnerships. This is particularly
and quantitative) that identify and measure content
important in services research, where much
of services, preferences and practices of consumers,
evidence-based research is lacking that can inform
and policies. The impact of services and policies as
future policies and practice. In policy as in ser-
well as the processes that foster cultural compe-
vices research, youth (high school and college
tence need to be captured with data. More specifi-
students) can be actively involved in the processes
cally, identifying the conditions under which certain
with mentoring so that they are encouraged to
cultural competency approaches contribute to
consider careers in the health sciences, perhaps
improved health outcomes are of great interest. To
services research in the future. These efforts
the extent that research endeavors can incorporate
actively seek out advocacy groups (through com-
community-based participatory research principals
munity organizations) and support pipeline pro-
and practices (itself an exercise in cultural compe-
grams (for enhancing minority enrollment in
tency), the knowledge gleaned from such research
health professions) for including in the research
can be more useful and can potentially contribute
and policy processes. Last, cultural humility
to informing the evidence for cultural competency
approaches can enhance cultural revitalization
for practice and policy.
through honoring and celebrating local culture
and ensuring inclusion of cultural elements in Michele A. Kelley
health services, health promotion messages, and
practices and local health policy processes. See also Access to Healthcare; Community-Based
Finally, cultural humility and participatory prac- Participatory Research (CBPR); Ethnic and Racial
tices in research can also identify the small-scale Barriers to Healthcare; Health Disparities; Health
culturally sensitive interventions that are often Resources and Services Administration (HRSA);
managed by indigenous groups (not outside National Healthcare Disparities Report (NHDR);
“experts”) and investigate the mechanisms by Vulnerable Populations
which these unique local interventions produce
outcomes in specific groups under specific condi-
Further Readings
tions. These culturally sensitive interventions are
often excluded from research that seeks to iden- Anderson, Laurie, Susan C. Scrimshaw, Mindy T.
tify empirically supported interventions. Fullilove, et al. “Culturally Competent Healthcare
274 Culyer, Anthony J.
Systems: A Systematic Review,” American Journal of

Preventive Medicine 24(3 Suppl.): 68–79, April 2003. Culyer, Anthony J.
Betancourt, Joseph R., Alexander R. Green, J. Emilio
Carrillo, et al. “Cultural Competence and Health Anthony J. Culyer is a senior scientist at the
Care Disparities: Key Perspectives and Trends,”
Institute for Work and Health, a professor of eco-
Health Affairs 24(2): 499–505, March–April 2005.
nomics (on leave) at the University of York in the
Castro, Felipe Gonzalez, Manuel Barrera, and Charles R.
United Kingdom, and an adjunct professor in the
Martinez. “The Cultural Adaptation of Prevention
Department of Health Policy, Management and
Interventions: Resolving Tensions Between Fidelity and
Fit,” Prevention Science 5(1): 41–45, March 2004.
Evaluation at the University of Toronto. He is
Israel, Barbara A., Amy J. Schulz, Edith A. Parker, et al.
recognized internationally for his work in health
“Critical Issues in Developing and Following economics, with special expertise in the appropri-
Community Based Participatory Research Principles,” ate use of health technology from both an eco-
in Community-Based Participatory Research for nomic and clinical perspective, and the effective
Health, edited by M. Minkler and N. Wallerstein, translation of this knowledge into practice. His
53–76. San Francisco: Jossey-Bass, 2003. interests extend to the economics of social policy,
Johnson, Timothy P., and Phillip J. Bowman. “Cross- and equity and social justice.
Cultural Sources of Measurement Error in Substance Culyer earned a bachelor’s degree in economics
Use Surveys,” Substance Use and Misuse 38(10): from Exeter University in 1964 and received an
1447–90, August 2003. honorary doctorate degree in economics from the
Lehman, Darrin R., Chi-yue Chiu, and Mark Schaller. Stockholm School of Economics in 1999. In 1964,
“Psychology and Culture,” Annual Review of he was awarded the Exeter University Leo T. Little
Psychology 55: 689–714, February 2004. Prize for economics, and he received a Fulbright
Lindsey, Randall B., Raymond D. Terrell, and Kikanza Travel Scholarship to study and work as a teaching
Nuri Robins. Cultural Proficiency: A Manual for assistant at the University of California at Los
School Leaders. 2d ed. Thousand Oaks, CA: Corwin Angeles in 1964–1965.
Press, 2003. During his expansive career, Culyer has held
Mullan, Fitzhugh, and Leon Epstein. “Community- academic positions in both England and Canada
Oriented Primary Care: New Relevance in a and has assumed administrative academic roles at
Changing World,” American Journal of Public Health the University of York. In addition, he has held
92(11): 1748–55, November 2002.
visiting professor positions in Australia, Germany,
Nutter, Donald, and Michael Whitcomb. The AAMC
and New Zealand. His editorial contributions
Project on the Clinical Education of Medical
have included being a founding coeditor of the
Students. Washington, DC: Association of American
Journal of Health Economics, editor of Nuffield/
Medical Colleges, 2001.
Parker, Ruth M., Scott C. Ratzan, and Nicole Lurie.
York Portfolios, advisory editor of Social Science
“Health Literacy: A Policy Challenge for Advancing
and Medicine, and member of the editorial boards
High-Quality Health Care,” Health Affairs 22(4): of numerous journals such as The Economic
147-53, July–August 2003. Review, Journal of Medical Ethics, the British
Wallerstein, Nina B., and Bonnie Duran. “Using Medical Journal, and Clinical Effectiveness in
Community-Based Participatory Research to Address Nursing. He has served the health economics com-
Health Disparities,” Health Promotion Practice 7(3): munity extensively through his involvement in a
312–23, July 1, 2006. variety of professional groups, including the Health
Economists’ Study Group, the Scientific Committee
of the International Institute of Public Finance, the
Web Sites Canadian Institute of Advanced Research, and the
Georgetown University Center for Child and Canadian Health Services Research Foundation
Human Development, National Center for (CHSRF). He has acted as an advisor, committee
Cultural Competence (NCCC): member, or chair for many groups, including
http://www11.georgetown.edu/research/gucchd/nccc health authorities, government agencies (in partic-
Health Resources and Services Administration (HRSA), ular the United Kingdom’s National Health Service
Bureau of Health Professions (BHPr): [NHS]), and commissions and advisory groups
http://bhpr.hrsa.gov/diversity/cultcomp.htm for research and development. He also served as
Current Procedural Terminology (CPT) 275
vice-chair of the United Kingdom’s National

Institute for Clinical Excellence (NICE), an organi- Current Procedural
zation that provides national guidance on promot- Terminology (CPT)
ing good health and preventing and treating ill
health in England and Wales. Current Procedural Terminology (CPT) is a code
Culyer has published over 200 articles, is a con- set that includes an array of medical, surgical,
tributor to 28 books, and has authored or coau- and diagnostic services tied to the financial reim-
thored more than 35 monographs or discussion bursement of physicians and healthcare services.
papers. His work is cited extensively. He has writ- The American Medical Association (AMA) main-
ten on a variety of health-related topics, with many tains the CPT, and it is regarded as the standard
focusing on public policy and issues of efficiency, for the accurate communication of medical infor-
effectiveness, and equity. He is also the author of mation and procedures among physicians, gov-
Supporting Research and Development in the ernment, third-party payers, and peer-review
NHS (1994), which is commonly known as the organizations.
Culyer Report.
Gregory S. Finlayson Overview
See also Canadian Health Services Research Foundation Procedural coding by physicians has evolved
(CHSRF); Equity, Efficiency, and Effectiveness in from a rudimentary classification system used
Healthcare; Health Economics; Health Services Research mostly for research purposes to a dynamic tool
in Canada; Health Services Research in the United that reflects the rapid advancements in health-
Kingdom; Public Policy; United Kingdom’s National care. The first Physician’s Current Procedural
Health Service (NHS); United Kingdom’s National Terminology was published by the AMA in 1966,
Institute for Health and Clinical Excellence (NICE) and it was periodically revised until the fourth
edition, which was published in 1977 as CPT-4,
Current Procedural Terminology—4th Edition.
Further Readings Since then, the basic format has been retained,
Culyer, Anthony J. “Need: The Idea Won’t Do—But We and all subsequent printings of CPT use the
Still Need It,” Social Science and Medicine 40(6): CPT-4 design. The revised Current Procedure
727–30, March 1995. Terminology is published annually, and the new
Culyer, Anthony J. “Equity: Some Theory and Its Policy revision takes effect each January 1. The AMA
Implications,” Journal of Medical Ethics 27(4): owns and develops CPT-4, and attempts by oth-
275–83, August 2001. ers to develop a medical procedural coding and
Culyer, Anthony J., and Joseph P. Newhouse, eds. medical nomenclature system have not been as
Handbook of Health Economics. Vol. 1A and 1B. widely recognized.
New York: North-Holland, Elsevier Science, 2000. The acceptance of CPT-4 was enhanced in
Culyer Anthony J., and Adam Wagstaff. “Equity and 1983, when the U.S. Department of Health and
Equality in Health and Health-Care,” Journal of Human Services (HHS) signed a contract with the
Health Economics 12(4): 431–57, December 1993. AMA designating CPT-4 as the standard coding
Rawlins, Michael D., and Anthony J. Culyer. “National system for describing physicians’ and other health-
Institute for Clinical Excellence and Its Value care providers’ services for Medicare and Medicaid.
Judgments,” British Medical Journal 329(7459): The Resource Based Relative Value Scale (RBRVS)
224–27, July 24, 2004.
is based on the CPT-4 coding. The Resource
Relative Value Scale is a system used to determine
physician reimbursement, and numerical relative
Web Sites values are assigned to each CPT code. This value is
Department of Economics and Related Studies, York multiplied by a dollar conversion factor, updated
University: http://www.york.ac.uk/depts/econ yearly by the Centers for Medicare and Medicaid
Institute for Work and Health: http://www.iwh.on.ca Services (CMS), to determine payment levels for
Tony Culyer’s Web Page: http://www-users.york.ac. physician and other healthcare services. Third-
uk/~ajc17 party insurance companies and others have adopted
276 Current Procedural Terminology (CPT)
the same method of payment as the CMS based on a capitalized letter F (e.g., discussion of osteoporo-
CPT-4 coding. sis prevention 4019F) and have no relative values
The AMA/CPT Editorial Panel maintains, assigned to them. CMS is presently conducting a
updates, modifies, and revises CPT-4. The AMA/ pilot study based on the Category II codes called
CPT Editorial Panel is composed of 19 members pay-for-performance—that is, using a reimburse-
selected by the AMA for 4- or 8-year terms. There ment scheme based on performance measures.
are 13 physicians who represent selected medical Category III codes are temporary tracking codes
and surgical specialties, in addition to a chair and assigned for new or emerging services and/or pro-
vice-chair. The CMS, third-party medical insur- cedures to facilitate data collection and assess-
ance carriers, nonphysician providers, and the ment. The criteria for Category III codes require a
American Health Information Management protocol for the study of procedures being per-
Association (AHIMA) each have one member on formed, support from specialists who would use
the panel. The AMA/CPT Advisory Committee the procedure, availability of peer-reviewed litera-
and AMA Health Care Professionals Advisory ture, and a description of current clinical trials
Committee also provide input into the AMA/CPT outlining the procedure’s efficacy. There are no
Editorial Panel. Additionally, there are 91 medical relative value units assigned to Category III codes.
and surgical societies and 17 healthcare profes- Category III codes are identified by four digits and
sional society representatives selected by the AMA followed by a capitalized letter T (e.g., 0052T).
for participation. These codes are archived after 5 years unless the
codes are promoted to a Category I code or there
is a demonstrated need for further study.
Code Categories
The CPT-4 publication divides physician services Code Requests
into three categories. Category I codes are based
on procedures consistent with contemporary med- Requests for a new code or the revision to an exist-
ical practice performed by many physicians in ing code can be submitted by anyone, and an
clinical practice. Category I code criteria include application form can be obtained from the AMA
approval by the Food and Drug Administration Web site. Code requests submitted are reviewed by
(FDA) of any drug or device; the service being a the AMA Editorial Research and Development
distinct procedure and/or service performed by Department staff. These requests are then sent to
many physicians and/or practitioners; the clinical selected members of the CPT Advisory Committee
efficacy of the service and/or procedure being well for proper code placement, comment, and approval.
established in peer-reviewed literature; the service The responses from members of the CPT Advisory
and/or procedure being neither a fragmentation of Committee and others are evaluated by the AMA/
an existing procedure or service nor currently CPT Editorial Panel. Sponsoring societies or indi-
reportable by one on more existing codes; and the viduals may request to appear before the AMA/
suggested service and/or procedure being not a CPT Editorial Panel during the CPT code consid-
means to report extraordinary circumstances eration. The AMA/CPT Editorial Panel members
related to the performance of a service and/or pro- then vote by secret ballot. The decisions of the
cedure already having a specific CPT code. The editorial panel may be appealed prior to the com-
CPT-4 coding system assigns a five-digit number pletion of the yearly CPT-4 update.
to each code in Category I.
Category II codes are supplemental codes used
for tracking performance measures. These codes Future Implications
are used to facilitate the collection of data on qual- The CPT coding system continues to evolve, and
ity of care by coding services and/or tests that sup- it is updated on a regular basis by the AMA in
port performance measures contributing to good response to changing demands. It is likely that the
patient care. These four-digit codes are followed by CPT will continue to play an important role in the
Current Procedural Terminology (CPT) 277
future for financial, administrative, and research Kesselheim, Aaron S., and Troyen A. Brennan.
purposes. “Overbilling vs. Downcoding: The Battle Between
Physicians and Insurers,” New England Journal of
Blair C. Filler Medicine 352(9): 855–57, March 3, 2005.
Miyamoto, Robin E. S. “Billing Effectively With the
See also Diagnosis Related Groups (DRGs); Healthcare New Health and Behavior Current Procedural
Financial Management; International Classification of Terminology Codes in Primary Care and Specialty
Diseases (ICD); Medicare Payment Advisory
Clinics,” Journal of Clinical Psychology 62(10):
Commission (MedPAC); Pay-for-Performance;
1221–29, October 2006.
Payment Mechanisms; Prospective Payment; Resource-
Qureshi, Adnan I., Pansy Harris-Lane, and Jawad F.
Based Relative Value Scale (RBRVS)
Kirmani, “International Classification of Diseases and
Current Procedural Terminology Codes
Underestimated Thrombolytic Use for Ischemic
Further Readings Stroke,” Journal of Clinical Epidemiology 59(8):
American Medical Association. CPT Changes 2009: An 856–58, August 2006.
Insider’s View. Chicago: American Medical
Association, 2008.
Web Sites
Dorman, Todd, Laura Loebb, and George Sample.
“Evaluation and Management Codes: From Current American Medical Association, Current Procedural
Procedural Terminology Through Relative Update Terminology: http://www.ama-assn.org/go/cpt
Commission to Centers for Medicare and Medicaid Centers for Medicare and Medicaid Services (CMS),
Services,” Critical Care Medicine 34(3 Suppl.): Healthcare Common Procedure Coding System:
S71–S77, March 2006. http://www.cms.hhs.gov/MedHCPCSGenInfo
D
State law can prevail when it is more stringent
Data Privacy than the federal HIPAA Privacy Rule. These state
laws vary in the protection they offer and gener-
Data privacy is an abstract term that, in health- ally pertain to the privacy protection of genetic
care, refers to the delicate relationship among the data. Laws, especially the Privacy Rule, limit the
legal rights of a person, the growing global demand disclosure to the minimum necessary. Minimum
for information, and the technology used in the necessary restricts disclosure or use to the mini-
collection, sharing, and use of data. The word pri- mum required to accomplish an individual’s
vacy invokes thoughts of freedom from unwanted healthcare or legal task that enabled the release of
access to one’s health-related information as guar- the information.
anteed by federal and state laws; it is also used
with or in place of the term confidentiality in
healthcare. Confidentiality refers to the right of a
Privacy and the Public’s Health
person to expect his or her health-related informa- The term data privacy becomes more obscure and
tion not to be accessed without his or her permis- indistinguishable from confidentiality as the global
sion except what is required for his or her medical demand for information grows each year. As epi-
care and as allowed by the laws of the land. demics such as bird flu affect the global popula-
tion, the terms public health and the common
good of the community take on new connota-
Laws and Rules
tions. Data privacy, or the anonymity of an indi-
A recent important rule is the Privacy Rule that vidual with regard to his or her medical data, is
was issued by the U.S. Department of Health and weighed against the common good of the commu-
Human Services (HHS) in 2002 with a compliance nity, such as a city, then a state, and, eventually, a
date of April 14, 2003, under the mandate of the nation. Now our community is the world, and the
Health Insurance Portability and Accountability data privacy of an individual must be weighed
Act of 1996 (HIPAA). The Privacy Rule provides against the common good of the global commu-
standards to protect individually identifiable health nity. Therefore, healthcare providers are required
information. However, the rule only sets con by law to report certain diseases and other health
ditions for use and disclosure of the data by health- conditions to specific health groups or registries.
care plans, healthcare providers, and healthcare The data sent to the health groups, such as the
clearinghouses. The rule still allows disclosure of state public health department, the Centers for
an individual’s health-related information under Disease Control and Prevention (CDC), and can-
certain public health and legal instances. cer or other registries, are in one of three forms:
279
280 Data Privacy
(1) individually identifiable data, (2) de-identifiable review board founded to assist researchers in meet-
data, or (3) linkable data. ing HIPAA privacy requirements.
Pharmaceutical companies are also in the data
and knowledge acquisition race. The data that are
Forms of Data
collected from the different registries, medical
Individually identifiable data consist of 18 items agencies, researchers, and others can and do end
listed within the HIPAA Privacy Rule as items that up in computer databases.
can be used to identify an individual. The items are The technological advancements in the past 5 to
name, zip code with some reservations, dates 10 years allow researchers and others with per-
(birth and death, without year) and the year when sonal computers and a connection to the Internet
the person is 89 years of age or older, and tele- to perform data-mining procedures that were once
phone number. The list also includes facsimile the total domain of large research companies. Data
number, e-mail address, social security number, mining is the process of searching large volumes of
medical numbers, and health plan beneficiary data using collective reasoning, associative rules,
numbers. Identifiable data also cover Web univer- and other techniques to search for data patterns
sal resource locators (URLs), account numbers, within multiple databases. Some programs will
certificate/license numbers, Internet protocol (IP) assist a researcher in data-mining efforts, so exper-
address, and vehicle identifiers. Also in the list as tise with this technique is not needed to accom-
identifying data are device identifiers and serial plish it.
numbers; biometric identifiers, full-face photos;
and any other unique identifying number, charac- Future Implications
teristic, or code.
The de-identifiable data have most, if not all, of The tentative relationship among the legal rights
the 18 items removed so that the information of a person; the growing global demand for data;
cannot be traced back to an identifiable individual. and the technology used in the collection, use,
Linkable data have limited identifiable informa- and sharing of data has transformed the term
tion and/or a code that can be used by the holder privacy into confidentiality in the context of the
of the information to identify the individual whose world of healthcare. To keep the data confiden-
data are being used or sent to the required agency tial, healthcare providers must ensure that all
or person. interfaced systems are properly secured and must
enforce the required level of protection against
loss of individually identifiable data to unau-
Research Uses thorized persons. Researchers and others who
Medical agencies are not the only ones that require are not covered by HIPAA will need to rely on
healthcare data. Researchers also require data in the IRBs, the privacy boards, the policies and
their pursuit of new knowledge and advance cures. procedures of the healthcare entity from which
While researchers are not under the jurisdiction of the data were received, and the researcher’s own
HIPAA unless they are employees of a healthcare professional ethics. Technology will need to fol-
provider, healthcare plan, or healthcare clearing- low the guidelines set down in the HIPAA
house; a provider themselves; or a business associ- Security Rule and follow the principles of best
ate of one of the aforementioned groups and security practices to lower the level of security
covered by contract or business agreement, they risk to confidential data.
must follow the stipulations of an institutional
Greer W. P. Stevenson
review board (IRB) or a privacy board. IRBs are
covered under Title 45 CFR (Code of Federal See also Computers; Data Security; E-Health; Electronic
Regulations) Part 46, referred to as the Research Clinical Records; E-Prescribing; Healthcare Informatics
Act of 1974. IRBs oversee the use of research Research; Health Insurance Portability and
data and the ethical and privacy problems that may Accountability Act of 1996 (HIPAA); Technology
arise from that use. A privacy board is an independent Assessment
Data Security 281
Further Readings the Health Insurance Portability and Accountability

Committee on the Role of Institutional Review Boards in Act of 1996 (HIPAA), the National Information
Health Services Research Data Privacy Protection. Infrastructure Protection Act of 1996, and the
Protecting Data Privacy in Health Services Research. Security and Freedom Through Encryption Act of
Washington, DC: National Academies Press, 2000. 1999. In some instances where providers or hospi-
Dupuenoy, Penny, Carlisle George, and Kai Kimppa, eds. tals offer financial plans, they are covered by the
Ethical, Legal, and Social Issues in Medical Sarbanes-Oxley Act of 2002. The main law that
Informatics. Hershey, PA: Medical Information covers data security in the healthcare arena is
Science Reference, 2008. HIPAA’s Security Rule, Title 45 CFR (Code of
Sullivan, June. HIPAA: A Practical Guide to the Privacy Federal Regulations) Parts 160, 162, and 164,
and Security of Health Data. Chicago: American Bar which had a compliance date of April 20, 2005.
Association, Health Law Section, 2004. The Security Rule applies only to covered
entities—namely, healthcare providers, healthcare
clearinghouses, and healthcare plans. The Security
Web Sites Rule requires that each covered entity institutes a
security plan that meets or exceeds the security
standards as set forth in the rule to protect the
http://www.ahrq.gov
confidentiality, integrity, and availability of elec-
American Medical Informatics Association (AMIA):
tronically protected health information and other
http://www.amia.org
information as set forth in the rule. The standards
Healthcare Information and Management Systems
are divided into three categories: administrative,
Society (HIMSS): http://www.himss.org
physical, and technical. Administrative safeguards
require a risk analysis, contingency/disaster recov-
ery plans, personnel security measures, sanctions,
security policies and procedures, termination pro-
Data Security cedures, and training requirements. The physical
safeguards cover media controls, physical access
Data security refers to the requirement to ensure controls, workstation controls and procedures,
confidentiality, integrity, and availability of data. and security awareness training. The technical
In security circles, confidentiality, integrity, and safeguards pertain to system access controls,
availability are called the CIA triad and are the encryption, authorization controls, data authenti-
bases for implementing data security. Confidentiality cation, and access authentication. These standards
is present when disclosure of data to unauthorized are either required or addressable. A required stan-
personnel and/or systems is prevented from occur- dard must be implemented. An addressable stan-
ring. Data have integrity when they are complete, dard can be implemented as described in the rule,
accurate, and reliable and when unauthorized or the entity can justify why it chose another
alteration and/or destruction is prevented. Data method to meet the standard.
security requires the active interventions of laws, The common laws that affect data security are
management, people, and technology to ensure numerous and usually are called into force through
that the triad is active and working effectively. civil litigation when due diligence or due care is in
question. Due diligence requires that an organiza-
tion make and continue to make a valid effort to
Laws and Regulations
protect the confidentiality, integrity, and availabil-
Numerous federal and common laws affect the ity of the data. Due care requires the organization
way data are secured by individuals and within to act as any prudent and rational organization
systems. A few of the federal laws that affect would when trying to protect the security of the
healthcare are the Computer Fraud and Abuse data. One law that is not always enforced by court
Act, the Computer Security Act of 1987, the action is the law that grew from the norms, mor-
Electronic Communications Privacy Act of 1986, als, and common laws of the land—ethics. Ethics
282 Data Security
guides professionals, especially in healthcare, to do Another concept related to security is called the
no harm and to protect the confidentiality of the “MOM” in security circles. It stands for means,
patient or client. opportunity, and motive. Workers have the means
and opportunity to obtain secure data, and all
they lack is the motive to cause a data security
Role of Management and Employees
breach. But although outsiders or hackers may
Data security at a company or healthcare facility have the means and the motive, security controls
cannot be met through pain of penalty alone or will normally block their entry into the network.
with the adage “Do as I say, not as I do.” Security If the security controls do not block access to the
must be from the top down and may sometimes network, the control might slow penetration into
involve a modification of behavior within the the network and give the network administrator a
entire organization. Management sets the tone chance to notice and stop the violation. Hackers
and direction of security through policies, goals, or crackers are individuals who penetrate secure
and mission statements. The first step in building networks for fun, profit, or fame or to cause
a data security program is to have top manage- havoc within the system. In the past, there was a
ment state in writing the importance of security difference in the meanings of hackers and crack-
and determine what assets are to be protected and ers. Hackers broke into a system for fun and
at what cost. It also directs and allocates resources fame, while crackers did it for profit and to cause
to perform a risk analysis for determining what havoc.
threats and hazards are being faced by which With MOM and the tendency for employees to
assets and how much it will cost to protect those try to assist superiors over the telephone, a
assets from those threats and hazards. Management healthcare organization must ensure that its secu-
must then assume the risk or allocate resources to rity policies and procedures are up-to-date and
protect the identified assets to a level it deems relevant. The organization must also use controls
appropriate. Management also is responsible for during hiring to ensure that the new recruits are
ensuring that all applicable policies and proce- trustworthy. Employees should be aware that
dures are in place; even if it delegates the author- they will face sanctions if they do not follow
ity, it still maintains the responsibility. policies and procedures. Behavior modification
Management cannot enforce data security in a can be achieved through education, observation
vacuum. Employees must assist in data security or by the management (seeing that controls apply to
it will fail. Employees must ensure that only autho- everyone no matter who they are), and awareness
rized individuals enter controlled areas where training.
access to secure data and systems can be obtained.
They also need to be observant enough to notice
Role of Technology
when someone is trying to peer over their shoulder
to view the information being entered into the sys- Technology is also necessary to ensure data secu-
tem. Employees must be careful of social engineer- rity. Technical procedures and mechanisms must
ing techniques and be aware enough to block the be put into place to control access to systems, net-
use of such security-breaking techniques. Social works, and facilities. Detection apparatuses can
engineering is an act of undermining security by sense viruses and other malicious software and
obtaining secure information through the use of deny them access to vital systems and networks.
deception. For instance, an employee may receive Audit logs should be used to track authorized and
a telephone call from someone pretending to be the unauthorized changes to data, but the logs need to
secretary of the chief executive officer (CEO) ask- be reviewed for inconsistency and possible secu-
ing for secured information. The employee should rity violations. Security patches and programs
realize that a secretary would not be asking for need to be tested before installation into a live
information that would not normally be released system as the patches themselves can cause the
over the telephone or in person. Security aware- introduction of errors or viruses. Security technol-
ness training can preclude or reduce the occurrence ogy must be checked and updated regularly if
of social engineering. security levels are to be maintained.
Data Sources in Conducting Health Services Research 283
Data security can maintain the confidentially, Although the list is not exhaustive, health ser-
integrity, and availability of data only if the laws, vices research generally addresses the following
management, people, and technology work together areas: (a) costs, cost-benefit, cost-effectiveness, and
to ensure a stable but flexible security program. other economic aspects of healthcare; (b) patient
and population health status/health disparities;
Greer W. P. Stevenson (c) outcomes of healthcare technologies and inter-
ventions; (d) practice patterns and diffusion of
See also Computers; Data Privacy; E-Health; Electronic technologies and interventions; (e) quality assur-
Clinical Records; E-Prescribing; Healthcare Informatics
ance programs; (f) clinical guidelines, standards,
Research; Health Insurance Portability and
Accountability Act of 1996 (HIPAA); Technology
and criteria for healthcare; (g) the need and
Assessment demand for health services; (h) utilization patterns
of health services; (i) patient satisfaction with
treatments, providers, and practice settings;
(j) organization and delivery of healthcare; and
Further Readings (k) the various means of financing healthcare.
Marcinko, David E., and Hope R. Hetico. Dictionary of Many federal, state, and trade associations and
Health Information Technology and Security. New professional societies actively collect and dissemi-
York: Springer, 2007. nate data that are used for health services research.
Whitman, Michael E., and Herbert J. Mattord. Principles At the federal government level, examples include
of Information Security. 3d ed. Boston: Course the Agency for Healthcare Research and Quality
Technology/Thomson, 2007. (AHRQ), the Centers for Medicare and Medicaid
Wu, Stephen, ed. Guide to HIPAA Security and the Law. Services (CMS), and the National Center for
Chicago: American Bar Association, Section of Health Statistics (NCHS). At the state government
Science and Technology Law, 2007. level, they include departments of public health,
departments of health and family services,
and health planning and development offices.
Web Sites Examples of trade associations and professional
societies include the American Hospital Association
(AHA), American Medical Association (AMA),
http://www.ahrq.gov
American Medical Information Association (AMIA):
and National Committee for Quality Assurance
http://www.amia.org
(NCQA).
Society (HIMSS): http://www.himss.org Major Databases
To conduct health services research, a large num-
ber of publicly accessible databases are available.
Data Sources in Conducting Below is a brief description of some of the major
databases.
Health Services Research
Health services research can be defined as the Minimum Data Set (MDS)
multidisciplinary field of investigation that studies The Minimum Data Set (MDS) is a part of the
how social factors, financing systems, organiza- federally mandated process for clinical assessment
tional structures and processes, health technolo- of all residents in Medicare- or Medicaid-certified
gies, and personal behaviors affect access to nursing homes. This process provides a compre-
healthcare, the costs and quality of healthcare, hensive assessment of each resident’s functional
and, ultimately, the outcomes of healthcare. Health capabilities and helps nursing home staff identify
services research often attempts to influence health health problems. Resident assessment protocols
policy and the practice of medicine through the (RAPs) are a part of this process and provide the
analysis of large databases. foundation on which a resident’s individual care
284 Data Sources in Conducting Health Services Research
plan is formulated. MDS assessment forms are the nation’s counties. It contains information on
completed for all residents in certified nursing health facilities, health professionals, measures of
homes, regardless of the source of payment for the resource scarcity, health status, economic activity,
individual resident. The MDS is available from the health training programs, and socioeconomic and
CMS. environmental characteristics. ARF is a collection
of data from various sources, including the AHA,
AMA, and the NCHS. ARF is available from
Medicare Current Beneficiary Survey (MCBS) Quality Resource Systems, Inc.
The Medicare Current Beneficiary Survey
(MCBS) is a survey of a nationally representative
American Hospital Association
sample of aged, disabled, and institutionalized
(AHA) Annual Survey
Medicare beneficiaries. It is the only comprehen-
sive source of information on the health status, The AHA’s Annual Survey collects information
healthcare use and expenditures, health insurance on numerous characteristics of hospitals and their
coverage, and socioeconomic and demographic patients. It collects data on the organizational
characteristics of the entire spectrum of Medicare structure, the facilities and services offered, utiliza-
beneficiaries. Data from the MCBS are available tion data, physician arrangements, managed-care
from the CMS. relationships, and hospital expenses and staffing.
The annual survey is the largest and most compre-
hensive source of information on the nation’s
Online Survey, Certification, hospitals, including the association’s member and
and Reporting (OSCAR) nonmember hospitals. Data from the annual sur-
The Online Survey, Certification, and Reporting vey are available from the AHA.
(OSCAR) system is a compilation of all data ele-
ments collected by surveyors during the inspection
Healthcare Cost and
conducted at nursing facilities for the purpose of
Utilization Project (HCUP)
certification for participation in the Medicare and
Medicaid programs. It is the most comprehensive Healthcare Cost and Utilization Project (HCUP)
source of facility-level information on the opera- databases bring together the data collection efforts
tions, patient census, and regulatory compliance of of state data organizations, hospital associations,
nursing facilities. Data from the OSCAR system private data organizations, and the federal govern-
are available from the CMS. ment to create a national information resource of
patient-level healthcare data. HCUP databases
include the Nationwide Inpatient Sample (NIS),
Healthcare Cost Report the Kids’ Inpatient Database (KID), the State
Information System (HCRIS) Inpatient Databases (SID), the State Ambulatory
The Healthcare Cost Report Information System Surgery Databases (SASD), and the State Emergency
(HCRIS) contains audited Medicare provider cost Department Databases (SEDD). Data from HCUP
reports submitted to the CMS. The HCRIS con- are available from the AHRQ.
tains five different cost reports: (1) hospital reports,
(2) hospice reports, (3) home health agency reports,
National Health Interview Survey (NHIS)
(4) renal facility reports, and (5) skilled-nursing
facility reports. The H and the Individual Facility The National Health Interview Survey (NHIS) is
Cost Report Information System are available the principal source of information on the health of
from the CMS. the civilian noninstitutionalized population of the
United States. Conducted since 1960 by the NCHS,
data from the NHIS are used to monitor national
Area Resource File (ARF)
trends in illness and disability and to track progress
The Area Resource File (ARF) is a database toward achieving national health objectives. Its
containing more than 6,000 variables for each of questions have remained fairly constant over time,
Data Sources in Conducting Health Services Research 285
although new questions are periodically added. service, access to care, and claims processing. The
The NHIS is available from the NCHS. HEDIS is available from the NCQA.
National Hospital Ambulatory Limitations of Available Databases

Medical Care Survey (NHAMCS)
While conducting research, many health services
The National Hospital Ambulatory Medical researchers often combine several databases. This
Care Survey (NHAMCS) is a data set on the utili- can sometimes be problematic because data sets
zation and provision of ambulatory-care services may be collected at different times using different
provided in hospital emergency and outpatient definitions of variables. Some data sets may have
departments. Findings are based on a national few cases, and the small numbers may make it dif-
sample of visits to the emergency departments and ficult to extrapolate to the population. Another
outpatient departments of general and short-stay major problem is missing data. Sensitive questions
hospitals, excluding federal, military, and Veterans may have few responders. Finally, although some
Health Administration hospitals. The NHAMCS is data sets are given to users for free, others can cost
available from the NCHS. thousands of dollars to purchase.
Surveillance, Epidemiology, Ethical Issues

and End Results (SEER) Program
When using databases, health services researchers
The Surveillance, Epidemiology, and End Results may encounter ethical challenges that arise from
(SEER) Program collects and publishes cancer inci- the tension between protecting the individual’s
dence and survival data in the nation. It collects privacy and meeting societal needs for informa-
data from population-based cancer registries cov- tion. The most important features of U.S. federal
ering about 26% of the U.S. population. The SEER regulations on the protection of human subjects
Program registries routinely collect data on patient are institutional review boards (IRBs) and informed
demographics, primary tumor site, tumor mor- consent from participants in research studies.
phology and stage of diagnosis, first course of Researchers need permission to use secondary data
treatment, and follow-up for vital status. It is the from IRBs.
only comprehensive source of population-based An IRB is a group that has been formally desig-
information in the nation that includes stage of nated to approve, monitor, and review medical and
cancer at the time of diagnosis and patient survival behavioral research involving humans with the
data. Data from the SEER Program are available aim of protecting the rights and welfare of the
from the National Cancer Institute (NCI). subjects. Furthermore, informed consent is required
for any research that directly involves individuals
and patients. The purpose of informed consent is
Healthcare Effectiveness Data to provide subjects information about the research,
and Information Set (HEDIS) including its purpose, procedures, risks, and antic-
The Healthcare Effectiveness Data and ipated benefits. It also is the investigator’s respon-
Information Set (HEDIS) is a tool used by more sibility to protect the subjects’ privacy when
than 90% of health plans in the nation to measure conducting research involving human subjects.
performance on important dimensions of care and
service. In total, the HEDIS consists of 71 mea- Keon-Hyung Lee and Thomas T. H. Wan
sures across eight domains of care. It is a set of See also Agency for Healthcare Research and Quality
standardized performance measures related to (AHRQ); American Hospital Association (AHA);
many significant public health issues, such as can- Centers for Medicare and Medicaid Services (CMS);
cer, heart disease, smoking, asthma, and diabetes. Healthcare Cost and Utilization Project (HCUP);
The HEDIS also includes a standardized survey Healthcare Effectiveness Data and Information Set
of consumers’ experiences that evaluates a health (HEDIS); Measurement in Health Services Research;
plan’s performance in areas such as customer National Center for Health Statistics (NCHS)
286 Davis, Karen
Further Readings Rice University, teaching from 1968 to 1970. In

Adams, Patricia F., Jacqueline W. Lucas, and Patricia M. 1970, she left the university and became a research
Barnes. Summary Health Statistics for the U.S. associate at the Brookings Institution in Washington,
Population: National Health Interview Survey, 2006. D.C. In 1974–1975, while on leave from Brookings,
HHS Pub. No. (PHS) 2008–1564. Hyattsville, MD: she was a visiting lecturer on economics at Harvard
National Center for Health Statistics, 2008. University. She returned to the Brookings Institution
Agency for Healthcare Research and Quality. Resource as a senior fellow. In 1977, she was appointed
Guide to Agency for Healthcare Research and deputy assistant secretary for planning and
Quality Child and Youth Health and Health Care evaluation (health) in the Office of the Secretary of
Services Data: Final Contract Report. AHRQ Pub. the U.S. Department of Health and Human Services
No. 07(08)-0088. Rockville, MD: Agency for (HHS). In 1980, she became the first woman to
Healthcare Research and Quality, 2008. ever head a U.S. Public Health Service agency
Boslaugh, Sarah. Secondary Data Sources for Public when she became the administrator of the Health
Health: A Practical Guide. New York: Cambridge Resources Administration. Davis served as the
University Press, 2008. administrator until the end of the Carter adminis-
National Center for Health Statistics. Disability and tration in 1981. From 1981 to 1992, she was a
Health in the United States, 2001–2005. HHS Pub. professor at Johns Hopkins University. She served
No. (PHS) 2008–1035. Hyattsville, MD: National as chairman of the Department Health Policy and
Center for Health Statistics, 2008. Management at the School of Hygiene and Public
Shi, Leiyu. Health Services Research Methods. 2d ed. Health from 1983 to 1992. In 1992, she left the
Clifton Park, NY: Delmar, 2008.
university to become the executive vice president
of the Commonwealth Fund, and in 1995, she
became its president.
Web Sites Throughout her career, Davis has served as a
Agency for Healthcare Research and Quality (AHRQ): member of numerous healthcare boards and com-
http://www.ahrq.gov mittees. These include the Congressional Budget
American Hospital Association (AHA): http://www.aha.org Office (CBO), Health Advisory Panel; National
Centers for Medicare and Medicaid Services (CMS): Academy of Sciences, Institute of Medicine (IOM);
http://www.cms.hhs.gov Board of Directors of the Geisinger Health System
National Center for Health Statistics (NCHS): Foundation; Baxter-Allegiance Foundation Prize
http://www.cdc.gov/nchs for Health Services Research Election Committee;
National Information Center on Health Services Council on the Economic Impact of Health Care
Research and Health Care Technology (NICHSR): Reform; Health Care Executive Forum; President’s
http://www.nlm.nih.gov/nichsr Council, Health Policy Forum, United Hospital
Fund; and Kaiser Commission on Medicaid and
the Uninsured.
Davis has authored or coauthored six books,
Davis, Karen numerous reports, and more than 100 journal
articles. Her most recent publications address
Karen Davis is the president of the Commonwealth issues such as access to healthcare, the healthcare
Fund, a large New York City–based, private foun- problems experienced by the uninsured, various
dation that promotes healthcare. Davis is a nation- state and national healthcare reform efforts, and
ally recognized health economist, with an extensive the overall performance of healthcare systems.
background in health services research and public Davis has received numerous awards and hon-
policy. ors for her work. She received the Picker Institute
A native of Oklahoma, Davis was born in 1942. Annual Award for Excellence in Patient-Centered
Davis earned a bachelor’s degree (1965) and a doc- Care and, in 2006, the Academy Health
toral degree in economics (1969) from Rice Distinguished Investigator Award. She was made
University in Houston, Texas. She started her an Alpha Omega Alpha Honorary Member in
career as an assistant professor of economics at 2001. She was awarded an honorary doctorate in
Davis, Michael M. 287
humane letters from Johns Hopkins University in Fund, the Committee for Research on Medical
2001. She was given the Baxter-Allegiance Economics, and the Committee for the Nation’s
Foundation Prize for Health Services Research in Health.
2000. And she received the Rice University Born in 1879 in New York City, Michael Davis
Distinguished Alumna Award in 1991. earned a bachelor’s degree (1900) and a doctoral
degree (1906) in sociology from Columbia
Amie Lulinski Norris University. While working on his doctoral degree,
Davis became interested in the social problems of
See also Access to Healthcare; Brookings Institution; New York’s Lower East Side. In 1905, he had
Commonwealth Fund; Health Economics; Health joined the staff of the People’s Institute at Cooper
Insurance; National Health Insurance; Public Policy; Union. He remained at the institute for 5 years,
Uninsured Individuals working in social settlements, where he learned
firsthand the many problems experienced by immi-
grants and the poor.
Further Readings From 1910 to 1920, Davis was the director of
Davis, Karen. Health Services Research and the the Boston Dispensary, where he investigated the
Changing Health Care System. New York: organization, delivery, and financing of health ser-
Commonwealth Fund, 1996. vices, a subject to which he was to devote his life.
Davis, Karen. “Paying for Care Episodes and Care At the dispensary, Davis studied the management
Coordination,” New England Journal of Medicine and structure of healthcare, its efficiency and
356(11): 1130–39, 2007. evaluation methods, and the interrelations between
Davis, Karen, Gerard F. Anderson, Diane Rowland, et al. health professionals and preventive and curative
Health Care Cost Containment. Baltimore: Johns care. He also introduced the idea of a “pay clinic,”
Hopkins University Press, 1990. where patients were charged a fee corresponding
Davis, Karen, and Stuart Guterman. “Rewarding to the costs of the services rendered.
Excellence and Efficiency in Medicare Payments,” In the 1920s, Davis was instrumental in setting
Milbank Quarterly 85(3): 449–68, 2007. up the CCMC, and he served as a member of its
Davis, Karen, and Andrew T. Huang. “Learning From executive committee. In 1928, he became the
Taiwan: Experience With Universal Health director of medical services at the Julius Rosenwald
Insurance,” Annals of Internal Medicine 148(4):
Fund in Chicago. His department promoted the
313–14, 2008.
concept of pay clinics and supported studies lead-
Davis, Karen, and Diane Rowland. Medicare Policy:
ing to the establishment of the Blue Cross system
New Directions for Health and Long‑Term Care.
of prepayment of hospital costs.
From 1932 to 1936, Davis was a lecturer in
sociology at the University of Chicago, where he
was instrumental in establishing the first graduate
Web Site
program in hospital administration in the country,
Commonwealth Fund: http://www.commonwealthfund.org under the auspices of the Graduate School of
Business. In 1934–1935, Davis assisted in drafting
the Social Security Act.
With a grant from the Rosenwald Fund, Davis
Davis, Michael M. established the Committee for Research in Medical
Economics in 1936. Under his leadership, the com-
Michael M. Davis (1879–1971) was a major fig- mittee funded a wide variety of studies in medical
ure in healthcare policy in the United States. Davis economics. It also published the first journal,
was a pioneer researcher in the economics, qual- Medical Care, solely devoted to the economic and
ity, and organization of medical care. During his social aspects of health services. The journal was
career of more than 50 years, he held executive published from 1941 to 1944.
positions on the Committee on the Costs of In 1945, Davis helped draft President Harry S.
Medical Care (CCMC), the Julius Rosenwald Truman’s message advocating a national health
288 Dentists and Dental Care
insurance program. And in 1946, Davis estab- Davis, Michael M. Medical Care for Tomorrow. New
lished and chaired the Committee on the Nation’s York: Harper & Brothers, 1955.
Health to promote national health insurance. With Davis, Michael M. America Challenges Medicine (the
the election of President Dwight D. Eisenhower in first Michael M. Davis lecture). Chicago: Graduate
1952, the prospects of national health insurance School of Business, University of Chicago, 1963.
diminished, and the committee was eventually Davis, Michael M. “What Are We Heading for in
abolished in 1956. Medical Care?” American Journal of Public Health
Over his long career, Davis authored 12 books 61(4): 651–53, April 1971.
Davis, Michael M., and C. Rufus Rorem. The Crisis in
and more than 250 articles. Some of his most influ-
Hospital Finance and Other Studies in Hospital
ential publications include Dispensaries, Their
Economics. Chicago: University of Chicago Press,
Management and Development (with Andrew R.
1932.
Warner), Immigrant Health and the Community,
Davis, Michael M., and Andrew R. Warner.
The Crisis in Hospital Finance and Other Studies Dispensaries, Their Management and Development: A
in Hospital Economics (with C. Rufus Rorem), Book for Administrators, Public Health Workers, and
Public Medical Services, America Organizes All Interested in Better Medical Service for the
Medicine, Medical Care for Tomorrow, America People. New York: Macmillan, 1918.
Challenges Medicine, and “What Are We Heading Rosen, George. “Michael M. Davis (November 19,
for in Medical Care?” 1879–August 19, 1971): Pioneer in Medical Care,”
Davis’s many contributions were recognized by American Journal of Public Health 62(3): 321–23,
the American Sociological Association (ASA) and March 1972.
the American Public Health Association (APHA).
The University of Chicago established a lecture
series in his honor in 1963, which continues to the Web Site
present. Davis gave the first lecture, titled “America
New York Academy of Medicine, Michael M. Davis
Challenges Medicine.”
Collection: http://www.nyam.org/library
Ross M. Mullner
See also Committee on the Costs of Medical Care

(CCMC); Health Economics; Health Insurance; Health Dentists and Dental Care
Services Research, Origins; Medical Sociology;
National Health Insurance; Public Health; Rorem, C. Dentistry is a branch of biomedical science address-
Rufus
ing the prevention, diagnosis, and treatment of
conditions, diseases, and disorders of the teeth,
Further Readings gums, jaws, oral cavity, and adjacent structures.
In most of the world, 4 years of undergraduate
Davis, Michael M. Immigrant Health and the
study and 4 years in a doctoral program are
Community. New York: Harper & Brothers, 1921.
required to become a dentist. In the United States,
Davis, Michael M. New Plans of Medical Service:
a dentist is qualified to practice after graduating
Examples of Organized Local Plans of Providing or
with a doctor of dental surgery or doctor of dental
Paying for Medical Services in the United States.
Chicago: Julius Rosenwald Fund, 1936.
medicine degree. There are 56 dental schools in the
Davis, Michael M. Eight Years’ Work in Medical United States and 10 in Canada.
Economics, 1929–1936: Recent Trends and Next The majority of practitioners are general den-
Moves in Medical Care. Chicago: Julius Rosenwald tists, who examine the oral cavity and diagnose
Fund, 1937. and treat diseases, decay, and injuries within it. The
Davis, Michael M. Public Medical Services: A Survey of American Dental Association (ADA) recognizes
Tax-Supported Medical Care in the United States. nine branches of dental specialization: (1) endo-
Chicago: University of Chicago Press, 1937. dontics, which is root canal therapy, or removing
Davis, Michael M. America Organizes Medicine. New the nerves of teeth; (2) oral and maxillofacial
York: Harper & Brothers, 1941. pathology, the detection and diagnosis of diseases
Dentists and Dental Care 289
in the oral cavity; (3) oral and maxillofacial radiol- high-speed handpiece, which made dental treat-
ogy, the radiologic interpretation of oral disease; ment much less painful, was invented by John
(4) oral surgery, the treatment of oral diseases and Borden in the 1940s.
abnormalities via surgery; (5) orthodontics, the
treatment of abnormalities in tooth position and
jaw relationships; (6) pedodontics, the provision of Problems in Dentistry
oral care to children; (7) periodontics, the treat-
There currently are approximately 199,000 den-
ment of gum disease; (8) prosthodontics, the cre-
tists in the United States, and there has been no
ation of artificial teeth and other dental appliances;
substantial change in the dentist-to-population
and (9) public health dentistry, the science of pro-
ratio in the past three decades. However, approxi-
moting dental health through organized public
mately 35% of dentists are aged 50 years or older,
efforts.
and approximately 20% are older than 60.
There are other specialties as well, such as gen-
Although there is no shortage of dentists today,
eral-practice residency (hospital training), cosmetic
because of the aging dentist population, the num-
dentistry, and geriatric dentistry (dental care for
ber of dentists retiring is expected to exceed the
older adults).
number of new dentists starting in 2014.
Dentists often work with dental auxiliaries,
There is a maldistribution of dentists in both the
including dental assistants (who pass instruments
United States and Canada as dentists simply do not
and retract tissues), dental hygienists (who special-
migrate to certain areas, according to the Academy
ize in preventive care, such as cleaning and scal-
of General Dentistry (AGD) Council on Dental
ing), and dental technicians (who fabricate dental
Care. There also is a severe lack of dentists in rural
appliances).
areas; for example, California, an urban state, has
This entry briefly describes the historical devel-
11.9 times the population of Mississippi, a rural
opment of dental treatment and then discusses the
state, but 22.9 times the number of dentists. There
current problems for dentistry and the emerging
is one dentist for every 2,359 residents of rural
trends and challenges that dentistry faces.
South Dakota, compared with one for every 1,714
people nationally. The dentists who practice in
those areas also tend to be older and close to retire-
Historical Development
ment. There also is a nationwide shortage of dental
Historical records indicate that dental treatment hygienists.
existed in the Indus valley of Asia as early as 3300 Although American dental care is considered by
BCE. In previous centuries, dentistry was not an some to be the best in the world, the cost of dental
independent profession and consisted primarily of care is high and is accessible to, at most, only half
tooth extractions, performed by everyone from of the population. Access to dental care is a serious
general physicians to barbers. problem in America today. The U.S. Surgeon
The 17th-century French physician Pierre General’s 2000 report Oral Health in America
Fauchard is considered the father of modern den- reported that minority, economically disadvan-
tistry, as he developed dental prostheses and dental taged, medically compromised, elderly, and rural
fillings. Porcelain teeth were introduced in the persons suffered from a lack of oral healthcare.
18th century, and the invention of Vulcanite rub- More than 100 million Americans have no dental
ber in the 19th century made dentures more insurance.
affordable to larger numbers of people. The federal Health Resources and Services
Nitrous oxide was introduced as an anesthetic Administration (HRSA) reports that 20% of the
in the 1830s. The first dental school, the Baltimore U.S. population resides in health professional
College of Dental Surgery, opened in 1840. Gold shortage areas (HPSA). According to a Workforce
foil fillings were invented in 1855 by Robert Study by the ADA, 37 states report a lack of prac-
Arthur. The first crowns were developed in 1880 ticing dentists in one or more area of the state.
by Cassius M. Richmond. Fluoridation of water, This lack of dental care has far-reaching educa-
proven to prevent cavities, began in the 1930s. The tional, economic, and health applications. Oral
pain interferes with the daily activities of 4 to 5 emphasis on it confuses members of the public, link-
million youngsters annually and is the leading ing the dentist more in their minds with the cosme-
cause of missed school days. The Surgeon General’s tologist and the small-business entrepreneur than
report cited research showing that chronic oral with the medical doctor. Such a link creates a risk
infections can lead to heart and lung diseases, dia- of the dental profession becoming marginalized.
betes, stroke, premature births, and low-birth- Still another threat to dentistry is that of the
weight infants. underfunding of public higher education, as many
Because Medicare does not pay for routine oral dental schools are part of public universities. After
care, nearly a third of those over 65 years of age World War II and with the GI Bill, American public
have untreated oral disease. More than 100 mil- higher education was held up as the right of
lion Americans are without fluoridated water. Americans. In the past 20 years, however, that view
Seniors living in rural areas are less likely to have has shifted to one of higher education being a com-
dental insurance, less likely to visit the dentist, and modity that is the student’s responsibility to fund,
more likely to be edentulous (without teeth) and to not the taxpayer’s. Dental education is hit particu-
have poor dental health than their urban counter- larly hard by this change in public perception,
parts. With the number of seniors in the United because dental education is the most expensive of
States, currently about 35 million, expected to any discipline other than veterinary medicine.
double by 2030, the problem of providing them Dentistry therefore runs the risk of becoming
with dental care will grow enormously. the exclusive purview of the well-to-do. If only
Both the very young and the very old are the those who already are financially secure can afford
parts of the population most vulnerable to oral dental school, the lack of access to dental care by
health problems, and they are the parts of the the underserved will only increase. Students are
population most lacking oral healthcare. leaving dental school with an average debt of
The lack of access to care is a serious threat to $141,541, according to the ADA, and will make
the way dentistry currently is practiced. As the situ- median annual earnings of $129,920. That
ation has worsened, state governments have stepped $129,920 brings a good living, but business school
in. California and Minnesota has passed legislation or medical school can provide a graduate with an
allowing foreign dentists to be licensed in those education leading to an even better living. Therefore,
states if they will treat the underserved. North dentistry also is running the risk of losing the best
Carolina provides Medicaid funds to pediatricians and brightest students to other professions.
and nurse practitioners to conduct oral health Another aspect of the crisis in dental education
screenings, apply fluoride varnish, and provide is the shortage in dental faculty. Three decades ago,
oral-care education to patients. In 19 states, dental a practicing dentist and a teaching dentist made
auxiliaries have been granted the right to perform approximately the same amount of money. Faculty
some procedures previously reserved for dentists. salaries have not kept up with the rising salaries of
If Medicare is altered to include oral care, it will practitioners, however, so there now are at least
mark perhaps the biggest change in dentistry of all, 250 vacant faculty positions around the country.
as the federal government will then be dealing Half the dental educators are over 50 years of age
directly with dentists’ treatments and payments on and are expected to retire in the next decade, mak-
a large scale for the first time. ing the faculty shortage even more acute.
Another threat to dentistry is deprofessionalization— This lack of faculty, along with aging dental
the perception by the public and the public’s repre- school facilities requiring modernization, is
sentatives in government that oral healthcare is not expected to result in some older dental schools
a part of general healthcare. closing, a trend that has already begun. Some new
That perception began in the 1960s, when the schools are opening, but they are operating under
dental profession as a whole declined to participate a very different model. They often do not have a
in the Medicare system. It is reinforced today by research mission like the older schools do; they
the focus on dentistry as a business and on charge at least $50,000 per year in tuition, and
cosmetic dentistry in many practices. Cosmetic den- that figure precludes them from doing much about
tistry is a lucrative part of the profession, but the diversity in their student population.
Dentists and Dental Care 291
Hope for the Future raise more than $500 million through 2014, to
deal with issues such as faculty shortages, lack of
Yet there are positive signs on the horizon for diversity, aging physical and clinical facilities, lag-
dentistry as well. The way dentistry is taught and ging governmental support, and escalating costs.
practiced is rapidly changing. As the solo practi- The dental schools committed to research are
tioner has been replaced by group practices, and seeking new knowledge vital not just to dentistry
the treatment of existing dental disease has been but also to medicine as a whole. For example,
replaced by preventive dentistry, dental school research on replicating or “cloning” teeth being
curricula have been changed as well. Discipline- undertaken at the University of Illinois at Chicago
based educational approaches formerly focused College of Dentistry will influence the replication
on surgical therapy performed by solo practitio- of other body parts as well. Dentists, already
ners; now they focus on integrated preventive familiar with making replacement body parts, are
patient care measures and collegiality. Large lec- at the forefront of stem cell science at the University
ture halls have been replaced by small-group prac- of Michigan.
tices within dental schools, in which students take There are programs in place to ameliorate fac-
a collaborative approach, perform Internet ulty shortages. For example, the American Dental
research, and work on patients earlier than ever. Education Association (ADEA) Academic Careers
Dental school curricula are increasingly focused Network links potential faculty with open posi-
on prevention, dental public health, research, tions. The ADEA/American Association of Dental
community-oriented healthcare, behavioral science, Research Academic Dental Careers Fellowship
cultural sensitivity, ethics, quality assurance, and Program, supported by the American Dental
practice management. In addition, many dental Association Foundation, provides students who
schools are sending students out to practice in com- are interested in careers in academic dentistry with
munity healthcare facilities in order to give them paid fellowships and other stipends. The federal
exposure to America’s underserved populations. HRSA Faculty Loan Repayment Program provides
American dental schools are seeing a generation a financial incentive for health professionals from
of students who do not just want to make money disadvantaged backgrounds to pursue academic
but want to make a difference. Schools are educat- careers. The ADA annually hosts a session for
ing more students who are interested in public practitioners interested in learning about opportu-
health dentistry. Even those who are not willing to nities to join the faculty of dental schools.
devote their entire career to public health dentistry There also are programs in place to increase the
are showing more interest in practicing in a com- numbers of dentists who are willing to provide oral
munity clinic a few days a week while they devote care to the underserved. The Robert Wood Johnson
the bulk of their time to their private practices. Foundation (RWJF) provides a “Pipeline, Profession,
While few young dentists are interested in becom- and Practice Community-Based Dental Education”
ing full-time faculty in dental schools, many are grant to several dental schools to help prepare an
interested in giving back to the profession by oral healthcare workforce competent and commit-
teaching part-time. Dental schools are therefore ted to treating oral diseases in vulnerable popula-
creating new curricula in which a large number of tions. The W. K. Kellogg/ADEA Minority Dental
part-time faculty are fulfilling the roles that full- Faculty Development Program provides grants to
time faculty did previously. some dental schools to increase the number of its
To bring awareness of the problems in dental African American, Hispanic American, and Native
education and the efforts to solve them to the pub- American faculty.
lic and the profession, “Dental Education: Our A gender shift also is occurring in dentistry.
Legacy—Our Future,” a national collaborative Among the active private dental practitioners in the
effort of partner organizations, has been created. It United States, nearly 83% are male, and slightly
is underwritten by the American Dental Association more than 17% are female. Among recently gradu-
Foundation with support from the ADA and is ated dentists, those who earned their degrees within
designed to help participating partner organiza- the past 10 years, slightly more than 65% are male,
tions, such as dental schools and dental societies, and nearly 35% are female. In addition, two thirds
of female dentists are under the age of 45. Women increase the availability of dental care for the pub-
make up nearly 44% of all dental students. lic and serve as a liaison between patients and
As female dentists have traditionally shown busy dentists, explaining procedures more fully on
more interest in devoting more of their time to behalf of the dentist and guide patients in decision
providing oral care to the underserved, this bodes making.
well for the profession. In addition, with women Dentistry likely will change both rapidly and
taking more and more leadership roles in orga- greatly in the future. Those educational institu-
nized dentistry, it is expected that dental societies tions and practitioners who cannot adjust to the
will take an increasingly activist role in solving the change will have difficulty, but those who can are
access-to-care problem. likely to experience a new golden age of dentistry.
The practice of dentistry itself is an attractive
profession. With some areas already experiencing William S. Bike
a dentist shortage and others about to, dentists can See also Access to Healthcare; Health Professional
practice just about anywhere they choose. Dentists Shortage Areas (HPSAs); Health Services Research,
increasingly keep flexible work schedules, achiev- Definition; Kellogg Foundation; Public Health;
ing financial independence in a relatively indepen- Robert Wood Johnson Foundation (RWJF);
dent environment. Surveys indicate that nearly Rural Health
95% of dentists are glad they chose dentistry as a
career. Dentists enjoy the people-to-people contact
and the artistry and creativity inherent in the pro- Further Readings
fession. While they often dislike business, person- Bates, Karl Leif. “Stem Cells: Why the Interest?”
nel, and administrative issues, firms such as DentalUM: 79, Fall 2006.
ProCare Dental Group PC have arisen to take such “Dentistry’s Vital Role: Mette Foundation Board,”
tasks off dentists’ hands, allowing them to spend DentalUM: 10, Fall 2006.
more time practicing. Fargas, Clemencia M, Janet A. Yellowitz, and Kathy L.
A technological revolution in dentistry is allow- Hayes. “Oral Health Status of Older Rural Adults in
ing dentists to provide better care to more people the United States,” Journal of the American Dental
more quickly. Digital radiography, dental lasers, Association 134(4): 479–86, 2003.
cone-beam tomography, intra-oral cameras, lighting Furusho, Cissy F. “Our Legacy: Our Future to Confront
enhancements, and dental implants are some of the Key Dental Education Issues,” Vision (University of
technologies that improve dental care every day. Illinois at Chicago College of Dentistry) 43: 45–46,
Patients are more aware of and more educated Fall–Winter 2006–2007.
Heymann, Harald O. “The ‘Golden Age’ of Dentistry:
about the need to maintain their dental health and to
Share the Wealth,” Journal of Esthetic Restorative
take responsibility for oral disease prevention, mak-
Dentistry 15(2): 69–70, 2003.
ing the modern dentist’s job easier as well. Through
U.S. Department of Health and Human Services. Oral
advertising, they are more aware of specific dental
Health in America: A Report of the Surgeon General.
procedures and come to the dentist as educated buy- Rockville, MD: National Institute of Dental and
ers. Approximately 55% of children between the Craniofacial Research, 2000.
ages of 5 and 17 have had no tooth decay—another Valachovic, Richard W., Richard G. Weaver, Jeanne C.
factor that makes the dentist’s job easier. Sinkford, et al. “Trends in Dentistry and Dental
Although some dentists object to it, the American Education,” Journal of Dental Education 65(6):
Dental Hygienists Association (ADHA) is working 539–61, June 2001.
on creating an “advanced dental hygiene practitio-
ner” who would provide diagnosis, preventive,
restorative, and therapeutic services to patients. Web Sites
The ADHA assures dentists that it is neither trying American Dental Association (ADA): http://www.ada.org
to compete with dental practitioners nor taking American Dental Education Association (ADEA):
away hygienists from practitioners. In any case, http://www.adea.org
the new advanced dental hygiene practitioner will Bureau of Health Professions (BHPr): http://bhpr.hrsa.gov
Diabetes 293
Bureau of Labor Statistics (BLS): http://www.bls.gov genetic conditions, surgery, drugs, malnutrition, and
Robert Wood Johnson Foundation (RWJF): infections. IFG is characterized by elevated (though
http://www.rwjf.org nondiabetic) fasting blood glucose levels, while
W. K. Kellogg Foundation (WKKF): http://www.wkkf.org IGT is characterized by elevated postmeal blood
glucose levels. Individuals with IGT and IFG have
a substantially increased risk of developing Type 2
diabetes.
Diabetes
Diabetes Complications
Diabetes mellitus, often referred to simply as dia-
betes, is not a single disease but a group of meta- A variety of acute and chronic complications are
bolic disorders characterized by hyperglycemia associated with diabetes. The acute complications
(elevated blood glucose) resulting from defects in are medical emergencies and include diabetic
insulin secretion, insulin action, or both. It is a ketoacidoisis (DKA), hyperosmolar hyperglycemic
major public health problem in the United States, syndrome (HHS), and hypoglycemia. The chronic
affecting 24.1 million individuals, of whom an complications include disorders associated with
estimated 6.6 million are undiagnosed. From microvascular (small vessel) changes in the eyes,
2002 to 2007, the number of individuals in the nerves, and kidneys, along with macrovascular
nation diagnosed with diabetes increased from (large vessel) changes in the heart, veins, and
12.1 to 17.5 million. In addition, an estimated 54 arteries. These changes result in retinopathy (eye
million individuals have abnormalities in glucose disease, e.g., blindness); neuropathy (nerve dis-
tolerance, which places them at high risk for ease, e.g., nerve damage affecting sensation and
developing diabetes. Approximately one third of pain pathways in the hands and feet, nerve dam-
the individuals born in the nation during 2000 are age affecting the ability to digest food); nephropa-
likely to develop diabetes during their lifetime. thy (kidney disease, e.g., end-stage renal disease
The social, economic, and personal costs of diabe- requiring dialysis or renal transplantation); and
tes are enormous. This entry describes the classifi- premature and accelerated development of coro-
cations, complications, and risk factors of diabetes. nary heart disease (CHD), cerebrovascular dis-
In addition, prevention and complications are disease, and peripheral vascular disease (PVD). In
cussed, along with the social, economic, and per- particular, heart disease and stroke account for
sonal costs associated with diabetes. Last, this 65% of deaths in people with diabetes. Diabetes-
entry addresses quality-of-life issues and policy related complications are associated with exces-
implications. sive morbidity and mortality from heart disease,
blindness, kidney failure, extremity amputations,
and other chronic conditions.
Classification
There are four clinical classifications of diabetes:
Risk Factors
(1) Type 1 diabetes, (2) Type 2 diabetes, (3) “other
specific types,” and (4) gestational diabetes melli- The development of Type 1 diabetes is associated
tus (GDM). In addition, there are two categories of primarily with an autoimmune destruction of the
abnormal glucose tolerance: (1) impaired glucose insulin-producing cells of the pancreas and is char-
tolerance (IGT) and (2) impaired fasting glucose acterized by a nearly complete loss of insulin secre-
(IFG). Type 1 and Type 2 diabetes are the most tion. In contrast, Type 2 diabetes is characterized
common forms of diabetes, representing approxi- by insulin resistance and decreased insulin secre-
mately 10% and 90% of the diabetes population, tion. The development of both Type 1 and Type 2
respectively. Gestational diabetes mellitus, a form diabetes is initiated by the interplay between genet-
of diabetes diagnosed during pregnancy, affects ics and the environment. Type 1 diabetes results
4% of all pregnancies. “Other specific types” of when an environmental insult, in an individual
diabetes may result from a variety of factors, including genetically predisposed to the disorder, initiates
294 Diabetes
autoimmune destruction of the insulin-producing why minority groups bear a disproportionate bur-
cells. The environmental factor initiating this den of diabetes is multifactorial; however, poor
destruction is not known and is an area of intense access to healthcare among these groups appears to
investigation. be a major contributor.
Risk factors for Type 2 diabetes include genet-
ics, age, ethnicity/race, dyslipidemia (excess levels
Primary Prevention of Type 2 Diabetes
of blood lipids or fats), obesity, hypertension (high
blood pressure), prior gestational diabetes, poly- Weight gain and physical inactivity are the pri-
cystic ovary syndrome, and physical inactivity. mary factors contributing to the epidemic of
Type 2 diabetes, a disease traditionally associated Type 2 diabetes. Lifestyle modification, involving
with middle-aged and older adults, has been change in diet, weight loss, and increase in phys-
increasing among children and adolescents. A vari- ical activity, can slow the progression to overt
ety of clinic-based reports and small-population diabetes. The Diabetes Prevention Program
studies indicate that this increased prevalence of (DPP), a large research study sponsored by the
Type 2 diabetes is highest among the youth of National Institute of Diabetes and Digestive and
Native Americans, Blacks, and Hispanics. Kidney Diseases (NIDDK), compared the effects
Currently, there are no large epidemiological stud- of dietary and exercise counseling (control group),
ies of Type 2 diabetes among the youth; however, intensive dietary and exercise interventions (life-
estimates from some urban clinic-based studies style group), and medications (particularly met-
range from 30% to 50%. formin, a popular antidiabetic drug) in preventing
The increased prevalence of Type 2 diabetes diabetes in men and women with IGT. After an
among minority youth is consistent with evidence average follow-up of 2.8 years, a 58% relative
that diabetes disproportionately affects the ethnic/ reduction in the progression to diabetes was
racial minority populations of the United States. noted in the lifestyle group, and a 31% relative
Among adults aged 20 years or older, the national reduction in the progression of diabetes was
prevalence of Type 2 diabetes is estimated to be noted in the metformin group compared with the
8.7% for Whites, 13.3% for Blacks, 9.5% for control group.
Hispanics, and 12.5% for American Indians/
Alaskan Natives. In addition, ethnic/racial popula-
Prevention of Diabetes Complications
tions have higher rates of diabetes-related compli-
cations. For example, there are higher rates of As the prevalence of diabetes increases, the com-
retinopathy and diabetes-related renal disease in plications of the disease also will increase, unless
Blacks and Hispanics than in Whites. In particular, aggressive treatment strategies are implemented.
diabetes-related renal disease is 2.6 times higher The results of two research studies—the Diabetes
among Blacks than among Whites. Diabetes- Control and Complications Trial (DCCT) and the
related complications among ethnic/racial minority United Kingdom Prospective Diabetes Study
populations are also associated with greater mor- (UKPDS)—clearly indicate that diabetes-related
bidity and mortality. During the years 1979 to microvascular complications (retinopathy, neu-
2004, diabetes death rates for Black youths were ropathy, and nephropathy) could be prevented or
approximately twice those for White youths. In reduced by maintaining normal blood glucose lev-
2004, the annual average diabetes death rate was els. In addition, there is evidence that diabetes-
estimated at 2.46 per million for Black youths and related macrovascular complications (CHD,
0.91 per million for White youths. The burden of cerebrovascular disease, and PVD) can be reduced
the evolving epidemic of Type 2 diabetes, particu- by factors such as blood pressure control, lipid
larly among minority youths, has yet to be realized. control, smoking cessation, and aspirin use.
As youths with early-onset Type 2 diabetes approach Patients with diabetes can use intricate pharmaco-
middle age, the excessive mortality and morbidity logical regimens (along with diet and exercise) to
associated with diabetes-related complications will normalize blood glucose levels. Newer insulin
contribute to the increasing social, economic, and preparations, insulin delivery systems, oral medi-
personal burden imposed by diabetes. The reason cations, and blood-glucose-monitoring systems
Diabetes 295
have been developed to assist patients in maintain- Quality of Life

ing normal blood glucose levels.
Diabetes profoundly influences the lives of those
There are specific goals for glucose level, blood
affected and their families. Patients with Type 1
pressure, and blood lipid concentration. Chronic
diabetes are treated with insulin, diet, and exer-
glucose control is measured periodically by hemo-
cise, wheras patients with Type 2 diabetes are
globin A1C level, which correlates to average
treated with diet and exercise and sometimes with
blood glucose levels over the previous 3 months.
insulin and/oral medications. Patients may use
Daily self-management of diabetes requires con-
insulin pumps or multiple insulin injections per
stant vigilance and adjustment of diet, medica-
day. Such a regimen necessitates frequent blood
tions, and physical activity to normalize A1C
glucose testing with portable glucose monitors.
levels. The best benefits can be achieved when
The ability to minimize complications largely
there is a strong problem-solving relationship
depends on the ability and willingness of patients
between the patient and the healthcare provider.
to integrate the treatment regimens into their life-
This allows the patient to make adjustments to the
style. The ability of patients to integrate treatment
plan of care (e.g., diet, exercise, oral medications,
regimens is influenced by many factors, including
and/or insulin) in a supportive atmosphere.
access to a healthcare provider, ability to pay,
insurance coverage, perceptions of complication
Social, Economic, and Personal Costs risk, and perception of treatment burden. End-
stage complications, such as blindness, have the
Diabetes and its related complications are associ-
greatest perceived burden on the quality of life;
ated with significant personal, social, and eco-
however, comprehensive treatment regimens also
nomic costs. National medical expenditures
have a high perceived burden on the quality of
attributed to diabetes in 2007 were estimated at
life. In a recent report, a small group of patients
$174 billion, including $116 billion in medical
stated that they were willing to give up 8 to 10
costs and $58 billion in indirect costs. Direct
years of life in perfect health to avoid life with
medical costs include expenditures related to hos-
treatment. The importance of understanding the
pital inpatient care, diabetes medications and sup-
factors that influence adherence to treatment regi-
plies, retail prescriptions for diabetes complications,
mens cannot be overestimated.
and physician office visits. Indirect medical costs
include the costs resulting from increased absen-
teeism from work, reduced productivity at work
Policy Implications
and home, unemployment, disability, and loss of
productivity due to premature death. Expenditures The United States is in the midst of an epidemic of
for diabetes were attributed to institutional care diabetes, which has increased exponentially over
($65.3 billion), outpatient medications and sup- the past two decades. Diabetes is associated with
plies ($27.7 billion), and outpatient care ($22.7 a number of acute and chronic medical complica-
billion). In particular, the costs were greatest for tions that lead to significant morbidity and mor-
inpatient hospital stays ($58.3 billion), physician’s tality. Minority ethnic/racial populations in the
office visits ($9.8 billion), diabetes medications nation disproportionately carry the burden of dia-
and supplies ($14.1 billion), and retail prescrip- betes complications. Lifestyle modification pro-
tions ($12.7 billion). grams, especially those incorporating intensive
Individuals with diabetes have medical expendi- weight loss and physical-activity interventions,
tures that are approximately 2.3 times higher than can result in the primary prevention of Type 2
what expenditures would be in the absence of the diabetes. In patients with diagnosed diabetes,
disease. Indirect costs related to diabetes include the treatments aimed at normalizing blood glucose
following: absence from work ($2.6 billion), reduced levels and controlling risk factors such as hyper-
performance at work ($20.0 billion, or a loss of 120 tension and dyslipidemia can delay the progres-
million days), reduced productivity for those not in sion and development of diabetes-related
the workforce ($0.8 billion), permanent disability complications. Health policy initiatives need to
($7.9 billion), and mortality ($26.9 billion). incorporate both primary prevention of diabetes
296 Diagnosis Related Groups (DRGs)
and prevention of secondary complications from

the disease. The challenge to healthcare policy- Diagnosis Related
makers is to balance the personal and societal Groups (DRGs)
benefits of preventing and treating diabetes with
their monetary costs. Diagnosis Related Groups (DRGs) is a system that
Laurie Quinn is used as a part of prospective payment to group
cases of patients into more than 500 categories
See also Access to Healthcare; Chronic Care Model; according to similar hospital resource use. DRGs
Disease; Disease Management; Ethnic and Racial have been used since 1983 by the nation’s Medicare
Barriers to Healthcare; Morbidity; Preventive Care; program to determine the level of payment to a
Public Health hospital since patients who are grouped together
under the same DRG code are expected to use
approximately the same amount of resources.
Further Readings DRGs are important in health services research
American Diabetes Association. “Standards of Medical since all hospitals in the United States must code
Care in Diabetes: 2008,” Diabetes Care 31(Suppl. 1): and are reimbursed by Medicare and other payers
S12–S54, January 2008. through this mechanism. Other nations have also
American Diabetes Association. “Economic Costs of adopted and use the DRG system.
Diabetes in the United States in 2007,” Diabetes Care
31(3): 596–615, March 2008.
Greenbaum, Carla J., and Leonard C. Harrison, eds. Background
Diabetes: Translating Research Into Practice. New
York: Informa Healthcare USA, 2008.
DRGs were first developed by Robert Fetter and
Marrero, David G., Robert Anderson, Martha M.
John Thompson at Yale University in the early
Funnell, et al., eds. 1,000 Years of Diabetes Wisdom: 1970s, with support from the federal agency
Inspiration and Insight the World’s Leading Diabetes Health Care Financing Administration (HCFA),
Professionals Gained From Their Patients. Alexandria, now the Centers for Medicare and Medicaid
VA: American Diabetes Association, 2007. Services (CMS). This system included the Medicare
Sloan, Frank A., M. Angelyn Bethel, David Ruiz Jr., population in addition to newborn, pediatric, and
et al. “The Growing Burden of Diabetes Mellitus adult populations.
in the U.S. Elderly Population,” Archives of DRGs were first implemented on a large scale in
Internal Medicine 168(2): 192–99, January 28, New Jersey in the late 1970s. The New Jersey
2008. Department of Health used DRGs as a form of
Williamson, David F., Frank Vinicor, and Barbara A. prospective payment whereby hospitals were paid a
Bowman. “Primary Prevention of Type 2 Diabetes fixed amount for a given patient. Since 1983, CMS
Mellitus by Lifestyle Intervention: Implications for has taken over the control of the Medicare DRG
Health Policy,” Annals of Internal Medicine 140(11): system as a form of prospective payment for hospi-
951–57, June 2004. tals, and the agency has been responsible for any
revisions to the definitions for Medicare DRGs.
As a concept, DRGs were originally created to
Web Sites classify hospital admissions of patients who had
American Association of Diabetes Educators: similar International Classification of Disease, 9th
http://www.diabeteseducator.org Edition (ICD-9) codes, or ICD-9 codes, so that the
American Diabetes Association: http://www.diabetes.org relationship between the types of patients that a
Centers for Disease Control and Prevention (CDC): hospital treated could be used to better understand
http://www.cdc.gov/diabetes the costs that the hospital incurred. The general
Juvenile Diabetes Research Foundation (JDRF): guidelines of DRGs were that they must use patient
http://www.jdrf.org data that are routinely collected by hospitals, such as
National Diabetes Education Program (NDEP): ICD-9 codes, age, and gender; they should include
http://www.ndep.nih.gov patients who have a similar pattern of resource use;
Diagnosis Related Groups (DRGs) 297
they should include patients with a similar clinical organ transplants, high-risk obstetric care, nutri-
condition; and there should be a manageable num- tional issues, pediatrics, and other populations. A
ber of DRGs that include all types of patients who limitation of the AP-DRG system has been that
are encountered as inpatients. The required data ele- there is no common set of formulas across states,
ments of a DRG include the principal and secondary unlike the Medicare DRG system, so therefore
diagnosis codes; procedure codes; and patient’s age, each state maintains its own information.
gender, and discharge disposition. CMS has also noted that the MDC 15 does not
DRGs are grouped in a hierarchical manner. properly capture the care that is provided to new-
First, DRGs are grouped into 25 major diagnostic borns and neonates and that updates to its DRG
categories (MDCs) that relate to a single organ system have focused primarily on the Medicare
system or etiology. HIV and multiple significant population. As a result, CMS has encouraged oth-
trauma were the two most recently added MDC ers to develop or choose other DRG systems that
groups. Next, MDCs are grouped as either surgical currently exist to fit these needs. In 1986, the
or medical categories. Last, patients in surgical National Association of Children’s Hospitals and
categories are grouped according to the type of Related Institutions (NACHRI) developed a
procedure performed, while medical patients are Pediatric Modified DRG (PM-DRGs) for neonates
grouped according to their principal diagnosis. and the pediatric population.
Some categories under DRGs have been designated Although Medicare DRGs were initially devel-
with complications and comorbidities (CCs). This oped primarily for payment, there was also a
represents a condition that causes an increase in growing need to compare hospitals on the basis of
the length of stay by at least a day for 75% of resource use and patient outcomes, examine differ-
patients. Age is also used to define some categories ences in inpatient mortality across hospitals, evalu-
of DRGs. ate differences in complication rates, and identify
The first Medicare DRG category is craniotomy continuous quality improvement projects, among
with CCs for those greater than or equal to others. Thus, the breadth and scope of DRGs
17 years of age, while Medicare DRG category needed to be expanded. From 1985 to 1993,
316 relates to renal failure. Medicare DRG cate- HCFA supported two projects at Yale to expand
gory 531 is for spinal procedures with CCs. the CCs categorization in addition to further
studying severity of illness. These projects resulted
in the Refined Diagnosis Related Groups (R-DRGs)
Critiques and Revisions
and Severity Refined Diagnosis Related Groups
The Medicare DRG system has been revised over (SR-DRGs). To date however, the SR-DRGs have
the years, and updates are generally made avail- not yet been implemented in practice.
able on October 1 every year. In 2007, CMS In 1990, the 3M Corporation and NACHRI
implemented a significant revision to the Medicare developed a new and enhanced DRG system that
DRG system and regrouped categories. Under ver- could better capture information on patients of all
sion 25, the CCs have been recategorized to ages and counter some of the shortcomings of
include the absence of CCs, the existence of CCs, Medicare DRGs. The starting point for this project
and the major presence of CCs. was the AP-DRGs and PM-DRGs. The expanded
One criticism of the Medicare DRG system is DRG system included subclasses for each DRG that
that it does not perform well for nonelderly popu- would be indicated as minor, moderate, major, or
lations. In the late 1980s, the New York State extreme for the severity of illness as well as mortal-
Health Department conducted an evaluation of the ity risk. The end product of this collaboration was
Medicare DRG system and found it to be inade- the All-Patient Refined Diagnosis Related Groups
quate for the non-Medicare population. As a (APR-DRGs). The APR-DRG system is the only
result, New York State entered into an agreement one to include the influence of multiple secondary
with the 3M Corporation to develop necessary diagnoses and their relation to the severity of illness
revisions to the Medicare DRG system. This and mortality. Thus, the APR-DRG system is able
resulted in the All-Patient Diagnosis Related Group to assess the severity of illness of patients who have
(AP-DRG) system that supported areas such as multiple comorbidities and has utility for payment
298 Diagnostic and Statistical Manual of Mental Disorders (DSM)
as well as quality-of-care initiatives. As of 2003, Shen, Yujing. “Applying the 3M All Patient Refined
Version 20.0 of APR-DRGs has been released, and Diagnosis Related Groups to Measure Inpatient
it includes 25 MDCs and 316 APR-DRG categories Severity in the VA,” Medical Care 41(6 Suppl.):
that classify a hospitalized patient into a mutually II103–II110, June 2003.
exclusive group. APR-DRGs are used by more than
20 states to compare hospital costs and mortality at
more than 1,600 hospitals. Web Sites
Centers for Medicare and Medicaid Services (CMS):
Future Implications http://www.cms.hhs.gov
Medicare Payment Advisory Commission (MedPAC):
Since its development, the DRG system has been http://www.medpac.gov
revised and updated by various parties to reflect National Association of Children’s Hospitals and
the many changes in the way healthcare is deliv- Related Institutions (NACHRI):
ered. The scope of DRGs has been expanded over http://www.childrenshospitals.net
the years to include reimbursement, benchmark-
ing, and comparison of hospitals as well as other
research. Additionally, prospective payment sys-
tems for various types of care have been estab- Diagnostic and Statistical
lished since the development of Medicare DRGs
to include the neonatal, pediatric, long-term care,
Manual of Mental
and Medicaid populations. Prospective payment Disorders (DSM)
continues to remain the primary method by which
providers are reimbursed for care, and DRGs are The Diagnostic Statistical Manual of Mental
the cornerstone of this mechanism. Disorders (DSM) is an authoritative and compre-
hensive reference book devoted to the classifica-
Jared Lane K. Maeda tion of psychiatric illnesses. The main purpose of
the DSM is to provide a categorical classification
See also Case-Mix Adjustment; Centers for Medicare and system that can be used in clinical practice,
Medicaid Services (CMS); Cost of Healthcare; research, and administration across healthcare
Hospitals; Medicare; Medicare Payment Advisory professions. It facilitates communication within
Commission (MedPAC); Prospective Payment; the field of mental health by providing a nomen-
Thompson, John Devereaux clature that supports the standardized identifica-
tion of psychiatric symptoms for diagnosis,
prognosis, treatment, research, reimbursement of
Further Readings services provided, and medical record keeping. It
does not address the causes of mental illness but
Evers, Sylvia, Gemma Voss, Fred Nieman, et al.
rather provides a framework for consistent descrip-
“Predicting the Cost of Hospital Stay for Stroke
tions of various illnesses.
Patients: The Use of Diagnosis Related Groups,”
Health Policy 61(1): 21–42, July 2002.
Malatestinic, William, Lee Ann Braun, James A. Revisions
Jorgenson, et al. “Components of Medicare
Reimbursement,” American Journal of Health-System The DSM has been revised five times over the past
Pharmacy 60(21 Suppl. 6): S3–S7, November 1, 2003. 25 years. In 1952, the American Psychiatric
Mayes, Rick, and Robert A. Berenson. Medicare Association (APA) published the DSM-I. It was
Prospective Payment and the Shaping of U.S. Health 130 pages long, defined 106 separate categories of
Care. Baltimore: Johns Hopkins University Press, 2006. mental disorders, and contained coding systems
Medical Management Institute. DRG Guidebook: A used by earlier diagnostic manuals, such as the
Comprehensive Resource to DRG Assignment. Salt Statistical Manual for Mental Diseases, which was
Lake City, UT: Medical Management Institute, 2007. published in 1933. The DSM-I also drew from
Diagnostic and Statistical Manual of Mental Disorders (DSM) 299
nomenclature developed by the U.S. Army and the syndromes and disorders, which focus on age-,
Veterans Administration. race-, and gender-specific problems. Other small
In 1968, the DSM-II was published, and it changes were made to the nomenclature, such as the
attempted to improve consistency with the renaming of multiple personality disorder to disso-
International Classification of Diseases (ICD). The ciative identity disorder.
ICD is published by the World Health Organization The latest version of the DSM is the DSM-
(WHO) for similar reasons that had motivated the IV-TR. Published in 2000, it consists of minor revi-
development of the DSM. The ICD provides an sions, such as updating the literature reviews,
international taxonomy that assigns numerical codes correcting factual errors, and updating ICD codes.
to disease conditions. In the United States, the DSM
is used in addition to the ICD codes. There were
Components
many new mental disorders added to the DSM-II,
increasing the total number of separate categories to Currently, the DSM consists of three major
182. Neither the DSM-I nor the DSM-II attempted components: diagnostic classification, diagnostic
to elaborate on specific psychiatric symptoms or criteria, and descriptive text. The diagnostic clas-
their manifestations. Rather, the DSM-I and DSM-II sification is a list of the mental disorders, paired
emphasized the psychological underpinnings of psy- with a diagnostic code. The diagnostic criteria
chiatric disease and were less focused on the item- consist of a summary of each disorder and include
ized symptom clusters that identified the illness. both inclusion criteria, a list of symptoms that
This was an important distinction beginning with must be present and their duration, and exclusion
the third edition of the DSM, DSM-III. criteria. Diagnoses may include subtypes that fur-
The DSM-III was published in 1980. It was 494 ther specify the symptom presentation or severity
pages long, and included 265 categories. The of the illness. The diagnostic criteria component
DSM-III attempted to transition from an explana- was developed to provide a framework to assist in
tory tome of mental disorders to an objective and clinical assessment. The descriptive text describes
descriptive model based on empirical data, not the diagnostic features, subtypes, culture, age, gen-
theories and hypotheses. The most significant der, familial pattern, differential diagnosis, as well
change was that the manual focused on symptom- as other relevant information.
based diagnostic criteria. Further developments
included a multiaxial diagnostic framework that
Multiaxial Framework
not only included the primary diagnosis but also
supplemented it with relevant clinical information The multiaxial system introduced in the DSM-III
on contributing medical, psychosocial, and func- consists of five dimensions called “axis,” used to
tional distinctions. evaluate the phenomenological aspects of a
The DSM-III-R was published in 1987, and it patient’s mental health. The biopsychosocial
not only refined definitions of many diagnoses but model allows for the manual to be applied across
also included exclusionary criteria to be consid- different psychiatric disciplines and theoretical
ered in ruling out a disorder. orientations. The axial system provides additional
After much research, the DSM-IV was published information designed to make clear a more com-
in 1994. It had a major focus on empirical research prehensive picture of the patient’s status.
gathered by extensive literature reviews. Almost Axis I consists of all major clinical disorders,
half of the categories included a clinical aspect, such as childhood disorders (i.e., attention deficit,
which required specific symptoms that cause impair- disruptive-behavior disorders, and tic disorders);
ment in various areas of functioning such as work, delirium, dementia, amnestic disorder, and other
school, or social interaction. Many disorders were cognitive disorders; mental disorders due to a gen-
deleted (i.e., sadistic personality disorder and pas- eral medical condition; substance-related disorders
sive aggressive personality disorder), and other dis- (i.e., alcohol or drug addiction); psychotic disor-
orders were reorganized. Disorders were also added ders (i.e., schizophrenia, schizoaffective and delu-
(e.g., bipolar-II disorder), as well as culture-specific sional disorders); mood disorders (i.e., depressive
300 Diagnostic and Statistical Manual of Mental Disorders (DSM)
disorders and bipolar disorder); anxiety disorders Despite attempts to address this through the devel-
(i.e., generalized anxiety disorder, obsessive- opment of a multiple axial system, the medical
compulsive disorder, and posttraumatic stress dis- model is believed to reduce the patient to a one-
order); somatoform disorders; factitious disorders; dimensional categorical, clinical impression rather
dissociative disorders; sexual and gender identity than recognize the multidimensional presentations
disorders; eating disorders (i.e., anorexia nervosa existing along a continuum, which in turn would
and bulimia nervosa); sleep disorders; impulse encourage clinicians to treat the whole person, not
control disorders (i.e., pathological gambling); and simply the diagnosis. Others have criticized the cur-
adjustment disorders. rent DSM as being too cumbersome. For example,
Axis II focuses on disorders that are considered under schizophrenia, there are 69 various combina-
less acute and less responsive to treatment with tions of symptoms to fulfill the DSM-IV Criterion
medication, such as personality disorders and A and 483 “clinical subtypes,” if seven possible
mental retardation. Personality disorders are fur- outcomes are taken into account, and many of
ther grouped in clusters that include specific these symptoms cross criteria and subtypes.
behavioral patterns. For example, Cluster A con- Despite the criticisms, the DSM has clearly
sists of paranoid, schizoid, or schizotypal person- advanced the field of mental health. The DSM has
ality disorders. Cluster B contains antisocial, undergone a great shift from its first publication,
borderline, histrionic, or narcisstic personality dis- which consisted of a theoretical basis of the etiol-
orders. And Cluster C includes avoidant and depen- ogy of disorders, to later versions that focus on
dent personality disorders. more empirical data. Inclusion of symptom-based
Axis III describes general medical conditions diagnostic criteria, as well as specific inclusion and
that might affect mental illness, such as depression exclusion criteria, has helped standardize diagnosis
resulting from a cancer diagnosis. of mental disorders in many disciplines worldwide.
Axis IV contains assessments of psychosocial All these factors have contributed to the DSM
and environmental problems. There are nine cate- being recognized and accepted as an important
gories of problems, consisting of family, social source of information and knowledge. The DSM-IV
environment, educational, occupational, housing, has been translated into 22 languages and is con-
economic, access to healthcare, legal system, and sidered the quintessential reference on psychiatric
other (i.e., disasters and war). disorders. The next major revision, DSM-V, is not
Axis V contains the overall functioning score expected until 2012 or later, and there is much
obtained from the Global Assessment of Functioning speculation as to the direction it will take.
Scale (GAF). The GAF rates the social, occupational,
and psychological functioning of adults. Scores Cherise Rosen, Cathy Batscha,
range from 1 to 100, with a score in the 91 to 100 and Kayla Chase
range meaning that the patient has superior func-
tioning in a wide range of activities and has no See also Health; Measurement in Health Services Research;
Medicalization; Mental Health; Mental Health
symptoms, whereas a score in the 1 to 10 range
Epidemiology; National Institutes of Health (NIH);
means that the patient is in continual danger of
Public Health; World Health Organization (WHO)
severely hurting himself or herself or others or has
made a serious suicidal attempt. The DSM-IV-TR
also has specialized scales included in the GAF for
Further Readings
Social and Occupational Functioning, Defensive
Functioning and Global Assessment of Relational American Psychiatric Association. Diagnostic and
Functioning. Statistical Manual of Mental Disorders. 4th ed., Text
Revised. Arlington, VA: American Psychiatric
Publishing, 2000.
Criticisms
Endicott, J., R. L. Spitzer, J. L. Fleiss, et al. “The Global
Although the DSM is highly regarded, it has Assessment Scale: A Procedure for Measuring Overall
been criticized. Some feel that attaching a label to a Severity of Psychiatric Disturbance,” Archives of
mental illness can result in a negative social stigma. General Psychiatry 33: 766–71, 1976.
Direct-to-Consumer Advertising (DTCA) 301
Fauman, Michael A. Study Guide to DSM-IV-TR. DTCA in New Zealand and to lift bans in Europe
Arlington, VA: American Psychiatric Publishing, and elsewhere.
2002. In 2006, global drug sales totaled $582 billion
Helzer, John E., and James J. Hudziak, eds. Defining (45% in the United States and 30% in Europe),
Psychopathology in the 21st Century: DSM-V and and DTCA expenditures were $4.5 billion. If
Beyond. Arlington, VA: American Psychiatric DTCA to the European Union (EU) is allowed, it
Publishing, 2002. is forecast to run to $1 billion. From 1997 to
Kupfer, David, Michael B. First, and Darrel A. Regier, 2002, DTCA expenditures in the United States
eds. A Research Agenda for DSM-V. Arlington, VA:
more than doubled. However, the rate of growth in
American Psychiatric Publishing, 2002.
DTCA expenditures has slowed, and pharmaceuti-
Phillips, Katherine A., Michael B. First, and Harold Alan
cal firms still direct 86% of their promotional dol-
Pincus, eds. Advancing DSM: Dilemmas in
lars toward direct marketing to physicians.
Psychiatric Diagnosis. Arlington, VA: American
Psychiatric Publishing, 2003.
World Health Organization. The ICD-10 Classification History
of Mental and Behavioural Disorders. Geneva,
In the 19th century, promotion of patient medi-
Switzerland: World Health Organization, 1992.
cines in the United States represented the largest
print advertising spending by any industry. The
Web Sites federal 1906 Pure Food and Drug Act, passed in
response to egregious abuses in the production
American Psychiatric Association (APA): http://www
and representation of food and drugs, was replaced
.psych.org
in 1938 by the Food, Drug, and Cosmetic Act
National Institute of Mental Health (NIMH):
(FDCA), which gave the U.S. Food and Drug
http://www.nimh.nih.gov
Psychiatry Online: http://www.psychiatryonline.com
Administration (FDA) more authority to regulate
the labeling of all drugs, then not distinguished as
prescription and over-the-counter drugs. The
FDCA prohibited “false or misleading labeling.”
The U.S. Congress assigned the regulation of drug
Direct-to-Consumer advertising to the U.S. Federal Trade Commission
(FTC). In 1951, the Dunham-Humphrey Act
Advertising (DTCA) legally defined prescription drugs as distinct from
those safe for consumers to purchase over the
In healthcare, the term direct-to-consumer adver- counter. In 1962, the Kefauver-Harris amend-
tising (DTCA) refers to the promotion of drugs and ments to the FDCA moved prescription drug
medical devices by their manufacturers directly to advertising regulation to the FDA, where it is cur-
prospective users. Advertising to users via the rently handled by the Center for Drug Evaluation
media, such as newspapers, magazines, radio, tele- and Research, Division of Drug Marketing,
vision, the Internet, pamphlets and brochures, Advertising, and Communications (DDMAC).
billboards, and direct mailing, is considered DTCA. Until the early 1980s, prescription drugs were
Most discussions of DTCA, though, focus on the advertised only to physicians, primarily through
promotion of prescription drugs, those requiring a detailing (company representatives who visited the
physician’s order, through mass print and broad- physicians), sampling (provision of drug samples
cast media, with growing attention to the Internet. to physicians’ offices), and professional medical
Before 1985, advertising of drugs available journals. The 1962 amended FDCA required that
only by physician’s prescription was directed advertisements not be “false or misleading,” con-
only at physicians. Advertising directly to contain what it called a “brief summary” (relating to
sumers is more recent and more controversial. It side effects, contraindications, and drug effective-
is legal in only two nations, the United States and ness), and have a “fair balance” coverage of risks
New Zealand. The global pharmaceutical indus- and benefits. To supply the brief summary, drug
try is lobbying to prevent a proposed ban of advertisements in medical journals simply reprinted
302 Direct-to-Consumer Advertising (DTCA)
the FDA-approved product labeling (package most cases, companies comply, so that the FDA
insert), constituting at least an entire page of very rarely uses its seizure or injunction powers. When
technical medical information in very small print. the latter does occur, companies become perma-
The mandated fair-balance requirement specified nently obligated to prescreening of their advertise-
that the advertisement present an evenhanded ments and to other restrictions.
account of all clinically relevant information and However, the FDA is hampered by understaff-
that the presentation not focus disproportionately ing, no ability to impose monetary penalties, and
on the benefits. Fair balance is measured not only under the George W. Bush administration, by a
in the quantity of information on both sides but requirement that notices of violations must clear
also in quality (major vs. minor risks) and in pre- through the Office of the Chief Counsel. Often the
sentation (legibility, readership, and size of font). violation letters arrive after the natural end of the
In 1981, after a few companies had tested advertisement’s use. The U.S. General Accountability
direct-to-consumer advertisements in the market- Office (GAO) reports that many companies receive
place, the pharmaceutical industry asked the FDA repeated notices of violations, sometimes for the
for permission to advertise directly to consumers, same drug. In 2005, the FDA issued 60 such letters
touting its educational benefits. Following a volun- for violations of direct-to-consumer guidelines as
tary moratorium while it studied the issue, the compared with 158 in 1998.
FDA ruled in 1985 that the standards established Scrutiny and criticism of DTCA by state and
in 1962 relating to advertisements to physicians local policy officials and organizations such as
were sufficient to protect consumers. The industry the APA and the AMA have steadily increased.
then began direct advertising. The FDA became The withdrawal of the Cox-2 inhibitor Vioxx,
the overseer of DTCA of the drug by its supplier one of the most heavily direct-to-consumer pro-
via print, audio, and visual matter. The rules for moted drugs in history, precipitated even more
DTCA were the same as they had been for adver- controversy. Concern over the advantages and
tising to physicians. disadvantages of DTCA led the FTC and the FDA
The industry quickly returned to the FDA to ask to hold hearings in 2003 and 2005, respectively,
for a variance from the required brief summary, to gather information about whether the regula-
claiming it to be too long, and therefore expensive, tions needed to be changed. Testimony ranged
for both print and broadcast media. Reflecting a from requests for changed regulation regarding
changed political and regulatory environment, the presentation of benefits and disadvantages, to an
FDA, in 1997, relaxed the requirement for broad- outright ban on all DTCA. The FDA issued more
cast advertising. It allowed the mention of both the complete guidelines (without the force of law) to
drug’s name and the condition it purported to treat help advertisers know what it expected in adver-
(heretofore prohibited), along with a shorter ver- tisements. Numerous bills to limit DTCA have
sion of the brief summary. In exchange for the been introduced in the U.S. Congress and in the
condensed information, the advertiser had to make state legislatures.
“adequate provision” for access to the complete In response to the heightened attention, the
required information (via Web page, toll-free tele- pharmaceutical industry adopted a “govern or be
phone number, or by mail). Requirements for print governed” approach to fend off impending gov-
advertisement remained the same. Drug advertis- ernment regulation. In 2005, the Pharmaceutical
ing increased rapidly thereafter. Research and Manufacturers of America (PhRMA),
The FDA enforcement of its regulations does an organization of major U.S. drug companies,
not include mandatory prescreening of advertise- approved 15 voluntary guidelines (called “Guiding
ments. When an advertisement goes into use, the Principles”), an accountability office, and a panel
manufacturer must submit it to the FDA. If it is (appointed by PhRMA) to track signatory com-
found to be in violation, the FDA can send warn- pany compliance. A total 23 companies signed on
ing letters and untitled letters (for less serious to the guidelines that took effect in 2006, but no
offenses) and occasionally, a request for corrective penalties accrue for violation of the guidelines.
advertising. These letters are posted on the Center Some critics doubt the potential success of the
for Drug Evaluation and Research Web site. In direct-to-consumer guidelines, pointing to the
Direct-to-Consumer Advertising (DTCA) 303
mixed impact of earlier voluntary industry guide- banner advertisements, pop-up ads, and e-mails as
lines regarding physician detailing and continuing promotion and may optimize their Web sites to
medical education. The guidelines call for, among increase “hits.” Critics point out that aspects of a
others things, FDA compliant advertising, a clear Web page may resemble both print and broadcast
educational focus, balance of benefits and side- media and may bridge the rules for labeling and
effects, voluntary, pre-use submission of new tele- for advertising. In addition, styles of information
vision advertisements to the FDA for comment, presentation may make it more or less obvious and
and a delay of unspecified length on DTCA of new accessible on Web pages as opposed to broadcast
drugs until physicians have been educated about advertisements or print ads. For example, Web
them. The national IOM calls for this moratorium page hierarchy affects how unbiased information
to be 2 years (the length of time proposed in an may be (e.g., homepage vs. a “deeper” page or
anticipated U.S. Senate proposal), but the drug number of “clicks” to access).
companies complain that their patent protection is The EU has banned DTCA, but pharmaceutical
too short to waste that long not advertising to industry pressure and, to some extent consumer
consumers. The AMA’s House of Delegates also demand, led observers to predict that the ban will
called for a moratorium on new drug advertising be lifted. The WHO Criteria for Medicinal Drug
at its 2006 meeting. However, manufacturers are Promotion says that advertising of prescription
circumventing the voluntary ban by use of more drugs should not be allowed. Meantime, as of
“news” and public relations activities to introduce 2008, New Zealand, the only country besides the
new products to the public. United States with legal DTCA, has a voluntary
In recent years, about three fourths of DTCA moratorium and is considering a legal ban of such
went to television advertisements. For 2006, advertising. Pharmaceutical companies are lobby-
about 5% of DTCA budgets seems to have been ing to prevent a permanent New Zealand ban and
diverted from television to magazine advertising. to lift the current prohibitions in Europe and
Pharmaceutical firm spending on DTCA has Canada. Currently, border crossing Internet adver-
continued to rise but at rates slower than those tising defies the bans outside the United States and
seen from 1997 to 2005. Compliance with the New Zealand.
PhRMA guidelines, changes in television viewer
behavior, better-informed but cynical consum-
Controversy
ers, and the rise of the Internet as a source of
information appears to explain this switch from A variety of issues make up the controversy
television. regarding DTCA. Thousands of studies have failed
Internet DTCA spending by drug companies is to find consistent results examining advertising
estimated at 1% to 10% of their advertising bud- impacts on healthcare utilization and costs, on
gets, and is expected to increase as they change patient and physician behavior and interaction,
from a scatter-shot mass media approach to one and on health outcomes. Drug manufacturers are
that targets patients with particular diseases. The in favor of DTCA, but advocates and opponents
1997 FDCA modifications allowing less brief sum- are found in nearly every other stakeholder group—
mary information being in broadcast advertise- consumers, physicians, insurers, and policy experts.
ments, companies must make the expanded Proponents point to the educational value of adver
information available to consumers by telephone, tising that informs consumers about diseases and
mail, or the Internet. Many U.S. adults prefer the drugs. Studies show that both consumers and phy-
Internet to follow-up on such advertisements. sicians agree that DTCA increases physician visits
Thus, the act alone feeds millions of self-selected and physician–patient discussions, and they have
potential patients to the drug Web pages for fur- shown that some traditionally underdiagnosed
ther information. No specific regulations exist for disorders (e.g., depression) are found and treated
presentation of information in Web-based sources as a result of this interchange. Studies show incon-
so those for print and broadcast advertising pre- sistent results on the perceived value of that discus-
vail. In addition to company or specific drug Web sion. Consumers report that the advertisements
sites, companies also sponsor disease Web sites, are useful, especially if the physician actually gives
304 Direct-to-Consumer Advertising (DTCA)
them a prescription. Some physicians like to have the advantage of patients’ mentioning their con-
informed, questioning patients, while others find it cerns after an advertising prompt. Critics point out
burdensome to spend extra time to disabuse patients that a physician may simply act on the information
of misconceptions. by prescribing a drug instead of carefully exploring
Proponents claim that the information included the patient’s complaints, possibly resisting the
in advertisements is valuable to consumers, while patient’s expectations for a drug treatment, or
many critics and studies show that it is biased, introducing the much harder recommendation for
misleading, and confusing. Although consumers behavior change.
cannot actually purchase drugs directly based on Studies find physicians split on the value of
advertised information, detractors claim that the DTCA. Some welcome the more informed patient,
quality of information is still important. Critics but virtually all dislike the pressure they feel to
point out that presenting truthful and balanced prescribe at all or to prescribe a particular drug.
information can conflict with a drug manufactur- Many report that convincing patients that they do
er’s primary responsibility—to make money for its not need a drug is a waste of their time, and some
stockholders. Studies have shown that some con- resent the imposition on their autonomy and ques-
sumers are appropriately skeptical of the informa- tioning of their recommendations. Studies have led
tion but that other consumers tend to concentrate to recent moves to delay DTCA of new drugs
on the benefits and not on the risks. Physicians because physicians report being embarrassed when
report that consumers have unreasonable expecta- asked for a drug that they have not yet studied.
tions and focus on the benefits advertised. Much research has explored whether DTCA
Furthermore, many consumers assume that adver- has an impact on the cost of drugs or of health-
tisements have been approved by a government care. Certainly, demand is induced by this form of
agency and are, thus, truthful. advertising. Exploring the impact of DTCA on
Critics fault the advertisements for medicalizing prescription drug spending, the Kaiser Family
too many conditions (especially those better rem- Foundation reports that a 10% increase in DTCA
edied with lifestyle changes), creating the false spending results in a 1% increase in sales for the
hope that there is a pill for every disorder and dis- class of drug. The Kaiser studies also found that
counting the importance of lifestyle and behavior physicians write prescriptions more for the most
changes. Advertisements aimed at youthful con- heavily advertised drugs. No proof of an exact
sumers (e.g., acne preparations) are questioned, cause-and-effect relationship has been established,
even by some proponents of DTCA. Critics also since DTCA is usually accompanied by increased
point to the possibility that advertisements create a marketing to physicians. However, a 10% increase
sense of fear in consumers. Studies show that when in spending on promotions to physicians resulted
“physicians” and celebrities promote a drug, sales in only a 0.2% to 3% increase in sales as com-
increase despite the fact that the physicians are pared with 1% for DTCA. The Kaiser studies also
actors and the celebrities may or may not have ever determined that for every $1 spent on DTCA in
used the drug. These techniques, plus the use of 2000, sales increased by $4.20. Some studies indi-
emotional images and words (rather than factual cate that the advertisements encourage switching
presentations), are decried by critics as misleading to an advertised drug, which is almost always a
and not educational. newer, more expensive option and may also be less
Most studies find that DTCA increases prescrib- well established with regard to efficacy and risks.
ing. Prescriptions for a class of drugs increase Certainly, a drug with a brand name costs more
when a drug from that class is advertised (not nec- than the generic drug, which are not advertised.
essarily for the specific drug in the advertisement). No evidence has been found indicating that DTCA
Studies are inconclusive about the extent to which causes increased drug prices.
the increase is due to necessary treatment of for- Insurers and government programs such as
merly undiagnosed illness or treatment of condi- Medicaid report pressure to add new, highly adver-
tions that probably do not need treatment. In other tised drugs to formularies. Indeed, DTCA creates a
words, they do not establish whether physicians “demand pull” that undermines the cost control
are prescribing unnecessarily. Proponents point to and utilization limits of insurers and policymakers.
Disability 305
Professional organizations have periodically Gellad, Zird F., and Kenneth W. Lyles. “Direct-to-
issued statements on DTCA. For example, the Consumer Advertising of Pharmaceuticals,” American
American College of Physicians (ACP), in 1998, Journal of Medicine 120(6): 475–80, June 2007.
supported it in principle but recognized the need for Kravitz, Richard L., and Robert A. Bell. “Direct-to-
careful regulation to ensure accuracy. Among other Consumer Advertising of Prescription Drugs:
recommendations, it suggested that physicians Balancing Benefits and Risks, and a Way Forward,”
receive DTCA before patients so that they can be Clinical Pharmacology and Therapeutics 82(4):
prepared. The AMA has issued guidelines for 360–62, October 2007.
Metzl, Jonathan M. “If Direct-to-Consumer
DTCA, and its 2006 House of Delegates called
Advertisements Come to Europe: Lessons From the
for a moratorium on new-drug advertising. Expre
U.S.A.,” Lancet 369(9562): 704–6, February 24,
ssing general support of DTCA, the American
2007.
Pharmaceutical Association (APhA) calls for enforce-
Weber, Leonard J. Profits Before People?: Ethical
ment of regulations and suggests that pharmacists Standards and the Marketing of Prescription Drugs.
be given prerelease knowledge of advertisements. Bloomington: Indiana University Press, 2006.
Future Implications
Web Sites
Most observers agree that DTCA is probably a
Henry J. Kaiser Family Foundation (KFF): http://www.kff.org
fixture in the U.S. health marketplace and that
Pharmaceutical Research and Manufacturers of America
Europe and Canada will likely approve it in some (PhRMA): http://www.phrma.org
form in the future. However, nearly every stake- U.S. Food and Drug Administration (FDA):
holder group has critics who are unlikely to go http://www.fda.gov
away. Critics call for more specific direction from U.S. Government Accountability Office (GAO):
the FDA regarding accuracy, balance, understand- http://www.gao.gov
ability, and more regulatory authority. In addi-
tion, they call for attention to the evolving
varieties of advertising (including the Internet and
cell phone) that do not fit within the mold of cur-
rent guidelines.
Disability
Ruth Ann Althaus While there is widespread agreement that disabil-
ity is a major concern in every society in the world
See also Access to Healthcare; Pharmaceutical Industry; today, there is considerable controversy about the
Pharmacoeconomics; Pharmacy; Prescription and definition, measurement, demography, healthcare
Generic Drug Use; Public Health; Supplier-Induced requirements, costs, politics, and personal, famil-
Demand; U.S. Food and Drug Administration (FDA) ial, and societal consequences of disability. In
2000, the U.S. Census Bureau counted 49.5 mil-
lion Americans with some type of long-lasting
Further Readings health condition or disability (19.5% of the
Abramson, John. Overdosed America: The Broken
nation’s total noninstitutionalized population).
Promise of American Medicine. New York: Many individuals (12% of the population) had
HarperCollins, 2004. multiple disabilities, and more than 4% reported a
Donohue, Julie M., Marisa M. Cevasco, and Meredith B. mental disability. Experts think that the rate of
Rosenthal. “A Decade of Direct-to-Consumer mental illness could well be underreported. On a
Advertising of Prescription Drugs,” New England global basis, the World Health Organization
Journal of Medicine 357(7): 673–81, August 16, 2007. WHO estimates that there are 600 million dis-
Federal Food, Drug, and Cosmetic Act. U.S. Food and abled people in the world. The United Nations
Drug Administration. U.S. Department of Health and (UN) estimate is 650 million. Recent global esti-
Human Services. Available from http://www.fda.gov/ mates conclude that by 2020, depression will be
opacom/laws/fdcact/fdctoc.htm the number two cause of disability in the world.
306 Disability
The World Bank and other international financial state of the economy and the availability of gov-
institutions have taken a recent interest in disabil- ernment resources.
ity because they see it as a major threat to eco- Underlying these different definitions and deter-
nomic development. Indeed, there is general mination of disability is a clash of paradigms used
agreement among experts that disability is more to conceptualize disability. The medical model
common in developing than in developed nations. views disability generally as a problem of the per-
son caused by disease, trauma, or other health
conditions and resulting in the need for individual
Disability Definitions
medical care. Individuals are diagnosed and are
Disability definitions, which are culturally specific generally referred to in terms of their primary
and contested, are used to signify a particular rela- medical diagnosis. Much of the medical and health
tionship of the individual to bodily norms, social services research conducted within this paradigm
role performance, and society in general. Disability focuses on functional limitations, return to work,
is a condition where individuals are identified as independence, and the performance of social roles.
not meeting the potential expected of them by In contrast, the social model of disability sees
society (expressed through social and cultural disability as a socially created problem. From this
norms). People are judged to be disabled because perspective, disability is not an attribute of the
of limitations in their physical and/or mental func- individual but results from conditions imposed on
tioning, lack of social support networks, inability people by oppressive physical, social, work, trans-
to perform normative social roles, and/or living in portation, and social policy environments.
a barrier-laden environment that prevents them According to this argument, society has the obliga-
from fully participating in society. In this context, tion to make reasonable accommodations to dis-
disability results from a maladaptive interaction abled people so that they can be independent and
between individuals and their environments. The live full lives. The WHO in its International
result is often dependency, isolation, and poverty. Classification of Functioning, Disability and Health
Disability definitions are culturally grounded. (ICF) has attempted to integrate these two posi-
For example, in the United States, disabilities are tions by incorporating concepts and measurements
typically determined by physicians according to of impairment, function, and communication along
diagnostic categories such as spinal cord injury, mul- with those of activity, participation, and consider-
tiple sclerosis (MS), and depression. While members ation of the environments within which disabled
of some cultures will say that impotence, infertility, people live and perform.
and diabetes are disabilities, according to the medi- More recent approaches to the understanding of
cal model, they are seldom classified as such. disability have come from scholars such as Amartya
Disability definitions are also strongly influ- Sen and Martha Nussbsaum, who conceptualize
enced by politics, ideology, and social policy. disability in terms of human capacity and societal
Physical disabilities are more likely to be diagnosed development. This approach has both moral and
and reported than mental illness because of stigma economic components, expressed in the obligations
and the added cost burden on governments and of states to all their citizens and the notion that
private health insurers to cover mental health ser- preventing and dealing with disability will reduce
vices. The full effects of these differences are dependency and improve the economic position of
expressed in U.S. social policy and law. A search of states. Disability and human rights advocates have
federal statutory definitions of disability in the also been using forms of moral arguments, human
U.S. Code in 2005 revealed that disability was rights initiatives, and quality-of-life analyses to
defined 67 times in different ways depending on advance the cause of disabled people based on what
whether the statute dealt with Veterans Affairs, is just and right in a society.
developmental disabilities, the Fair Housing Act,
Social Security Disability Insurance (SSDI), assis-
Disability as an Outcome
tive technology, or employment-based legislation.
In addition, the interpretation of these definitions In health services research, disability is conceived
is often constricted or relaxed depending on the as an outcome measured by functional status;
Disability 307
activity performance; role activities such as par- 1.6 million individuals received SSDI benefits as
enting, employment, and work; community dependent family members of disabled workers.
involvement; connectedness in social networks; In 2004, the U.S. Department of Veterans Affairs
independence; and quality of life. Newer work (VA) provided disability benefits to 2.7 million
sponsored by the Centers for Disease Control and veterans. In addition to these public programs,
Prevention (CDC) concentrates on the prevention many employees have private disability insurance
of disability through programs such as enforcing through their jobs and may have access to Worker’s
the wearing of helmets when riding a motorcycle, Compensation. This is a program administered at
genetic counseling, and prevention of secondary the state level designed to provide medical, reha-
conditions such as bed sores and urinary tract bilitation, and lost-time costs to injured workers.
infections related to spinal cord injury. Evaluation This contentious program historically has pitted
and intervention research on disability focuses on labor and business against each other, with busi-
programs designed to increase mobility (e.g., ness seeking to limit coverage and costs and labor
wheelchairs, cut curbs, and accessible transporta- unions seeking to expand benefits. In 2006,
tion), improve strength and flexibility (such as nationally these benefits amounted to approxi-
exercise and weight-bearing regimens), and keep mately $16.1 billion. Taken together, these insur-
people in school and at work. ance programs and their related benefit structures
On a familial level, disability outcomes are mea- are so complicated that experts suggest that any-
sured in terms of marital stability, having and rais- one seeking disability benefits or dealing with dis-
ing children, economic self-sufficiency, and ability insurance seek the counsel of healthcare
accommodation to roles and demands. On the soci- experts and legal advice before applying for them.
etal level, disability has been measured by the “bur- The programs and their interrelationships are not
den” that it exerts on social welfare systems and readily transparent to the consumer.
care institutions and by dependency and unemploy- The medical and rehabilitation care structures
ment indices. Most recent work by medical geogra- are composed of government inpatient and outpa-
phers and sociologists examines disability in terms tient services, care for the poor provided by the
of place. Where one lives has an enormous impact government through subcontracts with public and
on how one lives and the quality of life. Communities private hospitals, and care reimbursed by private
rich in resources and low in disruptive activities insurance at community and private hospitals and
such as crime, high poverty, and unemployment can rehabilitation systems and on an outpatient basis at
provide health and social support services and liv- many private rehabilitation clinics. In an effort to
ing conditions conducive to good health status, respond to pressures from the disability community
independence, and high quality of life. and to cut costs, a large 5-year Medicaid demon-
stration project is being launched to evaluate the
efficacy of providing long-term care in home and
Structure of Care for Disabled People
community settings rather than in nursing homes.
Care for disabled people is delivered through a
complex set of government, not-for-profit, and
Access to Care by Disabled People
private for-profit organizations in the United
States. The systems are typically organized along Disabled individuals in the United States face myriad
the separate lines of physical and mental health challenges in accessing care, receiving appropriate
disabilities. This causes problems for individuals treatment, and availing of rehabilitation services.
who have both physical and mental health dis- The first challenge for disabled people is that
abilities because the sources of care, services, and many do not have health insurance. According to
insurance are often different for physical and men- the U.S. Census Bureau, in 2005, there were 46.6
tal conditions. In 2005, Medicaid covered the million uninsured Americans, of whom a dispro-
medical and rehabilitation care for 14.6 million portionate number are disabled people. The num-
disabled and elderly recipients. In 2001, 5.7 mil- ber of uninsured has been growing since 2001. As
lion disabled workers received benefits through a result, many disabled people fall into Medicaid
Social Security Disability Insurance (SSDI), and by default and/or are forced to seek care for
308 Disability
episodic events in hospital emergency departments. accommodations, universal design, social support,
Such utilization of care is crisis oriented and does architectural, transportation, and diet and exercise
not promote prevention or continuity of treatment. professionals is frequently underappreciated. These
In an attempt to address some of these issues, elements of care may not even be integrated into
Medicaid spending has been authorized to expand the treatment plan.
access to care for certain children with disabilities. A sixth challenge to care concerns the portabil-
A second challenge is that there is differential ity of health insurance. If disabled persons are fired
access to care for disabled people depending on or change jobs, they may find that they are with-
whether or not their primary medical diagnosis is out insurance when they are between jobs and that
for a physical or mental disability. Individuals find the prospective employer will not hire them because
it much easier to arrange care for a physical rather they are disabled. This leaves them vulnerable
than a mental disability such as posttraumatic unless they immediately qualify for Medicaid or
stress disorder (PTSD) or depression. When indi- VA benefits. For these reasons, disabled people often
viduals have both sorts of disabilities, the physical remain at their jobs or end up poor.
disability is often dealt with, while the mental dis-
ability is ignored or undertreated.
Cost of Care for Disabled People
A third challenge to treatment of disability
involves continuity of care. Disability and rehabili- The economic costs of disability are enormous.
tation services are often delivered piecemeal and The national Institute of Medicine (IOM) esti-
from different sources and programs. The result is mates that the total costs of disability in the
that the program of support and care is not inte- United States is more than $300 billion annually,
grated and is frequently discontinuous. This can more than 4% of the nation’s gross domestic
result in logistical nightmares for disabled persons product (GDP). This sum is split about equally
and their families, services offered but not needed, into direct costs associated with medical and reha-
services and support needed but not delivered, and bilitation care and indirect costs due to lost pro-
costs involved in stopping and restarting care productivity. A critical question facing policymakers
grams due to lapses in eligibility. is how to allocate scarce resources across different
A fourth challenge to care is the bias toward kinds of disability conditions and situations.
institutionalizing the seriously disabled, mentally Current research is addressing whether costs
ill, and elderly. Such a bias results in a lower qual- should be considered on the individual level (treat-
ity of life and increased dependency for those insti- ment and support) or on the population level
tutionalized. There is widespread agreement that (burden of disability on society). The national
the more humane treatment option is to keep dis- Medical Outcomes Study relies on individual-level
abled people with their families and in their analysis to measure outcomes, while the Global
communities as much as possible and to have sup- Burden of Disease research has stressed commu-
portive and care services delivered in this context. nity- and population-level analyses in describing
As a result, disabled persons can continue to work the costs of disability to society.
and be socially engaged with their family and On the individual level, current research shows
friends instead of being institutionalized. that the costs related to specific conditions such as
The fifth challenge to care is that the American spinal cord injury, low back pain, ischemic heart
approach to disability is strongly dominated by the disease, brain injury, depression, schizophrenia,
medical model. In fact, physicians must determine and mood disorders vary considerably. Some con-
if a person is disabled to receive benefits, they must ditions are much more expensive than others. It is
medically treat the person, they must sign orders, clear that controlling for level of disability, more
and they must ascertain the person’s progress from money is being spent on visible, nonstigmatized
the disability. Since many physicians are focused conditions such as ischemic heart disease and spi-
on genetic, biological, surgical, radiation, and nal cord injury than on less visible and stigmatized
pharmacological interventions, the importance conditions such as hepatitis C, herpes, mood disor-
and expertise of assistive technology, reasonable ders, and depression. The cost of pharmaceuticals
Disability 309
is another source of high costs when evaluated in care from injury on the battlefield to transporta-
terms of desired, efficacious outcomes. Numerous tion, medical-surgical care, provision of prosthet-
studies have shown that more than 50% of patients ics and assistive devices, and extensive rehabilitation.
with depression and dementia were not being However, this quality of care is generally reserved
treated with appropriate drugs. for veterans who remain active members of the
On the population level, there is a tremendous military and who have certain types of physical
disparity between how much money is being spent disabilities. There are numerous examples of veter-
on diagnosis and treatment and how much is being ans with brain injuries resulting from explosive
spent on prevention and population-based interven- devices or sniper fire, PTSD, and neurological con-
tions. Only 3% of all healthcare costs in the United ditions that were not properly diagnosed or treated.
States are spent on public health programs and ini- In fact, the rehabilitation potential of many of
tiatives such as exercise programs for disabled these veterans was underestimated.
people, education and inoculation against human In the civilian disability world, the quality and
papillomavirus (HPV), injury prevention, nutrition comprehensiveness of care is predicated on an indi-
education, environmental pollution, motorcycle vidual’s place in the social structure and on an indi-
accidents, and disabilities caused by firearms. The vidual’s employment and insurance status. There
return on investment from each type of intervention are different experiences for the poor, the middle
is enormously different. Public health programs and class, and the wealthy, for the employed and the
interventions generally are much more cost-effective unemployed, and for the insured and the uninsured.
than treatment of individual conditions. In addi- Hence, there is considerable room for research on
tion, intervening upstream is much less costly than health disparities in the disability arena.
waiting for a problem of large proportions to hit. Quality of care is usually measured in terms of
Smoking is an example of this logic. The problem is structure (the resources of the institution, level of
that intervening on the population level produces training and staffing, staff-patient ratios, and
heated public debates, while treating a disabled expertise of the providers), process (how much
person after the problem has occurred is less con- care, of what type, over what period of time, and
tentious in the public’s eye. Therefore, cost-effective how comprehensive), and outcomes (lack of com-
solutions to disability-producing behavior and con- plications, level of function, return to school or
ditions and increased funding are unlikely to occur work, integration into the family and community,
on the population level until problems reach large and perceived quality of life). National initiatives
proportions. Much of this has to do with public such as the use of the Functional Index Measure
values, attitudes, and perceptions and is supported (FIM) to monitor the progress and outcomes of
by the strong lobbies of the medical and pharma- adults, seen at many of the physical rehabilitation
ceutical sectors of the economy. units and hospitals in the United States, and similar
work by the Vermont-Oxford Network to follow
patient progress and outcomes of pediatric patients
Quality of Care for Disabled People
provide invaluable evidence-based and outcomes
The quality of care for disabled people in the United data useful for clinical practice and research. Such
States is highly variable. On the one hand, care in monitoring and evaluation systems to assess the
integrated centers such as the Rehabilitation Institute quality and outcomes of disabling mental health-
of Chicago is as good as any in the world. On the care are not as well developed or prominent.
other hand, care for poor disabled individuals in
the inner city of large urban centers or in rural areas
Future Implications
often fails to live up to the same standard.
The recent scandal at the Walter Reed Army The task of balancing costs and quality of care is
Medical Center in Washington, D.C., represents a persistent topic in contemporary health services
the best and worst of American disability care. research. This theme is reflected in the rapid
Veterans of the Iraq and Afghanistan wars who growth in the disability literature on evidence-
lost limbs in combat were treated with exemplary based medicine (EBM) and medical outcomes. In
310 Disease
the disability arena, there does not seem to be a States, 2001–2005. HHS Pub. No. (PHS) 2008–1035.
strong correspondence between cost and out- Hyattsville, MD: National Center for Health
comes. For sure, disability is an expensive busi- Statistics, 2008.
ness, but throwing money at the problem does not
necessarily yield the desired benefits. Health ser-
vices research has much to contribute to disability Web Sites
and rehabilitation outcomes on both the individ- American Association of People with Disabilities
ual and the population levels. These priority areas (AAPD): http://www.aapd-dc.org
of interest concern (a) the mix and timing of ser- National Center for the Dissemination of Disability
vices, (b) integration of care, (c) consideration of Research (NCDDR): http://www.ncddr.org
both physical and mental disabilities and their National Center for Health Statistics (NCHS):
concomitant interactions, (d) reintegration of the http://www.cdc.gov/nchs
individual into the family and community, (e) sup- National Organization on Disability (NOD):
port that allow individuals to live independently http://www.nod.org
in the community, and (f) reduction of health dis- U.S. Census Bureau: http://www.census.gov
parities among disabled people. Encouraging more U.S. Social Security Administration:
interdisciplinary work involving healthcare, clini- http://www.socialsecurity.gov
cal, and social science researchers would enhance
the utility of future research. Even more impor-
tant, however, is including disabled people in the
design and execution of research projects and in Disease
translating research into action.
The term disease encompasses a broad range of
Gary L. Albrecht pathologic conditions and, as a concept, is pri-
marily objective in its nature and scope. Any
See also Access to Healthcare; Activities of Daily Living
condition that impairs the functioning of an
(ADL); Long-Term Care; Medicare; Mental Health;
Nursing Homes; U.S. Department of Veterans Affairs organism may be classified as a disease. This con-
(VA); Vulnerable Populations cept is much less complex than the seemingly
opposite idea of health. The state of health is
more subjective in characterization and, as defined
Further Readings by the World Health Organization (WHO), is a
state of complete physical, mental, and social
Albrecht, Gary L., ed. Encyclopedia of Disability. 5 vols. well-being and not merely the absence of disease
Thousand Oaks, CA: Sage, 2006. or infirmity. Thus, one cannot simply define dis-
Cutler, David M., and David A. Wise, eds. Health and
ease as the absence of health. The presence or
Older Ages: The Causes and Consequences of
absence of disease may, indeed, be strongly cor-
Declining Disability Among the Elderly. Chicago:
related with an individual’s perceived health sta-
University of Chicago Press, 2008.
tus; however, the relationship is not intrinsically
Falvo, Donna. Medical and Psychosocial Aspects of
linked. There are a multitude of cultural and
Chronic Illness and Disability. 4th ed. Sudbury, MA:
Jones and Bartlett, 2009.
social influences that alter an individual’s state of
French, Sally, and John Swain. Understanding Disability: health as perceived by himself or herself or by his
A Guide for Health Professionals. New York: or her community.
Elsevier/Churchill Livingston, 2008. Many different classification systems of disease
Kroll, Thilo, ed. Focus on Disability: Trends in Research exist; the ancient field of nosology is a branch of
and Application. New York: Nova Science, 2008. medicine that studies the classification of diseases.
MacKinlay, Elizabeth, ed. Ageing, Disability, and One common classification system categorizes
Spirituality: Addressing the Challenge of Disability in disease states as extrinsic or intrinsic to the
Later Life. Philadelphia: Jessica Kingsley, 2008. human body or of unknown origin. The extrinsic
National Center for Health Statistics, National Health category of diseases is sometimes referred to as
Interview Survey. Disability and Health in the United acquired diseases. Exogenous factors that may
Disease 311
contribute to this category of disease include Intrinsic Diseases

physical, chemical, nutritional, and biological
Hereditary factors contribute to a sizable number
factors. The intrinsic categorization includes
of intrinsic diseases. Diagnoses categorized within
hereditary and hypersensitivity (immunologic)
this category include diseases such as phenylketo-
disorders.
nuria, Down syndrome, Turner’s syndrome, and
diabetes mellitus Type I. It should be noted that
Extrinsic Diseases diabetes mellitus Type II, as well as other chronic
The physical factors that contribute to disease diseases, likely have some genetic component as
include mechanical injury, nonionizing energy well. However, these disease states are multifacto-
(e.g., electricity, microwaves, radio waves), and rial as behavioral factors contribute significantly
ionizing energy (e.g., x-rays, gamma rays, cos- to the manifestation and progression of these dis-
mic rays). Currently, in the United States, injury eases. Currently, chronic diseases are the leading
accounts for about 2.3 million hospitalizations cause of death in the world, causing 29 million
each year and is the leading cause of death deaths worldwide in 2002, an estimated 35 million
worldwide in young people between the ages of deaths worldwide in 2005, and an estimated 36.6
10 to 24. The chemical factors that contribute to million deaths worldwide in 2007. Hypersensitivity
disease include metallic poisons, nonmetallic factors, as well, contribute greatly to the category
inorganic poisons, alcohols, asphyxiants, corro- of intrinsic diseases, which includes diagnoses such
sives, pesticides, medicinals, warfare agents, and as asthma, lupus, and rheumatoid arthritis.
hydrocarbons. Many agents within this category
of chemical factors may be contributors to cer- Diseases of Unknown Origin
tain types of cancers. The nutritional deficiency
factors that contribute to disease states include Some disease states may not have a clear cause or
metals (responsible for anemia), nonmetals, etiology and are, thus, included within this cate-
proteins, and vitamins. Among the WHO’s gory. Alzheimer’s dementia is an excellent example
Millennium Development Goals established in of a disease classified in this category (although
2000 is the objective to reduce by half the num- some may place this disorder within a degenera-
ber of people (852 million) who suffer from tive disease category under the broad classifica-
daily hunger. The biological factors include tion of acquired, or extrinsic, diseases). The
plants such as tobacco, marijuana, and opium. prevalence of Alzheimer’s continues to rise in the
Cigarette smoking greatly affects the health of United States and in other high-income countries.
persons around the world. Every year, at least
4.9 million people around the globe die from
tobacco use. Other biological factors include
Other Disease Classification Schemes
bacteria, spirochetes, viruses, rickettsia, fungi, The field of pathology investigates the scientific
parasites, protozoa, and helminthes. Infectious mechanism of the disease process, and as this
diseases continue to play a prominent role in field of medicine becomes more precise, the
world public health. However, with the discov- cause of many diseases may be found to be mul-
ery of biological agents as the cause of certain tifactorial, and they fall within multiple catego-
diseases and subsequent medical discoveries ries, or they may constitute a not previously
such as vaccines and antibiotics, the world has recognized categorization. Other disease catego-
seen significant changes in the disease burden ries that in more recent years are being recog-
attributable to these factors. In addition, today, nized, while not adhering well to the historical
biological warfare is of prime political concern categorization scheme, include occupational,
in the United States and around the world, with psychiatric, degenerative, neoplastic (cancer),
attention being placed heavily on preparation and iatrogenic diseases.
for action by homeland security, medical and Diseases may, as well, be described in various man-
public health officials, and law enforcement ners. For example, some disease states may be acute
authorities. (severe in symptomatology but short in duration),
312 Disease
while others may be periodic (recurrent) or chronic in as there are sometimes negative connotations
nature (of a long duration). Diseases may also be associated with disease states, some cultural and
described by organ system, such as cardiovascular, social attitudes may attribute legitimization to
respiratory, and gastrointestinal diseases. disease states or provide social benefits to specific
diseases, or disease states in general. For example,
through social programs, monetary aid may
The Medical Approach to Disease accompany certain diagnoses, and work expecta-
The medical approach to disease centers on the tions are often affected, as well. Ideas of morality
manifestation apparent within the patient. The and ethical considerations challenge individuals as
initial diagnostic clues fall within a category of they attempt to mesh personal considerations of a
objective complaints, or symptoms, described by disease state with societal norms and medical
the patient to the medical practitioner. This patient expectations. Bioethical considerations exploring
history is elaborated through a series of open- quantity of life versus the importance of quality of
ended, ideally, or closed-ended questions from the life, for example, then become central in the con-
medical practitioner, providing him or her with a sideration of end-of-life issues.
set of information allowing the narrowing of the
differential diagnosis, or diagnostic possibilities.
Objective data are obtained through a physical Disease Acquisition
examination, laboratory testing, and diagnostic Medicine is primarily concerned with the diagno-
tests. This information is referred to as signs and sis and cure of disease states within individuals,
allows the practitioner to advance his or her while public health is concerned with the role that
approach to the disease in question through an disease plays within a population. Regardless of
algorithm. After, or during the process of, a medi- the level of intervention and study, one aspect that
cal decision, a patient may choose to have the both fields scrutinize is the manner in which dis-
practitioner initiate the use of medical or surgical ease states are acquired. Risk factors, at the indi-
interventions or other therapeutic modalities. vidual or population level, are directly tied to
Through this method, a disease process is delin- causation. By identifying these factors and under-
eated and addressed. standing the role they play, medicine and public
health have a greater understanding of the disease
state itself. In addition, the two fields are better
Cultural and Social Aspects of Disease
equipped to prevent or combat these disease states
Medical anthropologists and medical sociologists through this understanding. Commonly recog-
study the cultural and social aspects of health, ill- nized categories of risk factors include biologic
ness, and disease. There are many surrounding factors (such as genetic predisposition or age),
themes that become critical in the consideration of environmental factors (e.g., air and water quality),
disease in relation to these issues. The cultural and lifestyle factors, and psychosocial factors. In con-
societal views of life, individualism, morality, and sideration of populations—social, economic, and
normality, for example, can greatly influence a cultural factors have a profound effect on disease
particular disease state. There may be many social and health status. Many factors, at a population
ramifications of being affected by, associated with, level, have been determined to be underlying
and/or even discussing a certain disease. Many health determinants that may increase individual
disease states have been stigmatized in certain risk of disease acquisition and/or severity.
places and times, leading to societal judgments Examples of these health determinants include
and, in some cases, fear. These types of reactions social status, access to healthcare services, educa-
are not necessarily rational when viewed from a tional status, race, and family income. These and
scientific perspective but are, nonetheless, a sig- many other cultural and social factors influence
nificant result of the disease state and continuing greatly not only the manner in which disease
aspect of the individual’s state of health. The states may be acquired but also how they are
impact that these factors have on the patient and experienced and perceived, as well as the manner
his or her family can often be extraordinary. Just in which a community may respond to them.
Disease 313
Disparities and Disease chronic disease, and even in high-income coun-

tries, it is apparent that the socioeconomic gap is
Individual health behavior does play a significant
widening. Thus, as a general rule, around the world,
role in the development of diseases, but many
the effects of poverty are increasing.
other factors affected by inequities are central to
the determination of an individual’s health behav-
ior. Addressing issues such as poverty, education, The Global Burden of Disease
access to healthcare, and special protection for
The WHO suggests that disease policy should be
vulnerable groups allows for the possibility
based on comprehensive and integrated public
of healthy choices. As an example, the primary
health action, intersectoral action, a life course per-
risk factors contributing to chronic diseases—
spective, and a stepwise implementation based on
unhealthy diet, physical inactivity, and tobacco
local considerations and needs. It is important to
use—are consistent across divisions of economic
recognize individually and collectively the range of
status, gender, and age. However, the availability
public health priorities to ensure the well-being of
of resources plays a key role in the ability of an
the world’s population. These priorities include
individual to prevent or combat these conditions.
HIV/AIDS, other infectious diseases, hunger, access
Thus, often, low-income countries experience a
to healthcare, infrastructure, clean water, mother
“double burden” of disease, simultaneously over-
and child health, and immunizations, among oth-
whelmed with the effects of communicable and
ers, in addition to the importance of chronic dis-
noncommunicable diseases.
eases. It is also critical to recognize the social
Several misunderstandings surrounding chronic
determinants of health, including the social gradi-
diseases have caused them to be neglected on a
ent, stress, early life, social exclusion, work and
global scale, increasing their burden with the pass-
unemployment, social support, addiction, food,
ing years. A general view holds that chronic dis-
and transportation. It will be necessary in the years
eases are of significant health concern only in
to come to build cohesive, comprehensive, and eas-
high-income countries and that communicable dis-
ily accessible health systems and resources around
eases pose a more significant threat to low- and
the world in order to address the impact of diseases
middle-income countries now and in the future.
on individuals, communities, and society at large.
While the deaths attributable to infectious dis-
eases, maternal and perinatal conditions, and J. Andrew Dykens
nutritional deficiencies combined are projected to
decline by 3% in the world over the next 10 years, See also Acute and Chronic Diseases; Emerging
deaths due to chronic diseases are projected to Diseases; Epidemiology; Health; International
increase by 17%. Nearly two thirds of the cur- Classification of Diseases (ICD); Morbidity;
rently projected 64 million people who will die in Mortality; Public Health
the world in 2015 will die of a chronic disease.
The poorest people throughout the world are
the most at risk of developing chronic diseases and Further Readings
dying prematurely from them. Poverty leads to
Dobson, Mary J. Disease: The Extraordinary Stories
increased vulnerability due to associated greater
Behind History’s Deadliest Killers. Waltham, MA:
exposure to risks, higher levels of risk behavior, Quercus Press, 2008.
decreased access to healthcare services, social Nesse, Randolph M. “On the Difficulty of Defining
exclusion, increased psychosocial stress, and Disease: A Darwinian Perspective,” Medicine,
unhealthy living conditions. This social determi- Healthcare, and Philosophy 4(1): 37–46, 2001.
nant, thus, is consistent with an environment Scully, Jackie Leach. “What Is a Disease?” EMBO
where healthy choices and opportunities may not Reports 5(7): 650–53, July 2004.
be readily available. The critical importance of this Sherman, Irwin W. Twelve Diseases That Changed Our
fact is that poor health of the community impedes World. Washington, DC: ASM Press, 2007.
development, which in turn predicts worsening Stein, David B., and Steve Baldwin, “Toward an
health. Worst yet, low-income countries are affected Operational Definition of Disease in Psychiatry and
by a disproportionate share of the burden of Psychology: Implications for Diagnosis and
314 Disease Management
Treatment,” International Journal of Risk and Safety Background

in Medicine 13(4): 29–46, 2000.
Temple, Larissa K. F., Robin S. McLeod, Steven The rise in the prevalence of chronic diseases has
Gallinger, et al. “Essays on Science and Society: put an enormous strain on the economy because of
Defining Disease in the Genomics Era,” Science a reduction in worker productivity and the increase
293(5531): 807–8, August 3, 2001. in healthcare expenditures. The rapid escalation in
Yach, Derek, Corinna Hawkes, C. Linn Gould, et al. healthcare costs and the pressure to contain costs by
“The Global Burden of Chronic Diseases: the purchasers of healthcare was one of the primary
Overcoming Impediments to Prevention and forces that led the way toward disease management.
Control,” Journal of the American Medical
Because of these growing expenditures, purchasers
Association 291(21): 2616–22, June 2, 2004.
began to question what the relative value of health-
care was for their dollar and started to take a closer
look at inappropriate use of services.
Web Sites
Managed-care initiatives were another factor
American Association of Public Health (APHA): that led the way for disease management initiatives
http://www.apha.org in the late 1980s and early 1990s. Managed care,
Centers for Disease Control and Prevention (CDC): through its prepayment mechanism and risk shar-
http://www.cdc.gov ing with providers, created financial incentives
National Institutes of Health (NIH): http://www.nih.gov that encouraged the efficient and effective delivery
World Health Organization (WHO): http://www.who.int of care as opposed to traditional fee-for-service,
which rewarded providers for performing more
tests and procedures. Furthermore, because of
managed care’s involvement in the continuum of
Disease Management patient care, disease management was more feasi-
ble under this model. Based on the concept of case
Disease management is the concept of improving management, managed-care organizations began
or sustaining the health outcomes and quality of to look into disease management as an approach
life of populations with chronic conditions while to address chronic conditions at the population
reducing the cost of healthcare. The aim of dis- level. Beginning in the 1990s, disease management
ease management programs is to prevent and programs began to flourish primarily because of
minimize the effects of chronic conditions or dis- the goal of managed care plans to offer their mem-
ease in which patient self-care plays an important bers a product that was of high value.
role. This is achieved through a systematic, popu- The pharmaceutical industry was another major
lation-based approach of identifying individuals force that shaped disease management. Because of
who are at risk, intervening through targeted pro- the growth in pharmaceutical benefit managers
grams, using evidence-based guidelines, and mea- and managed care, the pharmaceutical industry
suring the results and outcomes of these efforts. underwent rapid consolidation and integration to
The model of disease management focuses on increase its leverage in the healthcare market. As a
coordinating a continuum of care for populations result, the pharmaceutical industry transformed its
with similar or the same chronic conditions. The image from a drug manufacturer to a healthcare
components of disease management programs company with direct marketing to consumers.
support the provider-patient relationship and the Pharmaceutical companies began to offer disease
plan of care; focus on the prevention of complica- management programs centered on prescription
tions and worsening of the condition through drug use in order to promote patient compliance
the use of clinical guidelines; and assess patient with medications. These programs often included
outcomes and costs on a regular basis with the provider education, patient information, and coun-
goal of improving overall health. Disease man- seling, and they were then sold to managed-care
agement is also known by the terms disease self- organizations and employers.
management, care management, and health The increased development of clinical practice
management programs. guidelines also helped facilitate the growth of disease
Disease Management 315
management. Clinical practice guidelines are gener- the improvement in patient outcomes, a patient-
ally evidence based, and they represent a systematic centered approach to treating and addressing mul-
approach to treating patients with similar condi- tiple conditions, and lowering costs by reducing
tions. Managed care’s influence over the healthcare unnecessary or redundant services and costs associ-
system promoted the use of clinical practice guide- ated with poor outcomes. Patients may have one or
lines by providers to increase the probability of more chronic conditions, and therefore, the coordi-
improved patient outcomes. Finally, research on nation of patient care is paramount to reduce dupli-
patient outcomes and cost-effectiveness that cover a cative and redundant efforts in disease management
variety of conditions has allowed the development of programs.
effective disease management strategies. The concept of disease management is different
Because of the several forces described above, from that of case management in terms of its strate-
disease management programs have gained popu- gies; however, there are similar shared goals between
larity and have become an accepted method to the two, such as reducing costs and improving
improve the health of populations with chronic patient outcomes through the use of interventions.
conditions. Disease management programs are Whereas case management tends to focus on an
designed to address a group of the population that individual patient for improving a medical condi-
is at risk for chronic conditions. Several aspects of tion on an episodic basis, disease management is
disease management have been around for many population based and is more proactive in its
years in medical practice; however, this strategy as approach. Nursing outreach programs is a strategy
a concerted effort has taken shape only recently. that many disease management programs use to
Disease management programs have not been able provide oversight and support to patients. The nurse
to become organized previously due to the frag- typically serves as a point of contact for the coordi-
mented nature of healthcare, minimal data collec- nation of patient care. Medication compliance is
tion efforts, insufficient information technologies, another example of a disease management initiative
and lack of treatment guidelines. Only recently that was used by pharmaceutical companies to
have disease management programs been able to increase patient adherence to treatment regimens.
accelerate in growth due to the enhancement of The Disease Management Association of
information technology systems, capitation reim- America (DMAA), the organization that represents
bursement that provided financial incentives to be disease management professionals, has identified
cost-effective, improved clinical guidelines, and six components that disease management pro-
increase in outcomes measurement. grams should contain: (1) the identification of
The evolution of disease management programs population processes; (2) clinical guidelines that
is described as maturing in sophistication, starting are evidence based; (3) a collaborative practice
from a program that began with a few services to model that includes self-support providers and the
address chronic disease care to one that focused on physician; (4) patient education focusing on self-
targeting the highest-risk patients with outreach management; (5) performance measures of pro-
and education. This then led to a model with a cesses and outcomes, as well as evaluation and
population-based approach, integrated care, and management; and (6) routine reporting.
the use of evidence-based clinical guidelines, and, The processes of disease management may
finally, to a model that aims to optimize health include self-management practices, patient educa-
through prevention efforts. The promise and tion, and provider training. The disease manage-
potentials of disease management programs include ment model is designed to increase communication
reduction in healthcare costs and improved patient between patients and providers and provide feed-
outcomes. back for necessary behavior modification, as well
as to assess the effectiveness of interventions. This
model, if it is structured properly, includes a com-
Disease Management Concept
prehensive approach to patient care that goes
Disease management has used effective strategies beyond the use of medications.
to improve the health of populations with chronic Some of the chronic conditions that disease
conditions. The aims of disease management include management has been developed for include
asthma, diabetes, heart failure, hypertension, and disease management. By analyzing patient utiliza-
chronic obstructive pulmonary disease. Asthma tion patterns, the Pareto principle generally holds
was one of the first targets that disease manage- that a small proportion of patients account for the
ment practices were developed for because high- vast majority of the total costs. Approximately
cost asthmatic patients are easy to identify, through 20% of patients are responsible for 80% of health-
their medication refills, clinical guidelines, and care expenditures; and therefore, this small group
outcome measures. of patients can be targeted with interventions to
Disease management can be offered through have the greatest impact in reducing costs. Data
different delivery models, such as a contracted can also be analyzed by provider service categories
carve-out model, or as primary-care case manage- to identify trends in utilization and medical costs.
ment (PCCM). In the carve-out model, patients Patient groups can be targeted based on (a) non-
with chronic conditions are cared for by disease compliance of their treatment regimen, (b) a high
management organizations that are contracted by probability of improved health outcomes or poten-
a health plan to provide this service. A managed- tial for intervention, and (c) inappropriate use of
care plan may contract with a disease manage- services and utilization that can be reduced. Patients
ment vendor through competitive bids. Under the from the claims analysis can also be stratified or
PCCM model, a specialized team within a man- selected into specific subgroups based on their
aged-care organization helps the primary-care belonging to certain categories such as Medicaid,
physician to treat patients with chronic condi- Medicare, managed care, or long-term care.
tions. Some early examples of PCCM include
Group Health Cooperative of Puget Sound,
Harvard Pilgrim Health Care, and Kaiser Health Intervention
Plan. The intervention is the central aspect in the
implementation of disease management programs
and entails both provider and patient participa-
Disease Management Design
tion. Disease intervention must include both pre-
There are four main parts that constitute a disease vention and the proper treatment and management
management program: (1) claims data analysis, of the given condition.
(2) population selection and targeting, (3) inter- The intervention goals of the provider are
vention, and (4) quality measurement. These com- implemented in this phase, and education on the
ponents are necessary to achieve lower costs and clinical guidelines, the monitoring plan of the
improved patient outcomes. patient, and the type of feedback that will be given
to the patient are established. Providers are also
made aware of the referral programs and case
Claims Data Analysis
management that are available to patients.
and Population Selection
The intervention targeted at the patient can
The disease management process entails the sub- comprise behavior modification, lifestyle change,
stantial use of data to meet the program goals as well and health education in addition to the use of
as to ensure its effectiveness. Claims data analyses medications. This phase also includes baseline
are used to evaluate which medical condition or con- assessments, risk assessments, feedback on perfor-
ditions are the most costly as well as to determine the mance and outcome goals, education on treatment
prevalence of disease within a given population. compliance, patient outreach, and other case man-
Disease management programs are generally agement activities. The patient intervention may
designed with the intent of improving care while incorporate the use of videos, brochures, and pre-
reducing costs in the long term. Therefore, the next scription reminders to facilitate compliance and
step is to identify the segment of patients with the may also include involvement of the family mem-
identified condition(s) who have the highest cost bers and caregivers. Disease management pro-
and utilization patterns. The results from the claims grams must be reviewed regularly to reflect updated
data analysis can be used to guide the selection of treatment recommendations and clinical guidelines
the patient population that will be targeted for as well as the accepted standard of care.
Disease Management 317
Patients who suffer from an acute episode, such performance measures represent the intermediate
as a heart attack, may also need continuity of care measures of an intervention, they can be used to
to lead to recovery. Aggressive case management predict patient outcomes.
may be used as a disease management tool to plan Finally, outcome measures reflect the end results
and monitor treatment across the different settings of a given intervention. The difficulties with out-
of care. The purpose of case management is to come measures is that outcomes can take a long
prevent complications and reduce the use of costly period to observe and measure and, as a result, are
and inappropriate services. A recovering patient more challenging and costly to obtain. Because
may need rehabilitation services, home health care, outcomes are frequently difficult and expensive to
and other services arranged, and therefore, a measure, performance indicators are generally used
managed-care organization may assign a case to assess the effectiveness of disease management
manager to coordinate these needs. programs. An example of an outcome measure in a
diabetes disease prevention program is the inci-
dence of blindness due to diabetic retinopathy.
Performance Measurement
The growth in the sophistication of information
Measurement Instruments
technology capabilities has allowed disease man-
agement programs to be implemented and evalu- To properly measure if the program is meeting
ated. The advancements in information technology its intended results, appropriate tools or instru-
systems, such as the electronic medical record, ments are needed. Some of the instruments used to
have permitted the measurement and analysis of measure patient outcomes include patient charges,
program performance. utilization of healthcare services, and patients’ gen-
Disease management programs that are success- eral and disease-specific health status.
ful must have a form of quality measurement. It is
essential that disease management programs have
realistic, feasible, and measurable goals for pro- Cost Assessments
gram evaluation. Cost, quality, provider and Disease management programs should assess the
patient satisfaction, and changes in health status total costs associated with the treatment of patients.
should be measured to monitor and evaluate dis- Prior to the implementation of the disease manage-
ease management programs. Measurement is an ment program, the methodologies used should be
important activity to evaluate whether a disease defined, and baseline assessments should be con-
management program is achieving its objectives. ducted to make comparisons after the program
Three specific dimensions of any disease man- implementation. One of the methods most com-
agement program that should be measured to monly used to assess financial outcomes in disease
assess quality improvement of patients are management programs is the total-population
(1) structure, (2) performance (process), and approach. However, the major limitation of this
(3) outcomes. Examples of structural elements are approach is that there is no control group because of
the organizational and administrative coordination the pretest-posttest design that could lead to errors
of patients and the delivery of healthcare services. in measurement. The major challenges that remain
Performance or process indicators include the in evaluating the effectiveness of disease manage-
measurement of performance and comparing it ment programs include accurately determining that
with predefined targets. To have an effective dis- a program is controlling costs and utilization of ser-
ease management program, performance indica- vices in populations with chronic conditions.
tors must be assessed regularly to track the
performance of the program goals and predefined
targets by comparing these results with baseline Reimbursement
measures through the use of benchmarking. An Providers of disease management programs may be
example of a performance indicator in a diabetes reimbursed through several different mechanisms.
disease management program is the tracking of These mechanisms include flat fee, flat fee plus
hemoglobin A1C levels of patients over time. Since incentives, or performance-based reimbursement.
Flat Fee and measurement systems have permitted the devel-

opment of disease management programs. Some of
Flat fee is a reimbursement structure where dis-
the challenges that remain regarding disease man-
ease management vendors or providers are paid a
agement are demonstrating that these programs are
set administrative fee, such as per member per
actually effective in controlling utilization and costs
month (PMPM), to care for a pool of patients.
and improving outcomes of populations with
This fee includes all the administrative expenses
chronic conditions. The tools, technologies, and
related to the pool of patients for disease manage-
methods for disease management programs are
ment activities, but it does not include the costs of
becoming more sophisticated and hold much prom-
direct patient care, such as physician visits or lab
ise and potential for achieving this goal.
tests. Some of the expenses that are covered by the
flat fee include patient education materials, case Jared Lane K. Maeda
management services, tracking and monitoring
patient outcomes, and monitoring patient and pro- See also Case Management; Cost of Healthcare; Disease;
vider compliance with treatment goals. Evidence-Based Medicine (EBM); Medicaid; Medicare;
Primary-Care Case Management (PCCM); Quality of
Healthcare
Flat Fee Plus Incentives
The flat-fee-plus-incentives model includes the
set administrative fee in addition to a financial Further Readings
incentive for disease management vendors or pro- Bodenheimer, Thomas C. “Disease Management:
viders who meet predetermined program objec- Promises and Pitfalls,” New England Journal of
tives. Some examples of these objectives could Medicine 340(15): 1202–5, April 15, 1999.
include decreasing inappropriate emergency room Ellrodt, G., D. J. Cook, J. Lee, et al. “Evidence-Based
utilization and hospitalizations. Under this pay- Disease Management,” Journal of the American
ment mechanism, the disease management organi- Medical Association 278(20): 1687–92, November
zation or provider is not obligated to meet the 26, 1997.
savings goal, and the health plan is placed at finan- Epstein, Robert S., and Louis Sherwood. “From
cial risk if the minimum savings are not achieved. Outcomes Research to Disease Management: A Guide
for the Perplexed,” Annals of Internal Medicine
Performance Based 124(9): 832–37, May 1, 1996.
Huber, Diana L. Disease Management: A Guide for Case
Under the performance-based model, disease Managers. Philadelphia: Elsevier Saunders, 2005.
management organizations are placed at financial Linden, Ariel, and Julia Adler-Milstein. “Medicare
risk of repaying administrative fees to the con- Disease Management in Policy Context,” Health Care
tracted health plan if the minimum savings are not Financing Review 29(3): 1–11, Spring 2008.
attained. Health plans may place participating dis- McAlister, Finlay, Fiona M. Lawson, Koon K. Teo, et al.
ease management organizations at full financial “A Systematic Review of Randomized Trials of Disease
risk if they are not meeting the program objectives Management Programs in Heart Failure,” American
and achieving cost savings that offset the adminis- Journal of Medicine 110(5): 378–84, April 1, 2001.
trative fee costs. Todd, Warren E., and David Nash, eds. Disease
Management: A Systems Approach to Improving
Patient Outcomes. Chicago: American Hospital
Future Implications Publishing, 1997.
Disease management is a strategy that continues to
be evaluated and assessed for its utility. Disease
management programs have increased tremen- Web Sites
dously since the 1990s to address the growing DMAA: The Care Continuum Alliance:
population with chronic illnesses and its associated http://www.dmaa.org
costs. The enhancement and growth of information International Disease Management Alliance (IDMA):
technologies, evidence-based clinical guidelines, http://www.dmalliance.org
Diversity in Healthcare Management 319
National Governors Association (NGA): http://www.nga.org in the field, African Americans held fewer top
National Pharmaceutical Council (NPC): management positions, worked less often in hos-
http://www.npcnow.org pitals, earned 13% less income, and were less
satisfied with their jobs.
In 1997, the Association of Hispanic Healthcare
Executives (AHHE) and the IFDHM joined ACHE
Diversity in Healthcare and NAHSE to repeat the study, this time including
their Hispanic and Asian members. The study found
Management that ethnic and racially diverse managers earned less
than their majority counterparts and felt that they
Diversity in healthcare management is important received less respect than Caucasians from supervi-
to the nation’s healthcare system as a strategy to sors, received less autonomy in doing their work,
advance the effectiveness of healthcare organiza- experienced discriminatory acts in the workplace,
tions and help them achieve greater representation and had to be more qualified than their majority
of underrepresented minorities in leadership, counterparts to get ahead in their organizations.
improve cultural competence, and decrease the In 2003, the survey sponsors conducted a fol-
ethnic and racial disparities that exist in the deliv- low-up study, and many of these findings revealed
ery of health services. There are many definitions in the initial study remained present among ethnic
of diversity. It has been defined as the total collec- and racially diverse managers. In contrast, the
tive mixture, made up of “main” ones and “oth- follow-up study showed that more than 50% of
ers”; it is not a function of race or gender or any the Caucasian members did not feel that diversity
other us-versus-them dyad but a complex and and inclusion were issues and that improvements
ever-changing blend of attributes, behaviors, and were not necessary concerning the lack of qualified
talents. Using this definition as a construct, the minority healthcare leaders. Although some posi-
Institute for Diversity in Health Management tive strides were observed nationally, it was esti-
(IFDHM) states that healthcare organizations rep- mated that less than 2% of all senior healthcare
resent all aspects of society, including—but not executives were ethnic or racial minorities.
limited to—ethnicity, race, national origin, gender,
age, physical ability, sexual orientation, religion,
and family status. Healthcare institutions should Current Situation
be totally inclusive organizations, which value the The ranks of healthcare executives, physicians,
differences in their staffs and recognize that diver- pharmacists, laboratory technicians, and espe-
sity adds value to the organization, its mission, cially nurses are far less diverse than in the general
and the quality of its programs and services. population, and based on statistics from ACHE,
American Hospital Association (AHA), and other
healthcare associations, the mismatch is of stag-
Background
gering proportions. This means, among other
In 1992, the American College of Healthcare things, a lack of role models and mentors for
Executives (ACHE), an international society of members of minority groups, a probable concern
healthcare executives, and the National Association that the chances of advancement in healthcare are
of Health Services Executives (NAHSE), an asso- limited, and the strong possibility that some of the
ciation of African American healthcare executives, healthcare industries’ “best and the brightest” will
conducted a joint study comparing the career seek careers in other areas.
attainment of their members. The study, titled Caucasian men still disproportionately hold the
Racial Comparison of Career Attainment in top jobs in healthcare, and although this is a pat-
Healthcare Management: Findings of a National tern common in almost all areas of American soci-
Survey of African American and Caucasian ety, it has particularly negative implications for
Healthcare Executives, documented that although healthcare. For one thing, prospective healthcare
African Americans and Caucasians had similar leaders may be unwilling to commit to careers in a
educational backgrounds and years of experience field that is unlikely to offer them the opportunity
320 Donabedian, Avedis
to fulfill their potential. For another, succession Administration (AUPHA); Ethnic and Racial Barriers
planning will suffer if current healthcare organiza- to Healthcare; Health Workforce; Nurses; Physicians
tion leaders are not willing or able to broaden the
pool of aspiring executives. In 2002, the IFDHM Further Readings
warned that many healthcare organizations were
struggling with the fact that although they are very Agho, Augustine, and Janice L. Dreachslin, eds. Case
Studies in Diversity: Managing and Educating a
diverse in some areas—housekeeping, food service,
Diverse Healthcare Workforce. Washington, DC:
and plant management, their leadership structure
does not reflect the diversity in their own work-
Administration, 2002.
force. So when potential employees look for role
Grady, Raymond, “The Mandate and Challenge of
models, there are none to be found, so they will Increasing Diversity in Healthcare Management,”
look outside their own organizations for advance- Healthcare Quarterly 5(2): 30–35, Winter 2001–2002.
ment. It is very important for those who want to Graham, Stedman. Diversity: Leaders Not Labels: A New
be the provider—the employer—of choice to have Plan for the 21st Century. New York: Free Press, 2006.
diversity in leadership. Smedley, Brian D., Adrienne Stith Butler, Lonnie R.
Bristow, et al., eds. In the Nation’s Compelling
Future Implications Interest: Ensuring Diversity in the Healthcare
Workforce. Washington, DC: National Academies
Societal trends and a rapidly changing demographic Press, 2004.
picture are forcing many healthcare organizations
to realize that they will have to look for new
insights, examples, and best practices to help them Web Sites
increase diversity. Frequently, they ask themselves
questions regarding how an organization is to suc-
http://www.ache.org
ceed in implementing a diversity program if it does
not know how to build a business case for diver-
Administration (AUPHA): http://www.aupha.org
sity. The business case for diversity is unique to Institute for Diversity in Health Management (IFDHM):
each organization. The circumstance, environment, http://www.diversityinc.com
and community demographics of one organization National Association of Health Services Executives
cannot be generalized to another, and there is no (NAHSE): http://www.nahse.org
one-size-fits-all solution. However, there are some
common elements that should be present in design-
ing a business case for diversity. The key compo-
nents should include the healthcare marketplace,
the available talent, and organizational effective-
Donabedian, Avedis
ness, which are all key drivers for the institutional
Avedis Donabedian (1919–2000) is considered by
investment in—and commitment to—diversity.
many to be the father of quality assurance in
Successful organizations have learned that in
healthcare. Donabedian is perhaps best known for
today’s very dynamic environment, diversity is a
his structure-process-outcome formulation for
competitive advantage for their organizations. For
quality assessment of healthcare. His research and
example, the Fortune Magazine Top 100 Companies
writing created much of the conceptual underpin-
have found that people of color, including women,
nings for quality assessment used today.
bring strategic input to their organizations and
Born in Beirut, Lebanon, in 1919 to an Armenian
generate productive dialogue. Different ethnic and
family, Donabedian earned a bachelor’s degree in
racial groups bring vital, diverse perspectives that
1940 and a medical degree in 1944 from the
help their companies succeed.
American University of Beirut. For a while, he
Rupert M. Evans practiced family medicine in Jerusalem but eventu-
ally left for the United States. He received a mas-
See also American College of Healthcare Executives ter’s degree in public health from Harvard
(ACHE); American Hospital Association (AHA); University School of Public Health in 1955. After
Association of University Programs in Health teaching at several universities, in 1961, Donabedian
Drummond, Michael 321
joined the faculty of the School of Public Health at See also Codman, Ernest Amory; Joint Commission;
the University of Michigan as an associate profes- Medical Errors; Outcomes Movement; Quality
sor of public health economics. In 1966, he was Indicators; Quality of Healthcare; Structure-Process-
appointed professor of medical care organization, Outcome Quality Measures
and in 1979, he became the Nathan Sinai
Distinguished Professor of Public Health. He Further Readings
retired from the university in 1989, although he
continued to consult, teach, and write. Darr, Kurt. “Quality Improvement: The Pioneers,”
Donabedian authored or coauthored 11 books Hospital Topics, 85(4): 35–38, 2007.
and more than 100 journal articles. His seminal Donabedian, Avedis. “The Quality of Medical Care,”
Science 200(4344): 856–64, May 26, 1978.
work was “Evaluating the Quality of Medical Care.”
Donabedian, Avedis. Exploration in Quality Assessment
In it, he introduced the concepts of structure, process,
and Monitoring. Vol. 1, The Definition of Quality
and outcome, which to this day make up the model
and Approaches to Its Assessment. Ann Arbor, MI:
used to evaluate the quality of healthcare. In the
model, structure (e.g., number of hospital beds, staff- Donabedian, Avedis. Exploration in Quality Assessment
ing levels, physician licensing) lays the foundation for and Monitoring. Vol. 2, The Criteria and Standards
process (e.g., medical procedures and surgical opera- of Quality. Ann Arbor, MI: Health Administration
tions), and process leads to healthcare outcomes (e.g., Press, 1982.
complication rates, death rates, length of stays). Donabedian, Avedis. Exploration in Quality Assessment
Other important publications of his included a and Monitoring. Vol. 3, The Methods and Findings of
large, three-volume set titled Exploration in Quality Assessment and Monitoring: An Illustrated
Quality Assessment and Monitoring, Vol. 1: The Analysis. Ann Arbor, MI: Health Administration
Definition of Quality and Approaches to Its Press, 1985.
Assessment, Vol. 2: The Criteria and Standards of Donabedian, Avedis. “The Quality of Care: How Can It
Quality, and Vol. 3: The Methods and Findings of Be Assessed?” Journal of the American Medical
Quality Assessment and Monitoring: An Illustrated Association 260(12): 1743–48, September 23, 1988.
Analysis. His last book was An Introduction to Donabedian, Avedis. An Introduction to Quality
Quality Assurance in Health Care. Assurance in Health Care. New York: Oxford
Donabedian was a member of a number of pres- University Press, 2002.
tigious professional societies. Specifically, he was a Donabedian, Avedis. “Evaluating the Quality of
member of the National Academy of Sciences, Medical Care,” Milbank Memorial Fund Quarterly:
Institute of Medicine (IOM); a fellow of the American Health and Society 44(3 pt. 2): 166–203, 1966.
Public Health Association (APHA); a member of the (Reprinted in Milbank Quarterly 83(4): 691–729,
Association of Teachers of Preventive Medicine; and 2005)
an honorary fellow of the American College of Schiff, Gordon D., and T. Donald Rucker. “Beyond
Structure-Process-Outcome: Donadbedian’s Seven
Hospital Administrators (now the American College
Pillars and Eleven Buttresses of Quality,” Journal
of Healthcare Executives, ACHE).
on Quality Improvement 27(3): 169–74, March
He received numerous awards and honors for
2001.
his work. The University of Michigan established
the Avedis Donabedian Distinguished University
Professorship in his honor in 2000. He was
awarded the Sedgwick Memorial Medal for Web Site
Distinguished Service by the APHA in 1999. The Avedis Donabedian Foundation: http://www.fadq.org
Avedis Donabedian Foundation for the improve-
ment of healthcare was created in Barcelona,
Spain, in his honor in 1989. He was awarded the
Baxter American Foundation Prize for Health
Services Research in 1986. He also received the
Drummond, Michael
first Richard B. Tobins Award from the American
Michael Drummond is a well-known United Kingdom
College of Utilization Review Physicians in 1984.
health economist and an expert in healthcare tech-
Ross M. Mullner nology assessment. Drummond is a professor of
322 Drummond, Michael
economics at the University of York and the for- and more than 500 scientific journal articles on
mer director of that university’s Centre for Health various topics. His most noted book is Methods for
Economics. He is a prolific writer on the economic the Economic Evaluation of Health Care Progammes.
evaluations of healthcare treatments and pro- He also serves on the editorial boards of a number
grams, including the following: care of the elderly, of academic journals, including Pharmacoeconomics,
neonatal intensive care, immunization programs, British Journal of Medical Economics, Journal of
services provided to people with AIDS, eye care Evaluation in Clinical Practice, and the European
problems, and pharmaceuticals. Journal of Health Economics.
Born in 1948, Drummond attended the University In his long career, Drummond has received
of Birmingham and earned a bachelor’s degree in numerous awards and honors. In 2004, he was
industrial metallurgy in 1970 and a master’s degree awarded the Avedis Donabedian Lifetime Achieve
in commerce and business administration in 1972. ment Award by the ISPOR—that organization’s
Drummond originally considered pursuing a doc- highest award. In 2008, he was awarded an honor-
toral degree in industrial relations. However, instead, ary doctoral degree from the City University,
he took advantage of a teaching opportunity in London.
public-sector management at the University of Aston Currently, Drummond continues to work on the
in Birmingham. While teaching a class in quantita- methods and practices of economic evaluations in
tive research administration, he became interested in healthcare. He also chairs a guidelines review
the emerging field of health economics. panel for the United Kingdom’s National Institute
Drummond was a research fellow in health eco- for Health and Clinical Excellence (NICE).
nomics at the University of York from 1975 to
1978. He left to become a lecturer in health services Amie Lulinski Norris
management at the University of Birmingham. After
receiving his doctoral degree in economics in 1983 See also Cost-Benefit and Cost-Effectiveness Analyses;
Health Economics; Pharmacoeconomics; United
from the University of York, Drummond became a
Kingdom’s National Health Service (NHS); United
visiting associate professor in the Department of Kingdom’s National Institute for Health and Clinical
Clinical Epidemiology and Biostatistics at McMaster Excellence (NICE); Williams, Alan H.
University in Ontario, Canada. In 1984, he returned
to the University of Birmingham as a senior lecturer
and assistant director of the university’s Health Further Readings
Services Management Centre. He served as the
director of that center from 1986 to 1990. In 1990, Drummond, Michael F., and Alistair McGuire, eds.
Drummond accepted the position of professor of Economic Evaluation in Health Care: Merging
economics and became the director of the Centre Theory With Practice. New York: Oxford University
for Health Economics at the University of York. He Press, 2001.
Drummond, Michael F., and Anne R. Mason. “European
served as the director of that center until 2005.
Perspective on the Costs and Cost-Effectiveness of
Drummond has served as a consultant to a num-
Cancer Therapies,” Journal of Clinical Oncology
ber of organizations, including the World Health
25(2): 191–95, January 2007.
Organization (WHO). He also was the project leader
Drummond, Michael F., Mark J. Sculpher, George W.
of the European Union Project on the Methodology Torrance, et al. Methods for the Economic Evaluation
of Economic Appraisal of Health Technology. of Health Care Programmes. 3d ed. New York:
Drummond also has served on the board of directors Oxford University Press, 2005.
of the International Society of Technology Assessment
in Health Care (ISTAHC) and was the president of
the International Society for Pharmacoeconomics
Web Site
and Outcomes Research (ISPOR).
Drummond is a prolific researcher and writer. He University of York, Centre for Health Economics (CHE):
has authored or coauthored two major textbooks http://www.york.ac.uk/inst/che/staff/drummond.htm
E
Access to health insurance coverage is driven by
Economic Barriers a number of factors—whether an individual is
to Healthcare employed full- or part-time, whether an employer
offers one or more health insurance plans, whether
Economic barriers to healthcare are economic or an individual qualifies for coverage through
market-based factors that impede an individual’s federal or state programs, such as Medicaid and
ability to access healthcare services. These barriers the State Children’s Health Insurance Program
increase the costs associated with accessing health- (SCHIP), the cost of health insurance premiums,
care and may prevent an individual from obtain- as well as enrollee cost-sharing obligations.
ing necessary preventive, chronic, or acute healthcare.
Economic barriers to healthcare may ultimately
Employer-Sponsored
increase the costs of care from both the individual
Health Insurance Coverage
and the societal perspectives by increasing the
likelihood of an individual becoming ill, increas- In the United States, obtaining health insurance
ing the severity of illness, or both, thereby increas- coverage through an individual’s employer has his-
ing the healthcare resources needed to treat the torically been the most common mechanism for
illness. In addition, by reducing the quality and individuals under age 65, although employment is
quantity of care provided, they decrease an indi- not a guarantee of coverage. When health insurance
vidual’s stock of health capital. Common eco- coverage is tied to employment, recessions and eco-
nomic barriers include lack of access to health nomic booms can have a significant impact on access
insurance coverage and other factors such as out- to employer-based insurance plans for those who are
of-pocket costs and income, among others. Each employed due to the effect on labor markets (e.g., a
of these barriers may interact with others such shift between full- and part-time employment) as
as ethnic and racial, and geographic barriers to well as an employer’s provision of health insurance
healthcare, thereby further intensifying the chal- coverage and its contribution to health insurance
lenges in accessing needed care. premiums. Health insurance coverage is a benefit
provided to employees—in times of economic pros-
perity, robust health insurance coverage may be an
Access to Health Insurance Coverage
important attraction to the firm; in times of eco-
While health insurance coverage is not the only nomic downturn, employers may reduce health
economic barrier to healthcare services, it is one insurance coverage as a means to reduce costs.
of the most important barriers in the United Even when employed, individuals face barriers to
States, and it is closely tied to other barriers. accessing health insurance coverage. For lower-wage
323
324 Economic Barriers to Healthcare
earners, the cost of the health insurance premium may Social Security Disability Income benefits (SSDI).
be unaffordable relative to the wages earned. Premiums Disabled adults enrolled in SSDI must wait
for workers employed less than full-time are often 24 months before receiving Medicare benefits, and
higher than premiums for workers employed full-time. SSDI has strict criteria for eligibility. Low-income
In addition, employers may have a waiting period disabled adults may also qualify for Supplemental
before health insurance benefits are effective. Access to Security Income (SSI) and Medicaid benefits, but
employer-sponsored health insurance coverage is an again, these programs have stringent eligibility
important enough benefit that it is not uncommon for requirements.
individuals to choose to remain employed with a par- Likewise, state programs such as Medicaid and
ticular firm simply to maintain their health insurance SCHIP cover certain groups of low-income indi-
benefits, and this close link between employment and viduals, and eligibility is based on various require-
coverage reduces job mobility. ments, including age; whether the individual is
In employer-sponsored health insurance, pregnant, disabled, or blind; income and assets
employers generally subsidize the cost of the pre- of the individual; and whether the individual is a U.S.
miums, such that employees bear only a portion of citizen or a legal immigrant. As a state-administered
the total premium cost, and since employers may program, each state has its own eligibility and reen-
be able to better spread risk as well as have a rollment requirements (e.g., reenrollment every 6
healthier worker base than that in the general months, 1 year, or 2 years; passive reenrollment vs.
population, aggregate premiums may be lower active reenrollment), which serve as an additional
than those available in the open market. Individuals barrier to accessing health insurance coverage.
who are self-employed can purchase an individual Although an individual gains coverage through a
health insurance policy through the open market; public program, it does not mean that he or she is
however, they bear the full cost of the premium indefinitely guaranteed coverage.
themselves. In addition, health insurance plans
available through the open market often exclude
or increase the cost of premiums for individuals The Uninsured
with preexisting medical conditions or other risk Individuals without health insurance coverage
factors. Even though options are available for self- experience the greatest barriers to accessing the
employed persons, self-employment by itself is a healthcare system. While a safety net of public
barrier to accessing coverage. hospitals, community health centers, and hospital
emergency departments exists, obtaining care
Government-Sponsored through these venues is a challenge. While an indi-
Health Insurance Coverage vidual’s out-of-pocket costs at safety net providers
are minimal, long wait times for medical or surgi-
The federal and state governments offer health
cal services or to obtain medications remain sig-
insurance programs in which individuals must
nificant barriers to care. Safety net providers may
meet specific eligibility requirements to enroll. It is
not have access to the newest and most advanced
a common misperception that all low-income indi-
technology, further limiting access to high-quality
viduals qualify for publicly provided health insur-
care. In addition, service cuts by safety net hospi-
ance coverage. While nearly all adults 65 years of
tals as cost-cutting measures can eliminate access
age or older have access to Medicare coverage,
to certain types of care through these providers.
individuals under age 65 have no guaranteed cov-
erage in the United States. Several government
programs provide coverage to narrowly defined Other Economic Barriers
groups of individuals without access to private
Out-of-Pocket Costs
health insurance coverage, but many individuals
are not eligible for any of these programs. For The out-of-pocket costs of healthcare are an
example, individuals under age 65 with permanent important economic barrier to accessing services,
disabilities may qualify for Medicare. However, regardless of health insurance coverage. Uninsured
Medicare eligibility is tied to the eligibility for individuals have historically been charged more
Economic Barriers to Healthcare 325
for healthcare services than those with health high out-of-pocket costs, and low income—are
insurance coverage, due to the ability of health associated with lower health status and an increased
insurers to negotiate lower rates than those charged risk of mortality.
by healthcare providers. Second, when individuals delay necessary health-
Out-of-pocket costs remain a significant barrier care because of any of these factors, they have an
for many with health insurance coverage. While increased likelihood of exacerbating their current
premium costs are a barrier to accessing health medical condition, becoming ill in the future, and
insurance coverage, demand-side cost-sharing mech- when ill, becoming more severely ill than those
anisms also serve as an additional barrier to insured who obtain needed care on a timely basis. Delays
individuals, once they have coverage. Deductibles, in needed care ultimately drive up healthcare costs
coinsurance, and copayment amounts are designed for both the individual and society more generally.
to discourage unnecessary utilization, thereby reduc- Third, barriers to appropriate primary and pre-
ing ex post moral hazard; however, they also may ventive healthcare services, such as a lack of pre-
be a barrier to obtaining needed care. ventive and primary-care providers in convenient
Health insurance products that shift more risk locations with evening and weekend hours to serve
to the individual enrollee, thereby increasing working people, increase healthcare costs to the sys-
deductibles, coinsurance, and/or copayments, also tem, shifting costs to hospital emergency depart-
increase barriers to healthcare. While premiums ments, which are often already overcrowded as well
may decrease as more risk shifts to the enrollee, as a more expensive delivery setting. Similar effects
the trade-off with an increased risk is larger out- occur with barriers to specialty and subspecialty care
of-pocket payments when healthcare is obtained. but may also increase the need for hospitalization.
While these products are designed to discourage Finally, delays in care that ultimately increase the
unnecessary utilization, they also prevent some total out-of-pocket amount paid by an individual
from accessing needed healthcare. may have a collateral effect of increasing medical
debt, and this medical debt may serve as a barrier
Income to accessing healthcare in the future, either because
individuals do not want to seek care at a provider
While income is an important factor in whether to whom they owe money or because the facility
individuals can afford to enroll in a health insur- will not provide services until the debt is repaid.
ance plan through either their employer or directly
in the open market or qualify for coverage through Future Implications
a public program, income serves as an additional
barrier, independent of obtaining health insurance Expanding health insurance coverage is not a
coverage. Income relates directly to an individual’s guarantee of access to healthcare, nor is it the
direct ability to pay the out-of-pocket costs of single solution to eliminating economic barriers to
healthcare services (or pay the coinsurance or healthcare more broadly. Even with public insur-
deductible for healthcare services). In addition, ance coverage, low-income individuals continue
income may be a barrier in accessing healthcare to face barriers to accessing the healthcare system.
due to the travel costs associated with getting to a The availability of healthcare providers who
provider. While a sufficiently low income may help accept patients with Medicaid or SCHIP coverage
qualify some individuals for publicly provided in some geographic areas, for example, limits
health insurance coverage, other economic barriers access. In addition, even with public insurance
related to having a low income may still prevent an coverage, having a low income makes it more dif-
individual from obtaining needed care. ficult to travel to a provider and to the extent that
lower-income individuals work in jobs that are
less flexible, for example, they face greater finan-
Implications
cial costs when seeking medical care due to the
The implications of these economic barriers that need to take vacation or sick or unpaid time from
reduce access to healthcare services are enormous. work to see a healthcare provider. In addition,
These barriers—a lack of health insurance coverage, individuals with health insurance coverage face
326 Economic Recessions
increasing out-of-pocket costs for healthcare, Committee on the Consequences of Uninsurance,

which affects not only lower-income individuals Institute of Medicine. Coverage Matters: Insurance
but also those in the middle-income bracket. and Health Care. Washington, DC: National
Healthcare reform proposals aim to increase Academies Press, 2001.
health insurance coverage to a larger group of indi- Daly, Hugh F., Leslie M. Oblak, Robert W. Seifert, et al.
viduals, either through a single-payer system or “Into the Red to Stay in the Pink: The Hidden Cost
through a combination of private and public health of Being Uninsured,” Health Matrix 12(1): 39–61,
insurance plans, and these plans may expand cov- Winter 2002.
Daschle, Thomas, Scott S. Greenberger, and Jeanne M.
erage, particularly for lower-income adults and
Lambrew. Critical: What We Can Do About the
children who did not previously qualify for federal
Healthcare Crisis. New York: Thomas Dunne Books,
or state programs and lower-income workers who
2008.
could not otherwise afford healthcare coverage.
DeVoe, Jennifer E., Alia Baez, Heather Angier, et al.
While expanding health insurance coverage will “Insurance Plus Access Does Not Equal Health Care:
reduce one barrier, other barriers will continue to Typology of Barriers to Health Care Assess for Low-
persist without targeted interventions. Society is Income Families,” Annals of Family Medicine 5(6):
not one of limitless resources—healthcare costs 511–18, November–December 2007.
have historically served as a mechanism to ration
healthcare. Increasing health insurance coverage
through the expansion of public programs, such as Web Sites
Medicaid and SCHIP, for example, to a broader
range of low-income adults and children will America’s Health Insurance Plans (AHIP):
increase coverage but does not guarantee access to http://www.ahip.org
care. Policymakers must also consider how to Center for Health Systems Change:
http://www.hschange.org
ensure an adequate supply of healthcare providers
Commonwealth Fund: http://www.commonwealthfund.org
who are geographically distributed in order to pro-
vide easy access to enrolled individuals. The inter-
http://www.kff.org
relation among economic and noneconomic
U.S. Census Bureau: http://www.census.gov
barriers to care must be considered in concert to
ensure that solutions to reduce one barrier do not
exacerbate barriers to care in other ways. Changes
to the financing of healthcare, for example, must
be considered in light of the effects on access to
Economic Recessions
care. When considered as a system, long-lasting
solutions to these barriers can be designed and Economic recessions periodically occur in all the
implemented. world’s economies. Despite the importance of
recessions, there has been relatively little conclu-
Tricia J. Johnson, Heather Forst, sive research conducted on their impact on a popu-
and Anjali Kartha lation’s health and healthcare providers. Those few
researchers who have studied the issue tend to
See also Access to Healthcare; Coinsurance, Copays, and break into two camps. In the one camp, econo-
Deductibles; Cost of Healthcare; Ethnic and Racial mists and public health researchers argue that
Barriers to Healthcare; Geographic Barriers to recessions and health are countercyclical; that is,
Healthcare; Health Insurance; Medicaid; Uninsured as the economy deteriorates, more individuals
Individuals
become ill and seek out healthcare services thereby
placing a strain on healthcare providers. In con-
trast, researchers in the other camp argue that
Further Readings recessions and health are procyclical; that is, as the
Aday, Lu Ann. “Economic and Noneconomic Barriers to economy deteriorates, fewer individuals have
the Use of Needed Medical Services,” Medical Care the economic resources to pursue unhealthy behav-
13(6): 447–56, June 1975. iors such as overeating, smoking, and consuming
Economic Recessions 327
alcohol, which lead to improved health and government to investigate disease occurrences were
decreased healthcare utilization. Both camps study related to the need to contain serious infectious
the issue by focusing on mortality data and/or diseases, such as smallpox, diphtheria, and yellow
healthcare utilization data. fever. To this was added the goal of studying the
distribution of diseases. In their focus on patients
as individuals, practicing physicians are likely to be
Definition of Economic Recession relatively unconcerned with their role in contribut-
Economic recession is defined in macroeconomic ing to a community-wide network of information
theory as two or more calendar quarters of con- about disease. However, through the use of medical
secutive decline in a nation’s gross domestic prod- billing data, the incidence of disease across net-
uct (GDP). The National Bureau of Economic works can be determined as patients present to
Research (NBER) more broadly defines recession healthcare facilities. Morbidity can therefore be
as a significant decline in economic activity spread analyzed by studying utilization of healthcare ser-
across the economy, lasting more than a few vices and can be a useful measure of the effects of
months. Recession may also have accompanying unemployment on a population’s health over time.
declines in employment rates, among other mea-
sures of a nation’s economic health such as busi-
ness profitability, stock market performance, and Healthcare Utilization
inflation. The analysis of the effects of economic recession
on the utilization of healthcare services generally
focuses on inpatient hospitalization but may also
Definition of Health
include an analysis of outpatient services. Inpatient
and Healthcare Measures
hospitalization (generally defined as an overnight
The study of economic recession effects on a stay in a hospital for more than 24 hours) analysis
population’s health includes the analysis of aggre- is more common given that data are uniformly and
gate health outcome statistics, such as the overall consistently gathered by hospitals through federal
population mortality and disease-specific mortal- requirements for participating in the Medicare
ity and morbidity. Most researchers have studied program. Data are captured in a uniform billing
the relationship of unemployment and popula- (UB) data set made available to researchers and
tion health using mortality data, while few have practitioners typically through state public health
studied the relationship of unemployment and departments or hospital associations. Outpatient
morbidity. data are less reliably captured and inconsistently
reported on and therefore are not well suited for
health services research.
Mortality and Morbidity
Mortality, a commonly used public health
Health Problems and Economic Recession
index, is a very crude measure of the health of a
population. The crude death rate is calculated as One of the first researchers to study the relation-
the total number of deaths in a year for a geo- ship between unemployment and health in the
graphic area divided by the average midyear pop- United States was M. Harvey Brenner. In the late
ulation expressed per 1,000 people. There are 1960s, Brenner studied the effect of economic
many ways to refine mortality rates, including change on the patterns of psychiatric hospitaliza-
adjusting for the population’s age (age-specific tions and psychopathological conditions in gen-
death rate), causes of death (cause-specific death eral. He initially studied the effects of economic
rate), and the period around birth (e.g., infant change on the mental hospitalization levels of
mortality rate, neonatal mortality rate, maternal various socioeconomic groups. Brenner found
mortality rate). that it was not necessarily the traditional poor
In the study of morbidity, defined as the relative alone who became psychiatric victims of precipi-
incidence of disease, the earliest attempts by tating economic stress—under sufficient economic
328 Economic Recessions
pressure, members of all socioeconomic stratum associated with the risk behavior increases. So, for
responded in terms of mental hospitalization. example, as more consumers smoke because they
Hospital utilization—a surrogate for the incidence have the resources to do so, the incidence of lung-
of disease or morbidity—in the larger population, related cancers increases over time. Or, similarly,
therefore, increased during times of increasing as more people consume more alcoholic beverages
unemployment and declining gross domestic prod- and drive automobiles, the incidence of motor-
uct growth. As unemployment increased, the inci- vehicle-related fatalities increases.
dence in job-loss related stress and macroeconomic In this relationship, the total mortality rate, age-
stressors increased, thereby increasing the utiliza- specific mortality rates, as well as most specific
tion of mental health services. mortality causes are procyclical or increase during
Economic recession appears to increase the times of economic expansion. Fixed-effect models
probability of a variety of losses and social changes are estimated using longitudinal data, with health
that potentially threaten health in at least three proxied by total and age-specific mortality rates
ways: Poverty or lack of material resources to meet and 10 specific causes of death. The 10 causes of
the ordinary requirements as well as the extraordi- death included cancer (malignant neoplasms),
nary problems of life can affect many of the unem- heart disease (cardiovascular diseases), pneumonia
ployed and others who experience financial loss; and influenza, chronic liver diseases, motor vehicle
the psychological stress associated with financial accidents, suicide, homicide, other accidents, neo-
loss is potentially damaging itself, especially if it natal mortality (death within 28 days after birth),
leads to withdrawal and the loss of potentially and infant mortality. These 10 conditions accounted
beneficial relationships; and attempts to alleviate for approximately 80% of all mortality in the
psychological distress by medicating with alcohol United States, on average. In addition, microdata
or legal and illegal drugs, by overeating or under- from the Behavioral Risk Factor Surveillance
eating, or by smoking tobacco will tend to exacer- System (BRFSS) were used to examine how risky
bate existing morbidity and produce additional behaviors and time-sensitive health investments in
health problems. physical activity, diet, and preventive medical care
In a more recent mental health example, there is vary with the status of the U.S. economy.
an emerging area of research related to the post- It was found that health improves when the
9/11 terrorist attack on New York City’s World economy temporarily declines—state unemploy-
Trade Center and healthcare utilization. In a pub- ment rates are negatively and significantly related
lic health phenomenon that may be described as to total mortality in 8 of the 10 specific causes of
posttraumatic stress, for weeks after the attack, mortality, with suicides representing an important
residents in New York City and other cities in the exception. The variation in death rates is strongest
nation went to hospital emergency departments in for those causes and age groups where fluctuations
increasing numbers with stress-related diagnoses. are most plausible, and there is some evidence that
the unfavorable health effects of temporary upturns
in the economy are partially or fully offset if the
Health Benefits and Economic Recession
economic growth is long lasting. Consistent with
Recent research conducted by Christopher J. these results, the microdata revealed that jobless-
Rhum and others suggests that health may actu- ness is associated with reduced smoking and obe-
ally improve during times of increasing unemploy- sity, increased physical activity, and improved
ment and declining GDP growth. The driving diet. The number of medical problems, the preva-
macroeconomic theory is that during times of eco- lence of acute morbidities, and the number of
nomic expansion, as relatively more consumers reported inpatient bed-days decreased during eco-
enjoy larger amounts of disposable income, con- nomic recessions. A 1-percentage-point rise in a
sumers assume greater amounts of risk-associated state unemployment rate, relative to its historical
buying behavior. Examples include purchasing average, is associated with a 0.5% to 0.6%
luxury automobiles, smoking, and consuming decrease in total mortality; Rhum therefore con-
alcoholic beverages. When this phenomenon cludes that economic recessions are “good for
occurs, the incidence of health-related problems your health.”
Economic Recessions 329
Effects of Health Insurance evidence for the negative effects of unemployment

on Economic-Related Mortality on some health aspects for at least some people.
The public-policy implications of the research
There are differences across social insurance sys-
indicate a focus on how the negative impact of
tems where stronger procyclical fluctuations might
economic upturns on mortality rates can be miti-
occur in nations with relatively weak social pro-
gated, if not avoided. These questions have pro-
tections if individuals have incentives to work
found implications for the development of national
particularly hard during good economic times to
policies that influence economic expansion/
offset the effects of reduced incomes during
recession and, by relation, those that influence the
downturns. Conversely, an employment-based
health of the population. Clarifying the relation-
system of health insurance, such as in the United
ship between economic downturn and the effect
States, may imply higher rates of insurance cover-
on the healthcare delivery system as a whole is also
age during macroeconomic expansions. It has
of utmost importance. If patterns of healthcare
been shown that procyclical fluctuations in mor-
utilization change as a result of economic reces-
tality are much stronger in nations with weak
sion, healthcare delivery systems must adjust to
social insurance programs. These results occur
meet either increasing or decreasing demand for
despite a protective effect of income, which, not
services.
surprisingly, is more pronounced in nations with
Although the evidence is far from conclusive,
weaker social safety nets.
recent research appears to show that there is a
procyclical relationship between recession and
The Underemployed health and that mortality decreases during eco-
nomic downturns. However, much more research
There is another group that is affected by eco- needs to be conducted to address the specific rela-
nomic change—the underemployed. Underem tionships for particular diseases and various popu-
ployment is defined as the condition in which lation groups, including those who are insured,
people in a labor force are employed at less than underinsured, and underemployed.
full-time or regular jobs or at jobs inadequate with
respect to their training or economic needs. Most Edward M. Rafalski
studies on the relationship between unemploy-
See also Access to Healthcare; Community Health;
ment status and health have contrasted just two
Economic Barriers to Healthcare; Epidemiology; Health
conditions, employment versus unemployment.
Economics; Morbidity; Mortality; Public Health
Because the underemployed share some of the
more stressful features of unemployment, such
as decreased income, status, or time structure, it Further Readings
seems plausible that they could produce adverse
effects on health similar to those reported for Brenner, M. Harvey. “Patterns of Psychiatric
unemployment. Hospitalization Among Different Socioeconomics
Groups in Response to Economic Stress,” Journal of
Nervous and Mental Disease 148(1): 31–38, January
Future Implications 1969.
Dooley, David, Karen Rook, and Ralph Catalano.
The question of whether health and healthcare “Job and Non-Job Stressors and Their Moderators,”
utilization is influenced by economic fluctuations Journal of Occupational Psychology 60(2):
is of significant interest from a number of perspec- 115–32, 1987.
tives. The importance of clarifying the relationship Gerdtham, Ulf G., and Christopher J. Rhum. “Deaths
between economic recession, individual health, Rise in Good Economic Times: Evidence From the
and the health of populations is foremost among OECD,” Economics and Human Biology 4(3):
them. It is possible that a recession lowers the mor- 298–316, December 2006.
tality risk for some individuals while worsening Rafalski, Edward M. The Effects of Economic Recession
the health status of other individuals, but short of on Emergency Department Utilization. PhD. diss.,
increased mortality. This need not contradict the University of Illinois at Chicago, 2007.
330 Economic Spillover
Rhum, Christopher J. “Are Recessions Good for Your immunization prevents or reduces the risk of an
Health?” Quarterly Journal of Economics 115(2): individual contracting a disease, it has an additional
617–50, May 2000. benefit of protecting the immunized individual from
Rhum, Christopher J. “A Healthy Economy Can Break spreading the disease to other members of society.
Your Heart,” Demography 44(4): 829–48, November When an individual makes a decision about whether
2007. to obtain an immunization, however, he makes this
decision based on his marginal cost of the immuni-
zation compared with his marginal benefit of pre-
Web Sites venting himself from contracting the disease. Because
Behavioral Risk Factor Surveillance System (BRFSS): spreading the disease to others bears no cost to the
http://www.cdc.gov/BRFSS individual, it is not a factor in his decision. From
Bureau of Labor Statistics (BLS): http://www.bls.gov the societal perspective, too few people will obtain
Centers for Medicare and Medicaid Services (CMS): immunizations if they bear the full cost.
http://www.cms.hhs.gov An example of a negative externality relates to
National Bureau of Economic Research (NBER): smoking. Smoking generates secondhand smoke,
http://www.nber.org which imposes health costs on others. The smoker,
National Center for Health Statistics (NCHS): however, does not bear the health costs borne by
http://www.cdc.gov/nchs others. Another type of consumption externality
exists if one individual’s utility or satisfaction
depends on another individual’s utility. Individuals
may, for example, benefit from knowing that
Economic Spillover everyone in society has access to healthcare.
Medical education provides another positive
Economic spillover, also referred to as an external- externality to society, because a community bene-
ity, is a cost or benefit that is created by an individ- fits from the human and health capital generated
ual or a firm that also affects other parties in a way by physicians. Medical education is often heavily
that is not captured by the price, or that spills over subsidized. For example, Medicare subsidizes
to other consumers or producers. Economic spill- teaching hospitals through graduate medical edu-
over is often classified as either a consumption or a cation and disproportionate share payments,
production externality. A consumption externality decreasing a teaching hospital’s marginal cost of
is associated with the consumption of a good or training residents and ultimately increasing the
service that creates costs or benefits for other mem- number of residents trained.
bers of society, and a production externality is asso-
ciated with the production of a good or service that Research and Development
creates costs or benefits for other members of soci-
Research and development also generate exter-
ety. Externalities may be positive, generating bene-
nalities in society. Research increases the overall level
fits for other consumers or producers, such that the
of knowledge in society, and often, the results of
societal benefits of the transaction are greater than
research created by one individual or firm are freely
the private benefits borne by the producer or con-
used by other entities. Without government grants
sumer. They may also be negative, generating costs
and subsidies to encourage research and develop-
for other consumers or producers, such that the
ment, too little research would likely be generated,
societal costs are greater than the private costs
since the individual or firm creating the new knowl-
borne by the individual producer or consumer.
edge does not reap all the benefits of the research.
Examples of Externalities in Healthcare

Problems With Externalities
General Examples of Externalities
Externalities are a concern for healthcare, because
Examples of externalities abound in the health- they can result in a market failure, a situation
care market. The market for immunizations is where too many or too few goods or services are
one example of a positive externality. While an produced relative to the socially optimal quantity.
Economies of Scale 331
Consumers and producers make decisions based A large number of positive and negative exter-
on their own private costs and benefits, not the nalities have existed and will continue to exist in
societal costs and benefits that accrue to others. healthcare. While an externality can lead to market
Without market interventions, the quantity of a failure, a situation where goods or services are not
good or service with significant externalities will allocated efficiently, solutions exist to mitigate these
not be socially optimal. That is, too much or too challenges when the externality is sufficiently large.
little of the good or service will be produced.
With a positive externality, consumers or pro- Tricia J. Johnson and Molly Higham
ducers will underconsume or underproduce the See also American Society of Health Economists (ASHE);
good or service, since their decisions fail to take Health Economics; International Health Economics
into account the societal benefits due to spillover Association (iHEA); Market Failure; Public Health;
to others in the market. Similarly, with a negative Tobacco Use
externality, consumers or producers will overcon-
sume or overproduce the good or service.
Further Readings
Solutions to Externality Problems
Baker, Laurence C. “Managed Care Spillover Effects,”
Externalities exist because of the lack of well- Annual Review of Public Health 24: 435–56, 2003.
defined property rights. With smoking, smokers Coase, Ronald H. “The Problem of Social Cost,” The
claim that they have the right to smoke, while Journal of Law and Economics 3:1–44, 1960.
nonsmokers claim that they have the right to Hurley, Jeremiah. “An Overview of the Normative
clean air. The government may step in and assign Economics of the Health Sector.” In Handbook of
property rights to one party or another. In the city Health Economics, vol. IA, edited by Anthony J.
of Chicago, for example, an ordinance was passed Culyer and Joseph P. Newhouse. Amsterdam, the
that bans smokers from smoking in restaurants Netherlands: Elsevier Science, 2000.
and bars, assigning property rights to nonsmok- Pauly, Mark V., and Jose A. Pagan. “Spillovers and
ers (i.e., the right to clean air while dining in a Vulnerability: The Case of Community Uninsurance,”
restaurant). Health Affairs 26(5): 1304–14, September–October
In addition to the government assigning prop- 2007.
erty rights, another common solution in healthcare Wang, Richard Y., and Mark V. Pauly. “Spillover Effects
of Restrictive Drug Formularies: A Case Study of
is to develop mechanisms for the externality to be
PacifiCare in California,” American Journal of
“internalized,” where the consumer or producer
Managed Care 11(1): 24–26, January 2005.
incorporates the external costs or benefits into the
private costs or benefits. Taxes and subsidies as
well as patents are common strategies to internal-
Web Sites
ize the social costs or benefits. With positive exter-
nalities, producers or consumers may be given a American Economic Association (AEA):
price subsidy to increase the marginal benefit of http://www.vanderbilt.edu/AEA
producing or consuming the good, paid by those American Society of Health Economists (ASHE):
who receive a benefit from the externality, and http://healtheconomics.us
increasing the quantity bought and sold. Likewise, International Health Economics Association (iHEA):
one solution to negative externalities is to tax the http://www.healtheconomics.org
producer or consumer of the externality, increasing World Health Organization (WHO): http://www.who.int
the marginal private cost of producing or consum-
ing the good or service that generates the external-
ity. It is important to note, however, that a tax
levied on the producer generally is not borne
Economies of Scale
entirely by the producer but instead is shared by
the producer and consumer. The price elasticities The notion of economies of scale in the production
of demand and supply determine the proportion of healthcare goods and services is central to under-
borne by each party. standing competitive forces, the diffusion of medical
332 Economies of Scale
technologies, the quality of care, and regulation in states’ certificate of need (CON) laws, designed to
the healthcare industry. Economies of scale are contain costs by avoiding extensive duplication of
present when larger-scale operations lead to reduc- services and redundant hospital capacity.
tions in average operating costs. Likewise, if an Studies investigating the possible existence of
increase in cost due to an increase in all inputs economies of scale in hospitals find mixed results.
causes the output to rise more than proportionally, In part, this could be related to the large variety
economics of scale are said to exist. of services offered by individual hospitals or to
A distinction is made between internal and demand conditions, such as transportation costs,
external economies of scale. When a company’s that limit the economies of scale that can be real-
production process is such that as the number of ized. However, studies that focus on individual
units produced rises, the average cost of each unit services characterized by high fixed costs, such as
falls, internal economies of scale have been open-heart surgery facilities, CT scanner units, and
achieved. In contrast, external economies of scale therapeutic radiology facilities, often find evidence
occur outside a firm, within an industry. For of economies of scale.
example, sharing technology, managerial expertise, Scale economies are not limited solely to provid-
and the creation of industry standards of health- ers. Payers face long-run average costs, which
care may lessen the burden of costly inputs. It is incorporate capital, and other fixed set-up costs.
important to note that economies of scale can exist High start-up costs in the insurance industry
with respect to the physical quantity of a good, the require many subscribers to cover those costs. The
number of patients served, or the quality of the flip side is, of course, that high set-up costs repre-
good or service. sent barriers to entry, which inhibit competition.
Firms in industries exhibiting economies of scale
therefore tend to have market power.
Economies of Scale in Healthcare Economies of scale are among the economic
There are several avenues through which econo- benefits that hospitals can reap by joining multi-
mies of scale are achieved. These include the fol- hospital healthcare systems relative to being free-
lowing: high fixed costs of production, improved standing facilities. Some of these cost advantages
bargaining power for inputs, organizational stem from improved access to capital, while others
design, coordination, and specialization. These are the result of better bargaining power versus
factors and their applicability to the healthcare insurers, referring physicians, and patients. Larger
industry are discussed below. companies can buy supplies in bulk and centralize
administrative functions as well as training and
maintenance. With a larger scale of production, a
Hospitals company may also apply better organizational
skills to its resources—such as hospitalists, physi-
Economies of scale are most likely to be found cians who specialize in the management of patients
in industries with large fixed costs in production. who are hospitalized. Clinical studies show that
Fixed costs are those costs that must be incurred hospitalists helped contain hospital costs without
even if production were to drop to zero. In the compromising on quality of care.
extreme case, high fixed costs could lead to a natu-
ral monopoly situation, in which the most efficient
Group Practices
(least costly) market structure would be to have
only one firm providing a particular kind of good Similarly, group medical practices have occa-
or service. In the long run, economists expect only sionally been touted as organizations that should
one firm to “naturally” survive even in the absence yield considerable economies of scale and thus
of legal regulations. Yet, in a world where the rate help raise output while moderating total costs.
of technological change is extremely high, one Taking advantage of scale economies may explain
cannot rule out a situation in which multiple firms the shift from sole to group practice. By pooling
are providing the good or service; even this would inputs such as offices, equipment, and administra-
be less efficient than a single firm providing the tive resources, physicians could increase their pro-
good or service. This is part of the rationale behind ductivity while lowering their costs.
E-Health 333
Technology Addiction Treatment,” Journal of Substance Abuse

Treatment 31(3): 255–65, October 2006.
Finally, the notion of economies of scale, which Gaynor, Martin, Harald Seider, and William D. Vogt.
speaks to the behavior of costs, is closely related to “The Volume-Outcome Effect, Scale Economies and
the notion of returns to production, which describes Learning-by-Doing,” American Economic Review
technology. For example, if a technology exhibits 95(2): 243–47, May 2005.
increasing returns to production, doubling inputs Preyra, Colin, and George Pink. “Scale and Scope
will more than double output. Since doubling Efficiencies Through Hospital Consolidations,”
inputs doubles the cost, average costs (i.e., cost Journal of Health Economics 25(6): 1049–68,
divided by output) will fall, hence economies of November 2006.
scale are achieved. Wholey, Douglas R., John Engberg, and Cindy Bryce. “A
Descriptive Analysis of Average Productivity Among
Health Maintenance Organizations, 1985 to 2001,”
Volume-Outcome Relationship Health Care Management Science 9(2): 189–206,
The division of labor and specialization are two May 2006.
key means of achieving increasing returns to pro-
duction. This is especially important in healthcare,
where, to improve the skills necessary to perform Web Sites
their jobs, physicians and other healthcare profes- American Economics Association (AEA):
sionals need to concentrate on a narrow set of http://www.vanderbilt.edu/AEA
specific tasks. These tasks can then be performed American Society of Health Economists (ASHE):
better and faster. Hence, through such efficiencies, http://healtheconomics.us
time and money can be saved and production International Health Economics Association (iHEA):
levels increased. http://www.healtheconomics.org
For instance, there is evidence of lower mortal-
ity rates in hospitals that perform more of a given
procedure. This may be a demand phenomenon,
whereby high-quality hospitals attract more E-Health
patients, or a supply phenomenon, whereby quali-
ty-enhancing scale economies cause large hospitals
E-health is a broad term for the diverse, evolving
to provide better quality of care. Therefore, scale
digital resources and practices that support health
economies can arise at the individual physician
and healthcare, with the Internet and its applica-
level, as learning-by-doing affects the cost struc-
tions at its core. Definitions of e-health vary greatly
ture the individual hospital faces.
depending on its uses, stakeholders, and target
The proponents of specialty hospitals, for exam-
areas. Some researchers define e-health as the use
ple, assert that their “focused factory” approach
of emerging information and communication
enables these facilities to enjoy positive returns to
technology, especially the Internet, to improve or
experience in the production of quality, thus lead-
enable health and healthcare. Other researchers use
ing to improved efficiency and outcomes along
a broader definition, defining e-health as including
with reduced costs.
medical informatics, public health, and business,
Guy David and Tanguy Brachet referring to health services and information deliv-
ered through the Internet and related technologies.
See also Certificate of Need (CON); Focused Factories; In a broader sense, the term characterizes not only
Health Economics; Hospitalists; Medical Group a technical development but also a state of mind, a
Practice; Multihospital Healthcare Systems; way of thinking, an attitude, and a commitment to
Volume-Outcome Relationship
networking and global thinking.
Further Readings Background

Corredoira, Rafael A., and John R. Kimberly. “Industry The e-health revolution was ignited by the advent
Evolution Through Consolidation: Implications for of Internet technology and its numerous ramifications
334 E-Health
in the late 20th century, along with the recogni- Uses

tion of the advantages to adapting and adopting it
in healthcare delivery and research. It encom- E-health is not confined to healthcare delivery; it
passes applications in the domains of public health, also applies to public health governance, finance,
preventive medicine, patient diagnosis, manage- education, research, and health-related economic
ment and care, consumer-oriented health aware- activities. Electronic media are increasingly used
ness, healthcare business management, professional for dissemination of information for public health
clinical informatics, electronic clinical records, promotion and awareness, medical education,
consumer health informatics, and health policy promotion of biomedical research and evidence-
formulation and implementation. E-health is an based medicine, and e-learning for healthcare
effective, fast, and convenient medium for local professionals. Health information systems are
and global education and communication on used in disease surveillance; for maintaining data-
health, healthcare delivery, health administration, bases for research and administration; and in
and health policy issues. The backbone of e-health financial, management, monitoring, evaluation,
is a combination of the computer and the Internet, and logistical applications pertaining to health-
along with a number of technologies dependent care. In health research, electronic databases such
on—or related to—their use, including, but not as population registers have galvanized epidemio-
limited to, interactive communication via the logical research, with immense value for health
World Wide Web, satellite connections, digital policy formulation. Informatics tools are used
TV, health kiosks, wireless networks, palm tech- to guide the selection of appropriate and cost-
nologies, CD-ROMs and DVDs, virtual reality effective priorities for policymakers. Geographical
(i.e., for remote/intercontinental surgery), and information systems are gaining popularity as
nanotechnology. tools for spatial projection and mapping of health
Numerous stakeholders are involved in e-health concerns to help in making policy decisions and
supply and use: consumers, advocacy and not-for- targeting outreach initiatives. In the field of
profit health organizations, community-based clinical medicine and patient care, e-health has
organizations, healthcare organizations such as made enormous strides, particularly in developed
hospitals and clinics, the health insurance industry, nations, where capacity exists to support such
healthcare administrators, clinicians, developers applications. Healthcare delivery technologies
and suppliers of e-health applications, public support diagnostics, health decision support sys-
health programs, and public and private health tems, treatment, electronic clinical communica-
policymakers and funders. The main purpose of tions tools (e-bookings, referrals, and discharges),
e-health is to provide more efficient, cost-effective, electronic networks, telemedicine, teleconsulta-
convenient, interactive, interconnected, evidence- tion, telesurgery, robotic surgery, and electronic
based services that benefit all parties involved. medical records, among other rapidly expanding
Most e-health tools are designed for specific options. The pharmaceutical and nursing fields
functions serving defined groups of people at the are also using systems tailored to their needs.
individual, organizational, or population level, with In the field of health education (e-learning),
some overlap. Personal health functions may include e-health technologies have opened up avenues for
the provision of health information, promotion of instant global exchange of health information and
behavior change or prevention strategies, provision education at little cost. This has enabled develop-
of resources for self-management of health, and ing countries to access evidence-based health inter-
formation of online communities and support ventions and research in order to guide their
groups. In healthcare provision and administration, own programs for improving population health.
tools are used for disease management, decision- Applications include tools for cognitive learning,
making support, personnel and financial manage- computer-aided instruction and training, continu-
ment, maintenance of electronic clinical records, ing education, and distance learning. The creation
transmission and sharing of health data and reports, of digital libraries has revolutionized health
and creation of interconnected networks that stream- research and learning by bringing expensive books
line healthcare delivery in a cost-effective manner. and journals into the home and office at little or no
E-Health 335
cost. The creation of digital knowledge bases and oriented, so a shift to providing consumer-friendly
online dissemination of health education has broad- applications may portend a wider adoption of
reaching applications in the public health sector as health technologies.
well as in consumer health education. Healthcare business intelligence and predictive
The concepts of consumer e-health and personal modeling are important applications of e-health.
health management are being promoted by health E-health provides support to clinical, financial, bud-
policymakers and thought leaders to enable people getary, and forecasting decisions based on realistic
to be responsible for their own health, signifying a and accurate predictive modeling. It enables a self-
shift away from the traditional paternalistic pat- service type of reporting for external and internal
tern of healthcare delivery. As these technologies clients and organizations. In the public health sec-
are becoming more widespread, more people are tor, systems are used to evaluate population health
using them to make informed, independent deci- status and develop, disseminate, and evaluate health
sions on how, when, where, and why to access promotion and disease management interven-
healthcare that is convenient, reliable, and afford- tions. For example, applications provide HEDIS
able or to adopt healthy behaviors. The most com- (Healthcare Effectiveness Data and Information Set)
mon tools are personal health records, patient quality and performance measurements for various
portals, and secure patient-physician e-mails. These public health programs and insurance companies.
can become important tools in promoting per- They can be used for conducting cost-benefit analy-
sonal, community, and population health. sis of alternative strategies and helping choose the
Interactive health communication (IHC) allows best option. Technology is used extensively in main-
individuals with an electronic device or communi- taining data warehouses for health statistics that
cation technology to access, transmit, or receive guide health policy and planning in both the public
health information, treatment guidance, or sup- and the private sectors. Software is used that enables
port on an issue related to their health. This con- accurate and credible budgeting and forecasting
sists mostly of Web sites or technology-mediated based on actual, predicted, and adjusted measures
applications that promote self-care and healthy of utilization and costs; reduces fraudulent or inap-
behaviors, enable individuals to make informed propriate claims billing and eligibility; and can be
decisions on health issues, promote exchange of used for predicting future requirements and short-
information, or allow remote access to physician falls. Excellent tools are available for human resource
care. The application permits improved individual management in the healthcare arena, and they are
access to specific health information, gives wider increasingly being used to improve efficiency and
choice in seeking and comparing treatment cost savings.
options, promotes user anonymity, and supports
wider group involvement in health concerns and
Telemedicine
advocacy. Another advantage is the capacity for
instant updates on recent advances. However, Telemedicine, the first and oldest form of e-health,
research on the quality or effectiveness of such is the interface of medicine and information and
approaches is still in its infancy. Preliminary communication technologies for delivery of health-
research has revealed a low level of use and sig- care services where distance is a critical factor.
nificant disparities in access to the socially disad- Telemedicine applications are making rapid strides
vantaged and in ethnic and racial minorities, even in the fields of emergency healthcare, homecare,
if access is similar. Possible explanations for these patient telemonitoring and a variety of clinical
disparities in use include differences in the quality fields such as teleradiology, -cardiology, -pathol-
or speed of the Internet connection; the percep- ogy, and -surgery. They are used to provide fast
tion of e-health as a valuable health tool; cultural and convenient expert medical services locally,
preferences; wariness of the trustworthiness and nationally, and globally, enabling two-way trans-
privacy of sites; and the typical lag time in diffu- mission of patient-provider information and
sion of innovations. Lack of reliability of sources images that permit patient or physician access to
is a cause for serious concern. Additionally, most remote experts to enable prompt diagnosis and
IHC systems in the healthcare arena are provider timely treatment in rural health centers, remote
336 E-Health
areas, and inaccessible geographic locations, apart Only those Web-based e-health patient service sites
from facilitating homecare. Teleconsulting is a that provide direct patient communication fall
corollary that allows experts to consult each other under the purview of telemedicine.
or advise physicians in remote areas. Telesurgery
and robotic surgery are state-of-the-art techniques
E-Health Terminology
that allow surgeons to perform remote-controlled
procedures or guide surgeons from a distance in Store-and-forward transmission of still digital
conducting innovative or emergency procedures. images or clinical data is frequently used in radiol-
Remote satellites enable the global use of these ogy, dermatology, and pathology. A digital camera
systems. is used to store and transmit relevant patient pic-
A wide variety of services fall under the umbrella tures. Originating site, also known as spoke site,
of telemedicine services: specialist referral services, patient site, remote site, and rural site, is defined by
patient consultations, remote patient monitoring, the Centers for Medicare and Medicaid Services
medical education, and consumer medical/health (CMS) as a site where the patient and/or the
information. Specialist referral services usually patient’s physician is located during the telehealth
involve a teleconsultation between one or several encounter or consult. A patient presenter is some-
specialists and/or a general physician to arrive at a one with clinical skills, such as a nurse, who is
correct diagnosis and treatment. More than 50 trained in the use of the camera equipment and
specialties are successfully using it to provide local who is in attendance with the patient at the origi-
or global patient care. Patient consultations are nating site to “present” the patient, manage the
direct, remote interactions between the patient and camera, and perform any hands-on activities
the health professional in which reports and other requested by the remote physician to arrive at a
health data are interchanged to guide treatment. diagnosis. A trained presenter is not necessary in all
Remote patient monitoring, or home telehealth, cases, as in radiology or pathology consults.
transmits and collects data from remote stations Bandwidth signifies the capacity of a communica-
(e.g., an ECG or pulse recording), usually via the tions channel to transmit information. Broadband
Internet, which is useful in controlling the use of communications carry a wide range of frequencies
visiting nurses. that permit simultaneous transmission of several
messages, as in broadcast TV and satellites. Interactive
video/television permits two-way, synchronous,
Delivery Mechanisms
interactive video and audio signals to deliver
Several types of delivery mechanisms are used in e-health services: ITV, IATV, or VTC (video tele-
e-health: networked programs, point-to-point con- conference) are commonly used acronyms. Firewalls
nections, primary or specialty care to the home, are computer hardware and software that block
home monitoring, and Web-based e-health patient communication channels between an institution’s
or consumer services sites. Dedicated networks link computer network and unauthorized external
health organizations with their partners, subsidiar- networks.
ies, or health centers in remote areas and are used
primarily for administrative purposes. Their use
E-Health Ethics,
in public health programs is growing as e-health
Confidentiality, and Safety
becomes more popular. Point-to-point connections
usually link private providers such as hospitals to The ethical and legal safety norms of e-health are
patients requiring telehelp or teleconsultation. still not well-defined. Ethical issues cover the pres-
Primary or specialty care to the home connects ervation of confidentiality, dignity, and privacy.
physicians and visiting nurses with patients over Legislation guaranteeing these values is essential,
single-line telephone-video systems for interactive along with liability for misuse, for all providers of
clinical consultations. Home-to-monitoring-center e-health information. The Internet is a particularly
links are useful for remote monitoring of lung func- difficult tool to control in the absence of well-defined
tions, fetal heart monitoring, or cardiac monitoring ownership or accountability regulations that
for patients needing extensive surveillance at home. can control cyberspace activities. The unrestricted
E-Health 337
proliferation of e-health sites has led to the release is common both in the United States and globally,
of health information that may often be undocu- the development of consumer-oriented tools and
mented, misleading, influenced by monetary or provision of infrastructure require the involve-
business reasons, and potentially harmful to con- ment of a number of stakeholders and the creation
sumers. Consumers need to be made aware of of multiple tools to ensure equitable access. As
the pitfalls of using or providing personal health e-health is essentially a multidisciplinary tool,
information to sources that do not originate from conflicts occasionally arise between stakeholders
reliable sites. All users of e-health may not be able in deciding the best technology or software to
to discriminate between reliable and unreliable adopt, as health is primarily a social responsibility
information, particularly as related to drugs and while technology is business oriented. Besides,
supplements, and may suffer from considerable creating networks involves coordinating several
personal and economic harm. organizations with different levels of needs, train-
ing staff in managing such systems, and overcom-
ing economic restraints, in addition to dealing
Digital Divide
with vendors who may not be familiar with the
The digital divide is the term used to describe the specific demands of healthcare delivery. A thor-
disparity in access to e-health tools between the ough needs assessment involving all stakeholders
rich and the poor. Most people who suffer from is necessary before adopting such technologies.
higher rates of preventable diseases and risk factors Globally, the majority of people will be unable to
for those diseases have limited access to healthcare. use e-health services because of socioeconomic
They are also likely to have little or no access to reasons for many decades to come, thus increasing
e-health technologies, both because of economic the health disparities.
reasons and because of the inability to understand
and use these technologies even if they are made
Future Implications
available. This is particularly true for disadvan-
taged populations such as the elderly, those with In a world governed by information and commu-
low literacy, people with disabilities, those who are nication technology, channels of e-health technol-
computer and/or health illiterate, and immigrants. ogy have opened up new avenues in the delivery
Public health policymakers need to seriously con- and management of healthcare. An increasing
sider this divide while making policy decisions to number of decision makers in the public and pri-
divert precious funds to adopting technologies that vate healthcare sectors are looking at e-health
may not benefit the underserved. tools to deliver innovative ways for healthcare
reform and improving personal and population
health. These tools possess the potential to reduce
Barriers
costs, improve efficiency and quality of care, pro-
E-health is an evolving tool that is expensive to vide wide access to healthcare and education, and
install initially, though some systems have proved improve the overall capacity of healthcare orga-
to be cost-effective over time. Research is ongoing nizations. However, the arena of healthcare has
as more organizations discover the advantages of been slow in adopting these technologies, partly
e-health and are adopting its technologies. because of the various sociocultural factors that
However, the provision of e-health that is user- govern health as compared with the business sec-
friendly and accessible to all is fraught with prob- tor. Much progress can be made in adopting
lems. Demographic, sociocultural, economic, and e-health strategies that are efficient and cost-
linguistic barriers exist in designing e-health tools effective. The emphasis should be on using an
for public consumption. To use such tools, people interdisciplinary approach that addresses the
need access to hardware, software, and an Internet diversity of healthcare delivery and management
connection, along with the ability to navigate the at all levels.
system, understand its content, and use it effec-
tively, often described as meaningful access. In a Karen E. Peters, Sunanda Gupta,
multilingual society with limited health literacy, as and Benjamin C. Mueller
338 Eisenberg, John M.
See also Computers; Electronic Clinical Records; medical degree from Washington University School
E-Prescribing; Healthcare Web Sites; Health of Medicine in St. Louis (1972). He trained as an
Communication; Health Informatics; Health Insurance internist at the University of Pennsylvania and was
Portability and Accountability Act of 1996 (HIPAA); one of the first cadres of Robert Wood Johnson
Health Literacy
Clinical Scholars, which allowed him to receive a
master of business administration degree in 1976
from Wharton School, University of Pennsylvania.
Further Readings
From 1978 to 1991, Eisenberg served as the chief
Demiris, George, ed. E-Health: Current Status and of the Division of General Internal Medicine at the
Future Trends. Washington, DC: IOS Press, 2004. University of Pennsylvania, which he made one of
Gustafson, David H., Patricia Flatley Brennan, and the top divisions of this discipline in the nation. In
Robert P. Hawkins, eds. Investing in E-Health: What 1991, he was one of the first general internists
It Takes to Sustain Consumer Health Informatics. selected to chair a department of internal medi-
New York: Springer, 2007. cine, and he served in this capacity at Georgetown
Latifi, Ritat, ed. Current Principles and Practices of Medical School until 1997, when he became
Telemedicine and E-Health. Washington, DC: IOS Administrator of the Agency for Health Care
Press, 2008. Policy and Research (AHCPR), later known as the
Spil, Ton A. H., and Roel W. Schuring, eds. E-Health Agency for Healthcare Research and Quality
Systems Diffusion and Use: The Innovation, the User, (AHRQ). In this last position, he also served as
and the Use IT Model. Hershey, PA: Idea Group,
assistant secretary for health.
2006.
In addition to numerous academic achieve-
Tan, Joseph K. H., ed. E-Health Care Information
ments, Eisenberg’s expertise on the impact of
Systems: An Introduction for Students and
financial incentives on physicians’ decisions led to
Professionals. San Francisco: Jossey-Bass, 2005.
his serving as a member in and then chairing
the Congressional Physician Payment Review
Commission (PPRC) from 1986 to 1994. He was
Web Sites
the first physician president of the Society for
Center for Telehealth and E-Health Law (CTEL): Medical Decision Making, and he also led the
http://www.ctel.org Society for General Internal Medicine, the
eHealth Initiative: http://www.ehealthinitiative.org Association for Health Services Research, and
eHealth Institute: http://www.ehealthinstitute.org served on numerous editorial boards and federal
peer review groups.
Eisenberg’s scientific contributions were exten-
sive and included a strong focus on multiple
Eisenberg, John M. dimensions of clinical decision making, including
diagnostic uncertainty, cost-effectiveness and cost-
John M. Eisenberg (1946–2002), an early leader in benefit analysis, and sociological influences on
the Society for Medical Decision Making, was a physicians’ decisions—such as the impact of the
general internist whose early grasp of the impor- patient’s race, ethnicity, and gender. His book
tance of economic and other nonmedical factors in Doctors’ Decisions and the Cost of Medical Care
clinical decision making fueled an exceptional was a seminal contribution to the fields of medical
career that included national leadership in medi- decision making and health economics.
cine, medical decision making, health economics, In his final position, leading what is now the
public policy, and health services research. In addi- AHRQ, Eisenberg was preeminent in assessing health-
tion to his own career accomplishments, Eisenberg care quality and patient safety. His efforts in response
was also renowned as one of the foremost leaders in to the national Institute of Medicine (IOM) report
general internal medicine and a lifelong mentor of To Err Is Human resulted in AHRQ’s becoming the
students and professionals in multiple disciplines. world’s leading supporter of research to ensure that
Born in Atlanta, Georgia, and raised in Memphis, healthcare is reliably and predictably safe.
Tennessee, Eisenberg received his undergraduate Eisenberg often said that he took the greatest
degree from Princeton University (1968) and his pride in the many individuals he had trained—from
Electronic Clinical Records 339
medical students to business students to residents, industry. Among the terms used are computerized
fellows and junior faculty members. The impact of patient record (CPR), which pertained to hospi-
his numerous contributions and his legacy is still tals patient records, and was used prominently
unfolding. from the 1960s through the 1980s; electronic
medical record (EMR), which pertained to ambu-
Carolyn M. Clancy latory care patient records and was used in the
1980s and 1990s; and electronic health record
(AHRQ); Health Economics; Institute of Medicine (EHR), the current designation that includes
(IOM); Medical Errors; Patient Safety; Quality of patient records from a variety of healthcare enti-
Healthcare; Robert Wood Johnson Foundation (RWJF) ties both within and outside a single healthcare
system. These terms, however, are still often used
interchangeably.
Further Readings
Eisenberg, John M. Doctors’ Decisions and the Cost of Function
Medical Care: The Reasons for Doctors’ Practice
Today’s healthcare industry professionals expect
Patterns and Ways to Change Them. Ann Arbor, MI:
electronic clinical records to provide the follow-
ing: patient information such as demographic and
Eisenberg, John M. “What Does Evidence Mean? Can
insurance data; patient health data such as aller-
the Law and Medicine Be Reconciled?” Journal of
gies, problem lists, history and physical data,
Health Politics, Policy and Law 26(2): 369–81, 2001.
Eisenberg, John M., Sankey V. Williams, and Ellen S. Smith,
advance directives, operative and other procedural
eds. The Physician’s Practice. New York: Wiley, 1980. summaries; access and management of test results,
Kohn, Linda T., Janet M. Corrigan, and Molla S. including laboratory, microbiology, pathology,
Donaldson, eds. To Err Is Human: Building a Safer and other examinations; patient orders; patient
Health System. Washington, DC: Committee on notes and clinician summaries; clinical decision
Quality of Health Care in America/National support specific to patient parameters; medication
Academies Press, 2000. lists; radiology and other imaged studies; diagno-
Pauly, Mark V., John M. Eisenberg, and Margaret ses; consult summaries; patient-specific scanned
Higgins Radany. Paying Physicians: Options for documents, pictures, and sounds; chronic disease
Controlling the Cost, Volume and Intensity of management and pathways/reminders; and access
Physicians’ Services. Ann Arbor, MI: Health to knowledge sources.
History
Web Sites While a few large hospitals first began using com-
Agency for Healthcare Quality and Research (AHRQ):
puters in the 1950s to support financial, billing,
http://www.ahrq.gov and administrative functions, it was not until the
Institute of Medicine of the National Academies (IOM): 1960s that EMRs were viewed as a possibility.
http://www.iom.edu The idea of using computers to record patient
Robert Wood Johnson Foundation (RWJF): treatments was part of President Kennedy’s vision
http://www.rwjf.org for the future of the nation. Early in his term of
U.S. National Library of Medicine (NLM), John M. office, President Kennedy proclaimed that the
Eisenberg Papers: http://www.nlm.nih.gov United States would land a man on the moon by
the end of the decade of the 1960s. This ultimately
led to increased federal funding of NASA and the
development of the nation’s space program.
Electronic Clinical Records The Lockheed Corporation, one of the major
beneficiaries of government funding for space
The term electronic clinical records encompasses a research and exploration, decided that it was in the
number of individual designations that have been public’s interest to use the recently developed space
used by the healthcare information technology program technology for the benefit of all citizens of
340 Electronic Clinical Records
the nation. Lockheed decided to develop a com- began to stratify because developers and their
puter application that would manage the patient client hospitals recognized the enormous com-
care delivery and clinical documentation processes puter-processing requirement of clinical patient
in hospitals. In the late 1960s, Lockheed began the record systems. These systems operating on large
project at El Camino Hospital, a community hos- computer mainframes became more functional,
pital in Mountain View, California. By 1973, the but they still were less developed than the system
first patient care unit was “live” on a computer developed earlier by Lockheed.
system, and the majority of the unit’s clinical pro- During the 1990s, computer technology
cesses, nursing observations and interventions, advanced, and the industry began to focus on the
patient orders, and test results were documented use of large-scale communication networks and
and automated in the first electronic clinical record distributed computing through the use of servers
system. This live unit was tweaked and debugged and more powerful personal computers. As the
during the next year, before the system was cost of computing decreased, healthcare informa-
expanded to other patient care units in the hospi- tion technology companies began emphasizing
tal. By 1976, the majority of El Camino Hospital client server technology using large servers and
was live on the first patient care system, using a extensive communications networks. However,
large IBM mainframe as its host computer. despite these advances, only a minority of the
By the mid-1970s, as word of the El Camino nation’s hospitals have a fully installed and fully
project spread, other development efforts began used electronic clinical record system.
to take shape. These efforts were led by a number There has been more success in the use of EMR
of companies, such as HBO (now part of McKesson systems in ambulatory care. Many physician prac-
Corporation), McDonnell-Douglas (the aircraft tices and outpatient clinics have been successfully
manufacturer whose healthcare information tech- implementing these systems since the early 1990s.
nology business is also now part of McKesson), Because patient records in these settings are less
ISM (product name of PCS/ADS), and SMS (now complex, computerization is more straightforward
part of Siemens), among several others. However, and more easily adaptable to available technology.
the majority of these developments resulted in a Today, a patient is more likely to have an EMR in
number of limited clinical systems that only com- a physician’s office or clinic than in a large acute-
municated orders from patient care units to other care hospital.
ancillary departments such as laboratory or radi-
ology. These systems were sold, but in many
cases, they were not expanded into functional Future Implications
CPR systems. In 2004, President George W. Bush issued an
In the early 1980s, other companies decided to executive order establishing the Office of the
develop CPR systems. Companies such as Medicus National Coordinator for Health Information
(bought by HBO and now part of McKesson), Technology (ONCHIT). Its mission is to imple-
Meditech, PHAMIS (bought by IDX and now part ment EHRs nationwide within 10 years. However,
of General Electric), SMS, Dynamic Control many barriers exist in achieving this goal, includ-
(bought by Baxter, which joint ventured with IBM, ing the cost of these systems and concerns over
then sold to HBOC, which is now also part of privacy issues. At this point, it seems unlikely that
McKesson), and Burroughs, among others, all the nation’s healthcare system will become totally
made large investments to develop CPR systems. A paperless in the foreseeable future.
number of hospitals invested heavily and spent
much time and resources to assist and serve as Lawrence M. Pawola
development sites, but in the end there was not
much success. And the majority of these compa- See also Agency for Healthcare Research and Quality
nies went out of this business segment, or larger (AHRQ); Ambulatory Care; Clinical Decision Support;
companies purchased them. Clinical Practice Guidelines; Health Informatics;
In the mid-1980s, the clinical application Health Insurance Portability and Accountability Act of
segment of the information technology industry 1996 (HIPAA); Hospitals; Patient Safety
Ellwood, Paul M. 341
Further Readings The latest idea that Ellwood has initiated is the
Carter, Jerome H., ed. Electronic Health Records: A Pathways to Healthy Outcomes (PATHOS), which
Guide for Clinicians and Administrators. calls for increased participation from the federal
Philadelphia: ACP Press, 2008. government in setting standards. The goal of
Hamilton, Byron. Electronic Health Records. Boston: PATHOS is to overhaul the healthcare system,
McGraw-Hill, 2009. enhance the power of patients, redefine the role of
Hartley, Carolyn P., and Edward D. Jones. EHR government as an agent of change and regulator,
Implementation: A Step-by-Step Guide for the and ensure health insurance for everyone. PATHOS
Medical Practice. Chicago: AMA Press, 2005. would accomplish these objectives through the use
Morena, Lornzo. Electronic Health Records: of the Internet to connect patients and physicians,
Synthesizing Recent Evidence and Current Policy. rely on evidence-based guidelines for prevention
Princeton, NJ: Mathematica Policy Research, 2005. and treatment, adopt the use of EMRs, and pro-
vide patients with better information on medical
treatments and comparative information on physi-
Web Sites cian performance.
American Health Information Management Association
Ellwood received his bachelor’s degree and a
(AHIMA): http://www.ahima.org medical degree from Stanford University. He then
Healthcare Information and Management Systems went on to complete his medical training in pediat-
Society (HIMSS): http://www.himss.org rics and neurology at the University of Minnesota
Health Information Technology (Health IT): and physical medicine and rehabilitation training at
http://www.hhs.gov/healthit the University of Washington. He worked as
a consultant at the Brookings Institution for 4 years.
Following this, he held various positions at
Harvard University, the University of Paris,
Stanford University, and the University of Rennes
Ellwood, Paul M. in France. Later, Ellwood served as the executive
director of the American Rehabilitation Foundation
Paul M. Ellwood is an innovative figure in health- and the Sister Kenny Institute of Minneapolis. He
care. He coined the term health maintenance organi- founded and was the chief executive officer of
zation (HMO), and he introduced the concept to the InterStudy, a Minnesota-based organization dedi-
Nixon administration as an entity that would com- cated to introducing market forces in healthcare.
pete on the bases of price and quality by combining He also founded the Jackson Hole Group in Teton
insurance and healthcare within a single organiza- Village, Wyoming, a healthcare reform policy
tion. In 1972, Ellwood tested the HMO concept as think tank composed of medical, public policy,
a pilot program with 5,000 patients at the Park and business leaders committed to improving the
Nicollet Clinic in Minneapolis, employees from nation’s healthcare system.
General Mills and other local corporations who Ellwood has received numerous awards and
were enrolled in this employer-sponsored prepaid honors. The Foundation for Accountability
health plan. He advised the Nixon White House on (FACCT) established an annual award in his
the Health Maintenance Act of 1973, which was honor. Ellwood has also served on many local and
passed into law. The HMO Act requires that all national boards, including the national Institute of
companies in the nation with 25 or more employees Medicine (IOM), the American Association of
must offer a federally qualified HMO option along Rhodes Scholars, and the RAND Corporation.
with traditional indemnity insurance. The act played
a significant role in shifting the direction of the Jared Lane K. Maeda
nation’s healthcare system toward managed care.
Ellwood, along with Alain C. Enthoven and the See also Employee Health Benefits; Enthoven, Alain C.;
Jackson Hole Group, later went on to propose the Health Maintenance Organizations (HMO); Managed
idea of managed competition, which is a purchas- Care; Outcomes Movement; Public Policy; Quality of
ing strategy for consumers and employers. Healthcare
342 Emergency and Disaster Preparedness
Further Readings integrated into community planning. Moreover,

Benko, Laura B. “Father Figures: HMO Creator Sees many hospitals remain unprepared in terms of
Need for New Model,” Modern Healthcare 36(25): 6, comprehensive response plans, adequate partici-
24, June 19, 2006. pation in drills, and resources and training. Many
Ellwood, Paul M. “Models for Organizing Health hospitals are also not collaborating with other
Services and Implications of Legislative Proposals,” agencies. Surveys of hospital emergency depart-
Milbank Memorial Fund Quarterly 50 (4 pt. 2): ments have found deficiencies in the knowledge,
73–101, 1972. plans, and resources for responding to hazardous
Ellwood, Paul M. “Does Managed Care Need to be materials (HAZMAT) or radiation incidents.
Replaced? ‘Father’ of Managed Care Unveils New Recent events that were small in scale by com-
Plan,” Physician Executive 28(1): 26–31, January– parison with the potential for damage have over-
February 2002. whelmed healthcare facilities; lack of appropriate
Ellwood, Paul M., and Alain C. Enthoven. “‘Responsible preparedness plans or familiarity with them as
Choices’: The Jackson Hole Group Plan for Health well as the delayed use of personal protection
Reform,” Health Affairs 14(2): 24–39, 1995. equipment (PPE) have resulted in healthcare staff
becoming unnecessarily exposed to toxic agents
and subsequently becoming ill. Such was the case
Web Sites
in Tokyo during the 1995 subway attacks with
Minnesota Historical Society, Health Maintenance sarin nerve gas. Yet during the initial 2 to 3 days
Organizations: http://www.mnhs.org/library/tips/ of a disaster, local agencies, including hospitals,
history_topics/87hmos.html are the initial responders. Therefore, hospital
personnel must be able to meet the challenges of
organizing and implementing a mass medical
Emergency and Disaster response that may require unfamiliar activities
such as decontamination, which is not a part of
Preparedness daily routine practices.
Clearly, community emergency and disaster
Emergency and disaster preparedness is taking preparedness is a complex undertaking given the
the necessary precautions and preparations in the number of stakeholders and responder agencies,
event of an emergency or disaster. Medical emer- local vulnerabilities, disparate resources, and
gencies, natural disasters (earthquakes, hurricanes, potential hazards. As such, it is imperative that all
flooding), technological disasters (hazardous healthcare facilities have preparedness plans in
material incidents, nuclear power plant failures), place, practice these plans on a regular basis, and
and terrorism pose an ever-present risk to life and ensure that these activities are integrated with mul-
property. Emergencies and disasters can cause dis- tiple agencies that are responsible for a mass
ruptions to the lives of many and can have serious casualty event.
and lasting effects. Being adequately prepared for
emergencies and natural disasters can help mini-
Components of Disaster Planning
mize the confusion and impact of the aftermath. If
proper precautions are taken, disastrous situa- Preparing for mass casualties from natural disas-
tions may be potentially avoided or their effects ters, technologic disasters, and terrorism requires
reduced. Hospitals and other healthcare providers a multisystem approach that involves local and
play a critical role in emergency and disaster pre- federal public health agencies along with other
paredness since they are on the front lines of emergency networks and healthcare facilities. The
responding to and caring for the ill and the injured basic components of such a plan include the fol-
in the event of such an occurrence. lowing: hospital incident command system (HICS),
hospital personnel, network of communication,
first responders, PPE, cancellation of nonessential
Overview
services and procedures, obtaining necessary sup-
Recent studies and government reports continue plies and medications, triaging both patients and
to express concerns that hospitals are not adequately vital resources, medical surge capacity, security
Emergency and Disaster Preparedness 343
issues, National Incident Management System communication with their departments so that they
(NIMS) compliance, and critical analysis. Each of know how many patients can be received and also
these components is discussed further below. can monitor the level of essential medical supplies.
As part of the overall communication strategy,
it is important to have communication plans
Hospital Incident Command System established that include the fire department, police
The HICS is a core component of the NIMS and department, ambulance services, emergency opera-
is mandated by the Joint Commission. HICS is a tions, and all hospitals within a reasonable distance.
standardized incident management tool that enables A common radio frequency and interoperability of
healthcare facilities to organize resources and staff equipment should be in place. Additionally, plan-
in order to remain operational during any emer- ning for disruptions and backup strategies are nec-
gency while promoting the restoration of routine, essary to keep communication channels open.
daily functions. HICS is based on a command-and-
control system. In this system, the designated inci-
First Responders
dent commander oversees the operational planning,
logistics, and financial aspects of the event, with First responders may be called on in the event
the ultimate goal of minimizing chaos. The respon- of a HAZMAT, radiological, or explosive event.
sibilities of the incident commander include moni- Therefore, the training of first responders to coor-
toring the cost of the incident, maximizing safety, dinate with healthcare facilities is essential. First
using personnel efficiently, and resuming normal responders will be transporting many patients to
operations as soon as possible. The key personnel healthcare facilities in the event of a major emer-
involved include the incident commander, public gency or disaster. As a result, healthcare facilities
information officer, safety officer, liaison officer, should be prepared to identify, triage, track, and
medical specialists, operations section chief, manage the large surge of incoming patients.
finance/administration section chief, environmen-
tal services, and planning or logistics section chief.
Personal Protection Equipment
PPE is necessary to protect responders from
Hospital Personnel
becoming contaminated. PPE is designed to pro-
The hospital emergency department is typically tect the rescuer in a disaster management scenario
the “first receiver” of an emergency or disastrous from becoming a victim and to prevent the delay
situation. Therefore, the mobilization of clinical of rescue operations. There are four levels of pro-
staff is an integral aspect of an emergency response. tective equipment. Level A provides the most pro-
A central labor pool may be needed to establish tection against vapors and liquids and includes a
order for the command center and coordinate self-contained breathing apparatus (SCBA) and
staffing requirements. Prior staff training to deal an airtight suit. Level B is used when there is no
with an increase in medical surge is paramount in danger against vapors and only a danger involving
preparing for disasters. chemicals. This level of equipment includes a chem-
ical-resistant suit and an SCBA. Level C includes a
full-faced air-purifying mask respirator and a
Network of Communication
splash suit that is chemical resistant to be used by
Communication is key to coordinate internal individuals who work in a triage area. Level D is
responses, interact effectively with multiple agen- used when there is no skin or respiratory hazard,
cies, and deliver important information in the form and it includes work clothes that cover an indi-
of risk communications to the public and media in vidual’s regular clothing.
a timely manner.
Hospitals must work to make sure that they
Cancellation of Nonessential
have a communication network setup within a
Services and Procedures
regional county in the event that they run low on
medical supplies or have an overflow of patients The cancellation of nonessential services and
during a disaster. Hospitals must also keep active procedures is pivotal if a healthcare facility knows
344 Emergency and Disaster Preparedness
ahead of time that it will be receiving an influx of or accommodate patients. The surge capacity also
patients from a disaster. Strategies to expedite dis- involves the ability of a healthcare facility to man-
charge of patients and cancel all elective surgeries age patients who may require specialized evalua-
should be considered to accommodate a surge in tions, intervention, and treatment. The surge
patients. capacity can be accomplished by transforming cer-
tain nonclinical areas of a healthcare facility, such
as a lounge, waiting area, or auditorium, to hold
Obtaining Necessary patients by adding gurneys or cots.
Supplies and Medications A concern regarding surge capacity is that many
The pharmacy plays a central role during a hospitals and healthcare facilities lack this avail-
mass casualty incident. Pharmacies should be ability as they are already overburdened with
stockpiled to treat enough patients for 48 to 72 patients on a daily basis. A significant challenge to
hours or until resources can be replenished from a meeting the surge capacity is to determine the
nearby facility. Pharmacies should also be in con- number of patients a healthcare facility should
tact with these facilities to obtain needed supplies. actually prepare for since estimation of the poten-
The National Pharmaceutical Stockpile (NPSP) tial demand varies by a given scenario. A common
can help ensure the rapid deployment of pharma- estimation that is used for surge capacity is to pre-
ceuticals, antidotes, medical supplies, and equip- pare for 500 victims per 1 million residents above
ment. It also maintains vaccines that can be made the daily capacity of the facility. This generally
readily available in the event of a biological attack results in a 20% increase in capacity.
or pandemic.
Security
Triaging Patients and Resources Security at both the site of the disaster and the
In the event of mass casualties, patients may not healthcare facility is essential to emergency pre-
arrive with first responders, but they may arrive on paredness. Crowd control is needed to prevent
their own at hospital emergency departments after anarchy and the disruption of healthcare providers
evacuating the scene of the incident. Because of from carrying out their duties. Steps should be
this, hospitals should be prepared to expect a large taken to contain traffic, especially at the triage
number of patients and anticipate more than what area, and a lockdown of the hospital emergency
is reported by responders on the scene. department should also be planned for. Coordi
Triaging patients during an overflow period nation and communication with local law enforce-
should only take 30 seconds per patient, and ment may be needed to ensure smooth operations
patients should be color-coded. Red indicates that during a disaster.
a patient is in need of immediate care. Yellow
signifies that a patient is in stable condition but
National Incident Management
needs care soon. Green indicates that a patient
System Compliance
has minor injuries and can wait a little while for
treatment. Finally, black means that a patient will In 2003, President George W. Bush issued
not survive. The goal of triage during a mass the Homeland Security Presidential Directive-5
casualty event is to help the patients who will (HSPD-5), which mandates state and location adop-
most likely survive and to treat patients with tion of the NIMS as a requirement for receipt of
reversible pathological processes by using as few federal funding. The NIMS Integration Center
resources as possible. (NIC) has been designated as the lead federal agency
to coordinate NIMS compliance. The National
Incident Management Capability Assessment Support
Medical Surge Capacity Test (NIMS CAST) is a self-assessment program
Medical surge capacity refers to the number for organizations to assess their ability to effec-
of potential patient bed spaces that can be made tively prepare for, prevent, respond to, and recover
available to triage, manage, vaccinate, decontaminate, from domestic incidents.
Emergency Medical Services (EMS) 345
Critical Analysis the Primary Care Physician. New York: Springer,

2008.
The debriefing and critical analysis of staff O’Leary, Margaret R., ed. The First 72 Hours: A
performance following a major traumatic event is Community Approach to Disaster Preparedness.
an essential component of any emergency pre- Lincoln, NE: iUniverse, 2007.
paredness plan. This process should occur once the Rosner, David, and Gerald E. Markowitz. Are We
disastrous event has passed but prior to the resump- Ready? Public Health Since 9/11. Berkeley: University
tion of usual routine activities. of California Press, 2006.
Implications for Healthcare Facilities

Web Sites
Healthcare facilities play a central role during an
emergency or disaster. Without the proper plan in American College of Emergency Physicians (ACEP):
http://www.acep.org
place and the right networks set up, healthcare
American Red Cross: http://www.redcross.org
facilities will be in chaos during an emergency or
disaster. During and after such an event, the facil-
http://www.bt.cdc.gov
ities will need to treat many more patients then
Federal Emergency Management Agency (FEMA):
they can normally accommodate. This can only be http://www.fema.gov
accomplished through appropriate planning, orga- Joint Commission: http://www.jointcommission.org
nization, and preparation. Preparedness is the key
factor in being able to effectively and efficiently
deal with an emergency or disaster.
Jerrold B. Leikin, Scott M. Leikin, Emergency Medical
and Robin B. McFee Services (EMS)
See also Access to Healthcare; Bioterrorism; Emergency
The purpose of emergency medical services (EMS) is
Medical Services (EMS); Hospital Emergency
Departments; Hospitals; Joint Commission; Public
to provide the highest level of prehospital care by a
Health; Vulnerable Populations trained professional until the patient is under the
care of a physician or other appropriate healthcare
professional. The person who provides such care is
Further Readings called an emergency medical technician (EMT). A
paramedic is the highest level of EMT and provides
Braun, Barbara I., Nicole V. Wineman, Nicole L. Finn, the most extensive prehospital care. The primary
et al. “Integrating Hospitals Into Community
goal of an EMT is to provide medical care out of the
Emergency Preparedness Planning,” Annals of
hospital environment or in a trauma situation, with
Internal Medicine 144(11): 799–811, June 6, 2006.
the objective of transporting the patient in a stable
Hochstein, Colette, Stacey Arnesen, Jeanne Goshorn,
medical condition to the hospital, whereupon emer-
et al. “Selected Resources for Emergency and
gency physicians will then take over. An EMT also
Disaster Preparedness and Response From the United
States National Library of Medicine,” Medical
may have to deal with environments that might not
Reference Services Quarterly 27(1): 1–20, Spring be completely safe. According to the National
2008. Association of Emergency Medical Technicians
McEntire, David A. Disaster Response and Recovery: (NAEMT), EMTs transport more than 16 million
Strategies and Tactics for Resilience. Hoboken, NJ: patients in the United States annually.
Wiley, 2007.
McFee, Robin B., and Jerrold B. Leikin, eds. Toxico-
History
Terrorism: Emergency Response and Clinical
Approach to Chemical, Biological, and Radiological The concept of out-of-hospital care can be credited to
Agents. New York: McGraw-Hill, 2007. Dominique Jean Larrey (1766–1842), who was
Melnick, Alan L. Biological, Chemical, and Radiological Napoleon’s chief army surgeon. Larrey recognized
Terrorism: Emergency Preparedness and Response for that it was imperative to treat wounded soldiers as
346 Emergency Medical Services (EMS)
quickly as possible. To accomplish this, he created the The report identified that there were 52 million
ambulance volante or “flying ambulance service” to accidental injuries in the nation, accounting for a
rapidly transport the wounded. The concept behind total of $18 billion in 1965. The report provided a
the idea was to perform medical procedures as close number of recommendations for the development
to the battlefield and as quickly as possible. He of EMS systems. It recommended greater training
believed that the quicker a procedure was done, the of EMTs to deal with various trauma situations.
better are the chances the patient would survive. The report proved to be highly influential, and
Larrey increased the mobility and improved the orga- many initiatives were undertaken by both private
nization of field hospitals, establishing the first Mobile and government organizations.
Army Surgical Hospital or MASH units. Larrey also One of the most important results of the report
created the concept of “triage,” which in French was the passage of the federal National Highway
means “to sort.” He established rules for the triage of Safety Act of 1966, which helped create the U.S.
the wounded; treating them according to the serious- Department of Transportation (DOT). From 1968 to
ness of their injuries and the urgency of their need for 1979, the DOT allocated more than $142 million to
medical care. help train EMTs. In 1973, the U.S. Congress passed
In 1865, during the American Civil War, the the Emergency Medical Services Systems Act, which
first civilian ambulance service was created. Four provided funding to help support the training of EMT
years later in New York City, ambulances were facilities. In addition, the National Highway Traffic
created that consisted of horse-drawn carriages Safety Administration (NHTSA) established state-
staffed by physician interns to assist at the scene of wide EMS technical assessment programs that defined
the trauma and treat the patient as quickly as pos- the basic components of an EMS system. The compo-
sible. However, it was not until the 20th century nents consist of the following: regulation and policy,
that ambulance services began to be used widely. resource management, human resources and training,
During World War I, the average evacuation transportation, facilities, communications, trauma
time for combat personnel was 18 hours, resulting systems, public information and education, medical
in a high mortality rate. Because of this, during direction, and evaluation.
World War II, focus was placed on the expedi-
tious transportation of injured personnel from the
Certification and Learning
frontlines to areas where physicians were avail-
able. Although many medical advancements were A high school diploma is required to begin formal
made during World War I and II, advancements in EMT training. There are essentially three levels of
training EMTs and prehospital care did not occur EMT training. EMT-Basic level involves training in
at home in America. basic stabilization and emergency skills that do not
It was not until the mid-1960s that prehospital involve medications. EMT-Intermediate level may
care received the attention of government and the require up to 350 hours in training of advanced air-
public. Many people before this time thought that way skills and limited medication use along with
all care for the sick and injured occurred in the hos- intravenous fluid administration. EMT-Paramedic is
pital and therefore saw no reason for paramedics the most advanced level and may take up to 2 years
to be well versed in life-saving techniques, believing to complete. Course work in this area involves
that hospital physicians would be able to save the extensive study in anatomy, physiology, and phar-
patients. In addition, most EMTs were poorly macology as well as advanced resuscitative skills.
trained and did not have adequate equipment. To be certified as an EMT, an individual must
However, in 1966, all this changed with the publica- successfully complete a course that is in accordance
tion of Accidental Death and Disability: The with the EMT-Basic, Intermediate, or Paramedic
Neglected Disease of Modern Society, which was National Standard Curriculum, which is published
written by the National Academy of Sciences, by the DOT. Licensure is required in all 50 states
National Research Council. This report was for all three levels. Generally, recertification must
extremely influential and represented a turning point be accomplished every 2 years with Continuing
in EMTs’ responsibilities. Medical Education requirements.
Emergency Medical Treatment and Active Labor Act (EMTALA) 347
Hazardous Material Teams See also Access to Healthcare; Bioterrorism; Emergency

and Disaster Preparedness; Geographic Barriers to
Today, EMTs must be ready to respond to many Healthcare; Hospital Emergency Departments;
types of HAZMAT incidents, including terrorist Intensive-Care Units; Physicians; Rural Health
attacks. EMTs may come into contact with vari-
ous HAZMATs such as biological, chemical,
or radiological agents. Chemical and other types Further Readings
of spills are foreseeable with 4 billion tons
Alexander, Melissa. Foundations for the Practice of EMS
of HAZMATs being transported across the coun- Education. Upper Saddle River, NJ: Pearson/Prentice
try each year. The most common route of expo- Hall, 2006.
sure in HAZMAT incidents is via inhalation. Brennan, John A., and Jon R. Krohner, eds. Principles of
The federal agencies that are responsible for regu- EMS Systems. 3d ed. Sudbury, MA: Jones and
lating the transportation of HAZMATs are the Bartlett, 2006.
Occupational Safety and Health Administration Elling, Bob, and Kirsten M. Elling. Principles of Patient
(OSHA) and the Environmental Protection Assessment in EMS. Clifton Park, NY: Thomson/
Agency (EPA). Furthermore, the National Fire Delmar Learning, 2003.
Protection Association (NFPA) has developed a Knott, Astrid. Access to Emergency Medical Services in
set of standards for responding to HAZMAT. Rural Areas: The Supporting Role of State EMS
NFPA Standard 471 establishes guidelines Agencies. Minneapolis, MN: Rural Health Resource
and tactical objectives for HAZMAT manage- Center, 2002.
ment while NFPA Standards 472 and 473 estab- National Academy of Sciences, National Research
lish responder competency for HAZMAT Council. Accidental Death and Disability: The
incidents. Neglected Disease of Modern Society. Washington,
A contaminated site is often classified into DC: National Research Council, 1966.
zones. The hot zone or red zone is where the Walters, Frank G., Richard G. Thomas, and Raymond
actual spill or contamination occurred, and only Klein. Advanced Hazmat Life Support Provider
professionals who have the correct protective Manual. 3d ed. Tucson: Arizona Board of Regents for
gear should enter this area. The warm zone or the University of Arizona, 2003.
yellow zone is next to the hot zone, and it is
where the decontamination occurs. The cold or Web Sites
green zone is where no contamination occurred,
and it is where the command post is located. The Advanced Hazmat Life Support (AHLS):
green zone is the safest zone, and no one should http://www.ahls.org
be allowed in this area unless they have been American Academy of Emergency Medicine (AAEM):
cleansed of all contaminants that they have come http://www.aaem.org
into contact with in the hot zone. EMT/HAZMAT American Trauma Society (ATS): http://www.amtrauma.org
National Association of Emergency Medical Technicians
personnel should approach the contaminated site
(NAEMT): http://www.naemt.org
upwind or uphill if at all possible. EMTs have
National Fire Protection Association (NFPA):
certain responsibilities in dealing with HAZMAT
http://www.nfpa.org
incidents. These responsibilities are based on
their level of training. A Level 1 responder is a
first responder who can provide care in the zone
outside the contamination area (cold zone) and
who does not pose a risk of secondary contami-
Emergency Medical Treatment
nation. A Level 2 responder can treat patients in and Active Labor Act
the contamination zone (warm zone) and can (EMTALA)
coordinate EMS activities.
The federal EMTALA, also known as the Anti-
Jerrold B. Leikin and Scott M. Leikin Dumping Law, was passed in 1986 as part of
348 Emergency Medical Treatment and Active Labor Act (EMTALA)
the Consolidated Omnibus Reconciliation Act. federal government failed to define emergency in
EMTALA requires all hospitals receiving certain the regulation; there were no punitive remedies for
federal funds to provide medical screening exami- violations; and despite the private right of action
nations to all persons who arrive at their emer- under Hill-Burton, most patients remained unaware
gency departments, whether they have health of their rights and remedies under the statute.
insurance or not. The Joint Commission has hospital guidelines
The intent of EMTALA is to ensure patient that state that individuals shall be accorded impar-
access to emergency medical care and to prevent the tial access to treatment or accommodations that
practice of patient dumping. Patient dumping occurs are available or medically indicated, regardless or
when patients in need of emergency care are trans- race, creed, sex, nationality, or source of payment
ferred to another hospital before they are medically for care. The American College of Emergency
stable. The practice was especially prevalent when Physicians (ACEP) also has issued guidelines against
hospitals thought that the patients were unable to patient dumping. However, neither of these organi-
pay for their care. Patient dumping of uninsured zations has the power to impose penalties for a hos-
patients from private hospitals to public hospitals pital’s failure to comply with these guidelines.
grew rapidly in the 1980s as insurance companies Starting in the early 1980s, a number of articles
promoted managed-care plans, reimbursement pat- were published in medical and public health jour-
terns changed, and hospitals were unable to shift nals as well as in the popular press addressing the
the costs of bad debt, charity care, and uncompen- issue of patient dumping. Several of the articles were
sated care to privately insured patients. written by physicians from Cook County Hospital
EMTALA imposes duties on all the nation’s (now John H. Stroger Hospital), the large inner-city
hospitals receiving Medicare reimbursement. public hospital in Chicago that primarily serves the
Generally, hospitals must offer an appropriate poor, detailing the large extent of patient dumping
medical screening examination to any patient seek- at that facility. The authors found that the majority
ing emergency services to determine whether or of the transfers were patients who were unemployed
not an emergency medical condition exists. If a or minorities, with 95% of those patients having no
life-threatening condition is found, the hospital health insurance. The reason stated most often for
must provide the patient with stabilizing treatment the transfers was lack of insurance in 87% of the
within the capabilities of the facility and its staff, cases. And nearly 25% of the patients were found
or if the patient cannot be stabilized, the hospital to be medically unstable at the time of the transfer.
must arrange for an appropriate transfer of the The practice of patient dumping was not limited
patient after considering the patient’s condition to Chicago. Most large cities with public hospitals
and the risks and benefits of the transfer. were also burdened by the practice. In 1986, it was
EMTALA was not intended to create a private estimated that nationally about 250,000 inappro-
cause of action against the hospital and physician, priate transfers of medically unstable patients
but it can result in fines of up to $50,000 per viola- occurred, which was thought to greatly increase
tion to both the hospital and the physician and the the patients’ morbidity and mortality.
loss of Medicare reimbursement. These articles, reports by the press, and news
programs profiling transfer patients contributed to
the enactment of EMTALA. According to one
Background
Senator, the law was passed to send a clear signal to
Prior to the passage of EMTALA, there were sev- the nation’s hospitals, pubic and private alike, that
eral laws, rules, and guidelines in place designed to all Americans, regardless of wealth or status, should
protect patients against patient dumping. Passed know that a hospital will provide whatever services
by the U.S. Congress in 1946, the Hospital Survey it can when they are truly in physical distress.
and Construction Act, more commonly referred to
as the Hill-Burton Act, required hospitals to treat
The Statute
and stabilize all emergency patients prior to dis-
charge as a condition for receiving federal funds EMTALA imposes a number of requirements on
for construction and modernization. However, the hospitals with emergency departments that have
Emergency Medical Treatment and Active Labor Act (EMTALA) 349
Medicare provider agreements. (Because Veterans The CMS receives EMTALA complaints at its
Health Affairs [VA] hospitals and other military 10 regional offices. If one of the CMS offices finds
hospitals do not participate in the Medicare pro- an EMTALA violation, it notifies the hospital that
gram, they are exempt from EMTALA.) The act it may be terminated from participation in Medicare
imposes several duties on hospitals, which were unless it takes appropriate remedial action. The
often unclear to healthcare professionals charged CMS office provides the hospital with a statement
with complying with these rules. of deficiencies and a notice of termination. If
There are essentially nine legal duties imposed a violation involves a medical issue, a quality
on hospitals by EMTALA: (1) a medical screening improvement organization (QIO) reviews the med-
examination must be performed for all patients ical issue from a physician’s perspective.
who come to the emergency room; (2) the screen- Subsequently, the regional CMS office notifies
ing must not be delayed to determine the patient’s the OIG so that it can determine whether to levy
ability to pay; (3) the medical screening examina- fines against the hospital. Under EMTALA, the
tion must be performed in a nondiscriminatory OIG can impose a civil monetary fine of up to
manner for all patients; (4) the hospital must use $50,000 per violation or a fine of $25,000 for
all available resources to stabilize the patient for small-size hospitals. In addition, physicians may be
transfer; (5) the referring hospital must transfer the fined up to $50,000 if they have been found to have
patient in an appropriate manner; (6) the receiving negligently violated their duty to examine, treat, or
hospital must accept the patient if the transfer is transfer an individual to a participating hospital.
appropriate; (7) the patient has the right to refuse The OIG is not required to impose penalties on
treatment and the transfer; (8) the hospital must hospitals found to be in violation of EMTALA.
log and document the emergency evaluation and However, if monetary penalties are imposed, they
treatment of every patient; and (9) if a receiving are subject to administrative and judicial review.
hospital suspects an EMTALA violation, it must be
reported within 72 hours, and in return, the gov-
Benefits and Limitations
ernment provides whistle-blower protection to the
reporting entities. The most important benefit of EMTALA is that it
In 2003, the Centers for Medicare and Medicaid is designed to ensure that everyone who needs
Services (CMS) issued the Final Rule and added emergency medical care receives it. Patients can
some new requirement to EMTALA. The addi- have some peace of mind knowing that if they need
tional requirements of the Final Rule specify that emergency care, they will usually receive it. Improper
hospitals providing EMS must post signs identify- and inappropriate transfers are significantly lower
ing the rights of individuals under EMTALA with now than before EMTALA was enacted.
respect to examination and treatment for emer- Another benefit of EMTALA is that the poten-
gency medical conditions and the rights of women tial negative publicity from a violation of the legis-
in labor. Hospitals also are required to maintain lation may be a deterrent against hospitals and
the records related to patients transferred to or physicians failing to fulfill the duties the act
from the hospital for a 5-year period. A list of phy- imposes on them.
sicians who are on call for duty must also be main- However, the specific language of EMTALA is
tained. Finally, the hospital must maintain a log of vague. The vague language serves to eliminate loop-
individuals who sought treatment at the emergency holes that providers may conjure up to deny neces-
department and whether the patients were treated, sary emergency treatment based on the patient’s
stabilized, or discharged. ability to pay, and it creates an impetus for respon-
sible healthcare professionals to interpret the regu-
lations broadly in their effort to satisfy all stated
Enforcement
and implied requirements of the law. Unfortunately,
The Office of the Inspector General (OIG) of the the vague language also creates significant room for
U.S. Department of Health and Human Services misinterpretations of the requirements.
(HHS) and the CMS jointly enforce the EMTALA A major limitation of EMTALA is that man-
regulations. aged-care organizations (MCOs) can potentially
350 Emerging Diseases
use the law to avoid payments for emergency

medical care. Many of these organizations require Emerging Diseases
pre-authorization before they agree to pay for
treatment that their clients will receive. This leaves Emerging diseases may be defined as any infectious
hospitals at risk of not being reimbursed for pro- or pathogenic agent that is capable of causing dis-
viding services for patients who actually have ease and/or has newly appeared in a population.
health insurance coverage, in addition to those The infectious agent may have not been previously
patients who are uninsured, for whom hospitals discovered, or it may be a new variant of an exist-
are also unlikely to be reimbursed. ing disease. Additionally, an emerging disease may
Another limitation of EMTALA is that it is an be one that has previously existed in a population
unfunded mandated program for hospitals. but is rapidly increasing in incidence or in geo-
EMTALA does not provide any payments for graphic range. An increased incidence, or the num-
uninsured patients who hospitals are required to ber of new cases of a disease, over the course of a
treat. This is especially troublesome for inner-city, 20-year period is considered to be an emerging
not-for-profit hospitals, which already bear a dis- disease by epidemiological standards.
proportionate share of uninsured patients and The source of emerging diseases may vary con-
Medicaid recipients. siderably and can result from pathogenic infec-
tious diseases caused by bacteria or viruses.
Allen Harrison Inorganic materials and carcinogens, such as
asbestos and dioxins, may also be responsible for
See also Access to Healthcare; Hospital Emergency
Departments; Hospitals; Medicare; Patient Dumping;
an increased incidence of autoimmune and genetic
Public Policy; Regulation; Uninsured Individuals diseases, such as cancer and birth defects. Also, a
preexisting disease may reemerge in a population
because of developing drug resistance or a break-
down in the public health system. Although the
Further Readings
number of deaths due to emerging diseases has
Bitterman, Robert A. Providing Emergency Care Under been decreasing in recent years, globally about 15
Federal Law: EMTALA. Dallas, TX: American million deaths each year are attributed to infec-
College of Emergency Physicians, 2000. tious diseases. In the United States alone, the
Bond, Paul G. “Implications of EMTALA on Nursing direct cost of infectious disease totals approxi-
Triage and ED Staff Education,” Journal of mately $30 billion a year and is the third leading
Emergency Nursing 34(3): 205–6, June 2008. cause of death. Furthermore, infectious diseases
Gatewood, Joseph, Loren Johnson, and Ellen Arrington. are responsible for approximately 30% of all dis-
A Practical Guide to EMTALA Compliance. ability-adjusted life years (DALYs) worldwide,
Marblehead, MA: HCPro, 2004. and they are a major cause of disability and poor
Moy, Mark M. The EMTALA Answer Book. 2008 ed. health.
New York: Aspen, Wolters Kluwer, 2007.
Strickler, Jeffery. “EMTALA: The Basics,” JONA’S
Healthcare Law, Ethics, and Regulation 8(3): 77–81, Overview
July–September 2006.
Emerging diseases have been in existence ever
since historical times, and they are responsible for
many deaths worldwide each year. For many cen-
Web Sites turies, however, humans remained helpless against
American Academy of Emergency Medicine (AAEM): these diseases as their causes were relatively
http://www.aaem.org/emtala unknown. The establishment of the germ theory
American Hospital Association (AHA): http://www.aha.org eventually led to tremendous progress in the
Centers for Medicare and Medicaid Services (CMS): understanding of emerging diseases and of how to
http://www.cms.hhs.gov/emtala prevent and treat these occurrences. The discovery
U.S. Department of Health and Human Services, Office of penicillin, vaccines, and treatment for infec-
of Inspector General (OIG): http://oig.hhs.gov tious diseases in the 1900s caused the U.S. Surgeon
Emerging Diseases 351
General in 1967 to prematurely claim a victory in One of the most common ways in which
the battle against this enemy. emerging infectious diseases are spread is through
The battle against emerging diseases, however, is zoonoses or transmission from animals to humans.
far from over as it continues to take a significant The mechanism of transmission for the bubonic
toll on human life. Acquired immune deficiency plague was by way of an animal reservoir (rats)
syndrome (AIDS) is likely to surpass the Black and a vector (fleas). In this case, fleas that live on
Death and the 1918 influenza pandemic as one of and bite rats were infected with the bacteria and
the world’s worst killers. Other recent emerging were able to transmit the bacteria to humans
diseases include severe acute respiratory syndrome through the same mechanism.
and monkeypox. Some newly emerging infectious During the plague epidemic, overcrowded cities,
diseases result in chronic diseases that are caused by open sewers, human waste, and garbage in abun-
infectious agents. Examples of this include certain dance provided an ideal breading ground for both
variants of the human papillomavirus that cause rats and fleas. Both the reservoir and the vector
cervical cancer and the herpesvirus, which causes living in very close proximity to the human popu-
Kaposi sarcoma. lation allowed the widespread infection and pro-
Emerging diseases have inflicted tremendous gression from one geographic area to another.
suffering, particularly among people in resource- The cause of the emergence and the reemer-
poor areas and developing countries. In developing gence of agents that may result in disease are com-
nations, the burden of infectious diseases predomi- plex, but they typically can be traced to the ability
nantly affects infants and children, while in devel- of most microbes to evolutionary adapt geneti-
oped nations the poor and minority groups are cally. Natural genetic variations, recombination,
disproportionately affected. Although there has and adaptations allow new strains of pathogens to
been tremendous progress made to prevent and appear to which the human immune system has
treat many of these pathogens, emerging diseases not been previously exposed and is therefore not
continue to exist throughout the world and remain primed to recognize. Furthermore, human behav-
a constant threat. ior plays an important role in the reemergence of
The majority of cases of emerging diseases can diseases. The increased and sometimes imprudent
be directly linked to infectious agents and their use of antimicrobial drugs, including antibiotics,
variants. There are six major classes of agents that has led to the development of resistant pathogens,
are commonly responsible for the emergence of allowing many diseases that were once treatable
infectious diseases. These classes include bacteria; with pharmaceuticals to reemerge with increased
viruses; fungi; protozoa; helminthes; and a newly virulence, which allows the pathogen to reinfect
recognized agent, prions. These six classes of infec- exposed individuals as well as infect previously
tious agents represent the majority of newly classi- nonexposed humans. Additional behavioral issues
fied emerging infectious diseases, with bacteria arise when an individuals is prescribed an antibi-
and viruses being the most prevalent. otic for an infection and fails to complete the entire
Emerging infectious diseases may spread through regimen of the drug. This situation tends to spe-
microbial traffic. Microbial traffic is the introduc- cifically select for and propagate the hardiest of
tion of an infectious agent that already exists in a bacteria.
population (human or otherwise) from other spe- Another contributing factor to the spread of
cies. This includes the spread of infectious agents emerging diseases is that of demographics and
from smaller to larger populations and/or new geography. This is due to the fact that the sustain-
geographic areas, such as the avian flu and West ability of an epidemic depends on a population
Nile viruses. Other factors that contribute to the exceeding a certain threshold density of susceptible
propagation of infectious disease are human demo- individuals. Over the course of the past 5 years,
graphics, human behavior, technology, economic approximately 20 million refugees and 30 million
development, natural disasters, commerce and displaced peoples have been on the move world-
trade practices, as well as the breakdown of basic wide, crossing borders and relocating for a multi-
public health measures, as is the case with tubercu- tude of reasons. This combined with modern
losis in the developing countries. modes of travel and decreased travel time, which
352 Emerging Diseases
allows an individual to move between continents Malaria

within the time span of a day, create unique demo-
Although once controlled, malaria has reemerged
graphic opportunities and pressures as well as
as one of the most important diseases confronting
increasing the amount of microbial traffic. With
the developing world, and it has disproportion-
worldwide travel occurring in the time period of a
ately affected children in sub-Saharan Africa.
day and becoming more frequent, the possibility
Malaria causes about 1 million deaths each year,
for a pathogenic variant being transmitted to a
and it has affected more than 300 million indi-
completely immunologically naive population is
viduals in the world. Although for many years,
not only possible but under certain circumstances
dichlorodiphenyltrichloroethane (DDT) was used
quite probable.
in mosquito abatement programs, the insecticide
is no longer widely used because of potential
HIV/AIDS health concerns and insect resistance. As a result,
malaria has reemerged as a public health problem
Human immunodeficiency virus (HIV) has infected
worldwide.
more than 60 million people worldwide, and it is
the leading cause of death for those aged from 15
to 59 years. This disease possibly emerged from the Influenza
consumption of nonhuman primates in sub-
In the United States, influenza causes an estimated
Saharan Africa between 60 and 100 years ago. The
200,000 people to be hospitalized, and about
spread of HIV likely emerged because of the vast
36,000 individuals die each year from this condi-
movement of human populations from rural to
tion. Globally, each year, about 3 to 5 million
impoverished urban areas combined with sexual
people are infected with influenza, and it causes
promiscuity. The complex interactions between
between 250,000 to 500,000 deaths.
agent, host, and environment demonstrate how
Influenza has gained attention in recent years
changes and movements in the population led to
with the outbreak of the avian influenza in
this pandemic.
Southeast Asia. An estimated 42 individuals died
Although many individuals in the developed
from this highly virulent strain, which killed mil-
nations have benefited from highly active antiret-
lions of birds and chickens. Although few cases of
roviral therapy (HAART) to treat this condition,
human-to-human transmission have been reported,
few people in the developing nations have been
this virus may infect humans from other species.
able to receive appropriate treatment. Developing
The avian flu is being closely monitored to see if
a vaccine to prevent the transmission of HIV has
variants of this disease may cause transmission
proved to be a very difficult challenge.
more easily among humans, which could result in
a pandemic, such as the 1918 influenza outbreak.
Tuberculosis
Tuberculosis (TB), caused by Mycobacterium tuber- West Nile Virus
culosis, was once a controlled disease after the dis-
covery of isoniazid and other drugs. However, in West Nile virus is a reemerging disease, commonly
recent years, TB has reemerged as one of the world’s found in Africa, West Asia, Europe, and the
most lethal diseases, killing more than 2 million Middle East, that has recently made its way to the
people each year. The reemergence of TB was pro- United States. This disease was first reported in
pelled by the large number of immunologically sup- New York City in 1999, where there were a total
pressed individuals infected with HIV/AIDS. The of 62 cases. West Nile virus is known to mostly
inappropriate use of TB treatments has also resulted affect birds; however, humans may be infected
in drug-resistant strains and costly treatments, fur- through a mosquito vector. This virus generally
ther complicating this problem. With many people spreads during the warm, summer months.
in the world continuing to live in poverty, control- Currently, there are several therapies being tested
ling TB remains an enormous challenge. to treat the disease.
Emerging Diseases 353
SARS unpredictable, therefore a timely response is

needed to detect, diagnose, and contain these
Severe acute respiratory syndrome is a respiratory
threats. Coordination of international and local
disease caused by the SARS coronavirus, and it
agencies is needed for surveillance and to ade-
results in flulike symptoms. SARS emerged in late
quately respond to these threats. Additionally,
2002 in Asia, and it quickly spread, alerting pub-
continued clinical and translational research into
lic health officials. Although it is still considered
these pathogens is paramount.
to be a rare disease, the near pandemic of SARS
Several initiatives have been started by the
resulted in 774 deaths. The rapid emergence of
United States, the United Kingdom, and the
SARS highlights the need for public health author-
World Health Organization (WHO) to increase
ities and researchers to work closely together.
surveillance and the early detection of emerging
infectious diseases in an attempt to curtail wide-
Drug-Resistant Microbes spread transmission and to prevent mass infec-
tions of populations at risk. Through cooperative
Drug-resistance viruses and bacteria are quickly
efforts between governments, early-warning com-
reemerging and are the result of mutations and of
munication and countermeasures to the threats of
bacteria acquiring genes through transformation
newly emerging infectious diseases can be accom-
or infection with plasmids. Consequently, antibi-
plished. These concerted efforts should provide
otics such as sulpha drugs, penicillin, methicillin,
the best possible chance of avoiding widespread
and vancomycin, which were once routinely used
epidemics and pandemics in the future.
to treat bacterial infections, no longer work.
Streptococcus pneumoniae and Staphylococcus Darin P. Gonzalez
aureus have now become resistant to existing lines
of treatment and are causing serious concern. See also Bioterrorism; Centers for Disease Control and
Because of these resistant pathogens, continued Prevention (CDC); Disease; Emergency and Disaster
efforts must be made to find treatments that are Preparedness; Epidemiology; Infectious Diseases;
effective against these microbes. Public Health; World Health Organization (WHO)
Bioterror Agents
Further Readings
Some emerging diseases may be deliberately
released, as in the case of microbial warfare and Fauci, Anthony S. “Emerging and Re-Emerging Infectious
bioterrorism. Deliberate release of diseases may Diseases: The Perpetual Challenge,” Academic
include the use of microbes that have been geneti- Medicine 80(12): 1079–85, December 2005.
cally engineered or produced to cause extreme and Fauci, Anthony S., Nancy A. Touchette, and Gregory K.
severe harm—for instance, the 2001 anthrax Folkers. “Emerging Infectious Diseases: A 10-Year
attack targeted at U.S. congressional leaders. Perspective From the National Institute of Allergy and
Because of these growing bioterror threats, the Infectious Diseases,” Emerging Infectious Diseases
11(4): 519–25, April 2005.
U.S. government has initiated the construction of
Jones, Kate E., Nikkita G. Patel, Marc A. Levy, et al.
several regional biocontainment laboratories to
“Global Trends in Emerging Infectious Disease,”
detect, prevent, and treat diseases that are the
Nature 451(7181): 990–93, February 21, 2008.
result of these pathogens.
Morens, David M., Gregory K. Folkers, and Anthony S.
Fauci. “The Challenge of Emerging and Re-Emerging
Future Implications Infectious Diseases,” Nature 430(6996): 242–49, July
8, 2004.
Emerging and reemerging diseases continue to Weiss, Robin A., and Anthony J. McMichael. “Social
challenge public health officials, and they pose and Environmental Risk Factors in the Emergence of
an ever-present threat to the public’s health. The Infectious Diseases,” Nature Medicine 10(Suppl. 12):
effects of emerging and reemerging diseases are S70–S76, December 2004.
354 Employee Health Benefits
Web Sites be highly restricted and may contain provisions

Centers for Disease Control and Prevention (CDC): that exclude any coverage of healthcare needs
http://www.cdc.gov deemed by the insurer to relate to preexisting con-
Infectious Diseases Society of America (IDSA): ditions. As a result, access to benefits in the work-
http://www.idsociety.org place is a significant determinative of coverage.
National Institutes of Allergy and Infectious Diseases
(NIAID): http://www3.niaid.nih.gov
World Health Organization (WHO): http://www.who.int Overview
Employer-sponsored health insurance coverage
has been referred to as the accidental system,
because its origins can be traced back to a decision
Employee Health Benefits to exclude employer contributions to coverage
from family income during World War II, when
Employee health benefits are a service that is strict wage and price controls were in effect. This
provided by an employer to employees in addition decision was formalized as a part of the Internal
to wages or a salary. Employer-sponsored health Revenue Code Amendments of 1952, following
benefits is the most common source of health which the proportion of persons with employer-
insurance coverage in the United States, and it is a sponsored coverage began a dramatic climb,
major source of health insurance for the working- reaching its apex in the mid-1970s. Changes in
age population and, to a lesser extent, retirees. labor patterns, family composition, and the under-
Most Americans receive health insurance coverage lying economy have all contributed to the slow
through their job or through a family member’s erosion of the system, along with a more precipi-
employer. In 2005, nearly 162 million individuals, tous decline in the number of retirees. In the early
or more than 93% of all persons with private 1990s, two thirds of all retirees had employer-
health insurance, were covered by an employer- sponsored coverage; by 2005, this figure had
sponsored health plan, either as direct plan par- declined to one third.
ticipants or as the beneficiaries of a participant’s Employer-sponsored benefits create several
plan. Employers generally use health benefits to distinct advantages for covered persons and are
attract and retain workers; however, the rising both tangible and intangible. First, because cover-
costs of healthcare have become an increasing age is based on a group, the cost of coverage is
concern in recent years. Many experts believe that significantly lower and coverage is significantly
employer-sponsored health coverage has reached more generous than coverage obtained on an
a tipping point as the number of covered individu- individual basis. Second, under the provisions of
als has been declining since 2000. Because the the tax code, employer contributions to coverage
provision of health benefits is a matter of discre- are excluded when calculating taxable income,
tion on the part of employers and plan participa- thereby greatly reducing the cost of coverage (of
tion is generally voluntary by employees, health course, cash wages may also be lower in recogni-
insurance coverage follows a distinct pattern tion of this contribution to income). Third, many
linked to family income: The higher the family employers have adopted tax-advantaged arrange-
income, the more likely the presence of benefits. ments that permit employees to contribute toward
Similarly, because the U.S. tax code extends their own premium costs—where applicable—on
favorable economic treatment to health insurance a pretax basis, further reducing the cost of cover-
when purchased through an employer-sponsored age. Fourth, many employers now offer tax-
plan, lower-income persons—the very individuals advantaged savings accounts in conjunction with,
least likely to have employer-sponsored benefits— or in addition to, health benefit plans, thereby
also have no tax subsidies available to help offset further reducing employee healthcare costs by
the cost of securing individual coverage. Further permitting employees to contribute to these
more, even when individuals can find affordable accounts and purchase uncovered healthcare on a
plans in the individual marketplace, coverage may pretax basis.
Employee Health Benefits 355
Actual revenue losses to the U.S. Treasury Trends in Employer-Sponsored Insurance

resulting from employer-sponsored health plans
The patterns of employer-sponsored insurance have
are considerable, surpassing $200 billion in FY2006
generally followed the overall trends of the econ-
alone. Furthermore, since state tax codes generally
omy. Although the number of nonelderly with
mirror the U.S. tax code where employer-
employer-sponsored insurance grew in the early to
sponsored income is concerned, revenue losses
mid-1990s, the proportion of U.S. residents with
actually are significantly higher.
employer-sponsored insurance declined from 69.1%
Finally, health insurance coverage has an incal-
to 63.1% between 1994 and 2005. It has been sug-
culable value to covered individuals because it
gested that the decline in employer-sponsored insur-
protects against economic loss from both foresee-
ance is due to the lack of take-up by employees.
able and unforeseeable healthcare expenditures.
Because health plan participation by employees is
Whereas traditional notions of insurance would
generally voluntary, not everyone who is offered
limit coverage to losses related to unanticipated
employer-sponsored insurance takes advantage of
events (such as serious illness or injury), it is in fact
this benefit. The affordability of health insurance
customary for employer-sponsored plans to cover
coverage is an important concern among many
at least some level of preventive and primary
low-wage workers. The decision to take up health
health benefits, such as well-child care, screening
insurance may be influenced by several factors,
mammography, and immunizations. In essence,
including the level of out-of-pocket expenses, the
therefore, employer-sponsored plans function as a
quality of the benefits package, and the availability
tax-free means of supplementing family income.
of insurance through alternative sources.
In addition to health insurance coverage,
Regardless of the trends in employer health
employee health benefits may also include dental
insurance coverage, studies have shown that
and vision coverage, sick leave, maternity leave, and
sociodemographic characteristics such as race,
family medical leave. Employers have also realized
gender, and position in the labor market are asso-
the cost savings potential of health-education-
ciated with the receipt of health benefits. For
related programs, known commonly as employee
instance, younger and lower-income workers are
assistance programs, that reduce the health risks of
less likely to be covered through employers, and
employees. As a result, employers have developed
full-time workers are more likely to be covered
worksite health promotion programs to assist
than part-time workers. Furthermore, workers in
employees modify their lifestyle through, for exam-
occupations that require higher skill levels and
ple, cessation of smoking, increase in physical activ-
have more responsibility, such as managerial and
ity and weight loss, and change of diet. Research
professional services, are more likely to have
has shown that a comprehensive worksite health
employer-based health insurance coverage than
promotion program can have positive benefits for
workers who are in the service industry. In addi-
employee health and for the employer through
tion, public-sector workers are more likely to have
reduced absenteeism and employee turnover.
employer-sponsored coverage than private-sector
workers. Among private-sector workers, however,
Employee Retirement employees who work in larger firms are more
Income Security Act likely to receive health benefits than those who
work in smaller firms.
The Employee Retirement Income Security Act
(ERISA) has played a central role in protecting
and standardizing employee health benefits. ERISA
Health Plan Enrollment
covers most private health plans, and it ensures
and Healthcare Costs
the rights of employees and beneficiaries by pro- Over the past decade or so, the number of indi-
viding protections and ensuring access to informa- viduals enrolled in traditional fee-for-service plans
tion on health plans. Employers who manage their has declined substantially. The majority of employ-
own plans must also make sure that certain stan- ers generally now offer their employees a
dards are met to be in compliance with ERISA. managed-care plan with level-dollar contributions,
356 Employee Health Benefits
meaning that if an employee chooses a more Employers have also been trying to implement
expensive plan, he or she will have to pay for the new strategies to control costs. For example, high
difference in cost. The reason for the growth in deductible health plans in combination with health
managed care is because it slowed the rising costs savings accounts is a model of consumer-driven
of health insurance for employers in the 1990s. health plans that is gaining popularity but still
The rapid escalating costs of health insurance accounts for only a relatively small portion of cov-
are one of the largest employee health benefit con- ered individuals. These types of consumer-driven
cerns of employers. In 2006, of the average health health plans allow employees to put pretax dollars
insurance premium of $4,242, employers paid into special health savings accounts. Because of
approximately $3,563, while employees paid the this type of arrangement, employees generally
remainder. In the same year, both public and pri- assume a larger share of their overall healthcare
vate employers spent roughly $2.33 trillion on costs because they must decide what types of
employee benefit programs, which is an almost healthcare services they are willing to pay for.
50% increase from 2000. Approximately 43.5% Again, these types of plans have been shown to
of the employee benefit payments were for health result in risk selection, attracting healthier and
benefits. Small businesses face greater challenges in more affluent individuals. Additionally, there are
providing their employees with affordable health concerns that some individuals may delay seeking
insurance due to the higher premiums they face care and endanger their health because they are
because of their decreased bargaining power. As concerned about exhausting their health savings
the cost of healthcare continues to increase, it is accounts.
estimated that health benefits will surpass retire- Employers may also change the health benefits
ment benefit costs as the single largest employer that are offered to employees by transitioning from
expense for benefits. a defined benefits package to a defined contribu-
To rein in costs, employers have reduced health tions package. This approach fixes the total
benefits spending by increasing the level of employee amount that a company contributes toward an
cost sharing, reducing benefits, or eliminating cov- employee’s benefits. Some companies have also
erage entirely. Many companies believe that they implemented a pay-based contribution method,
have no other option but to have employees pay whereby lower-income employees receive a greater
for a greater portion of their health-related subsidy to help keep health insurance coverage
expenses. affordable. Thus, employee contributions may
Several reasons have been offered for encourag- vary according to the level of their salary or as a
ing employee cost sharing. It has been suggested fixed percentage of their income. In 2005, about
that if employees shoulder a greater portion of 8% of large employers incorporated the use of a
their actual healthcare costs, they will be more pay-based strategy. A limitation of a pay-based
sensitive to this cost and it will create financial strategy, however, is that it does not address the
incentives for individuals to make more cost- rising healthcare costs. Therefore, some employers
effective and informed decisions from the range of may decide to opt out of providing insurance cov-
available options. Having employees directly con- erage entirely, and others may link employee con-
tribute a greater portion of their health benefits tributions to lifestyle and behavior modifications
may make individuals’ behavior more cost sensi- that create incentives for individuals to reduce
tive, but it may also affect employees’ ability to their health risks. Another extreme measure that
retain health insurance coverage. Another reason some employers have taken includes imposing a
for employee contribution is that if it is required, spousal surcharge, which requires employees to
then a company only needs to provide insurance pay an additional contribution to enroll their
for those employees who demand it. Therefore, the spouse, who already has available insurance cover-
company is able to pass on any potential cost sav- age through another employer. Some employers
ings back to employees directly through higher may also decide to lock out spouses who have
wages. A consequence of this action, however, is available coverage through their workplace.
adverse selection, where healthier and more afflu- As the cost of healthcare continues to rise,
ent individuals benefit the most. employer-sponsored health insurance may no
Employee Retirement Income Security Act (ERISA) 357
longer be financially feasible for many companies Bad Jobs Getting Worse?” Journal of Health
to offer since it has become extremely difficult for Economics 19(1): 93–119, January 2000.
industries to remain competitive in a global market. Gabel, Jon, Gary Claxton, Isadora Gil, et al. “Health
Because of this, many researchers are convinced Benefits in 2005: Premium Increases Slow Down,
that there needs to be a fundamental shift in the Coverage Continues to Erode,” Health Affairs 24(5):
way health insurance coverage is obtained in the 1273–80, September–October 2005.
United States. Gabel, Jon, Gary Claxton, Erin Holve, et al. “Health
Benefits in 2003: Premiums Reach Thirteen-Year
High as Employers Adopt New Forms of
Future Implications Cost Sharing,” Health Affairs 22(5): 117–26,
September–October 2003.
Employers remain the largest source of health Gabel, Jon, Larry Levitt, Erin Holve, et al. “Job-Based
insurance coverage for the nation’s citizens. In light Health Benefits in 2002: Some Important Trends,”
of the tangible and intangible benefits that flow Health Affairs 21(5): 143–51, September–October
from employer-sponsored health plans, it should 2002.
come as little surprise that health insurance reform Gruber, Jonathan, and Robin McKnight. “Why Did
is so difficult to achieve. The nearly 162 million Employee Health Insurance Contributions Rise?”
persons who have employer-sponsored coverage Journal of Health Economics 22(6): 1085–1104,
highly value it, as measured in numerous public November 2003.
opinion surveys. Likewise, employers consider Monheit, Alan C., and Barbara Steinberg Schone. “How
health benefits to be an important dimension of Has Small Group Market Reform Affected Employee
their employee compensation policies and an impor- Health Insurance Coverage?” Journal of Public
tant means of attracting and retaining a competent Economics 88(1–2): 237–54, January 2004.
workforce. Allegiance to employer-sponsored cov-
erage thus has remained considerable, even as the
Web Sites
nation has witnessed a significant decline in cover-
age over the past generation. The rising cost of Agency for Healthcare Research and Quality (AHRQ),
healthcare and the economic decline have resulted Employer-Sponsored Health Insurance, Trends in
in increased cost sharing by employees. To ensure Cost and Access: http://www.ahrq.gov/research/
access to the healthcare system, healthcare costs empspria/empspria.htm
must be controlled and coverage must be made Henry J. Kaiser Family Foundation (KFF), Employee
affordable. It is likely that any future reforms to the Health Benefits Annual Survey: http://www.kff.org/
U.S. healthcare system will include an expansion of insurance/ehbs-archives.cfm
the current employer-based model. National Center for Health Statistics (NCHS), National
Employer Health Insurance Survey (NEHIS): http://
Sara Rosenbaum www.cdc.gov/nchs/about/major/nehis/nehis.htm
National Coalition on Health Care (NCHC), Facts on
See also Compensation Differentials; Consumer-Directed the Cost of Health Care: http://www.nchc.org/facts/
Health Plans (CDHPs); Cost of Healthcare; Cost cost.shtml
Shifting; Employee Retirement Income Security Act National Conference of State Legislatures (NCSL), State
(ERISA); Flexible Spending Accounts (FSAs); Employee Health Benefits: http://www.ncsl.org/
Health Savings Accounts (HSAs); Tax Subsidy of programs/health/stateemploy.htm
Employer-Sponsored Health Insurance
Further Readings Employee Retirement Income

Enthoven, Alain C. “Employment-Based Health
Security Act (ERISA)
Insurance Is Failing: Now What?” Health Affairs
Web Exclusive W3: 237–49, May 28, 2003. The Employee Retirement Income Security Act
Farber, Henry S., and Helen Levy. “Recent Trends in (ERISA), a federal law created in 1974, provides
Employer-Sponsored Health Insurance Coverage: Are protection to individuals who participate in
358 Employee Retirement Income Security Act (ERISA)
voluntary private health and pension plans. contributions to coverage from family income dur-
Designed to establish minimum standards for ing World War II, when strict wage and price con-
these plans, ERISA requires plans to provide par- trols were in effect. This decision was formalized
ticipants with important information about plan as part of the Internal Revenue Code Amendments
features and funding and provides fiduciary of 1952, following which the proportion of per-
responsibilities for those who manage and control sons with employer-sponsored coverage began a
plan assets. The law requires plans to establish a dramatic climb, reaching its apex in the mid-1970s.
grievance-and-appeals process for participants to Changes in labor patterns, family composition,
get benefits from their plans. Importantly, it gives and the underlying economy have all contributed
participants the right to sue for benefits and to the slow erosion of the system, along with a
breaches of fiduciary duty. This entry discusses more precipitous decline in the number of retirees.
the history of employee benefits in the United In the early 1990s, two thirds of all retirees had
States, examines the development of ERISA, employer-sponsored coverage; by 2005, this figure
explores the interpretation of the federal legisla- had declined to one third.
tion, and highlights the likely role of ERISA in Benefits sponsored through employers create
future public policy development. several distinct advantages for covered persons
and are both tangible and intangible. First, because
coverage is based on a group, the cost of coverage
History of Employee Health Benefits
is significantly lower and coverage is significantly
In the United States, employer-sponsored health more generous than coverage obtained on an indi-
benefits represent a central source of health insur- vidual basis. Second, under the provisions of the
ance for the working-age population and, to a U.S. tax code, whose roots trace back to World
lesser extent, retirees. In 2005, nearly 162 million War II, employer contributions to coverage are
persons, more than 93% of all persons with private excluded when calculating taxable income, thereby
health insurance, were covered by an employer- greatly reducing the cost of coverage. Cash wages
sponsored health plan, either as direct plan partici- may also be lower in recognition of this contribu-
pants or as the beneficiaries of a participant’s plan. tion to income. Third, many employers have
Because the provision of health benefits is a matter adopted tax-advantaged arrangements that permit
of discretion on the part of employers, health insur- employees to contribute toward their own pre-
ance coverage follows distinct patterns linked to mium costs, where applicable, on a pretax basis,
family income: The higher the family income, the further reducing the cost of coverage. Fourth,
more likely the presence of benefits. many employers now offer tax-advantaged savings
Similarly, because the U.S. tax code extends accounts in conjunction with, or in addition to,
favorable economic treatment to health insurance health benefit plans, thereby further reducing
only when purchased through employer-sponsored employee healthcare costs by permitting employ-
plans, lower-income persons, the very individuals ees to contribute to these accounts and purchase
least likely to have employer-sponsored benefits, uncovered healthcare on a pretax basis.
also have no tax subsidies available to help offset Actual revenue losses to the U.S. Treasury
the cost of securing individual coverage. Further resulting from employer-sponsored health plans
more, even when individuals can find affordable are considerable, surpassing $200 billion in
plans in the individual marketplace, coverage may 2006 alone. Furthermore, since state tax codes
be highly restricted and may contain provisions generally mirror the U.S. tax code where employer-
that exclude any coverage of healthcare needs sponsored income is concerned, revenue losses
deemed by the insurer to relate to preexisting actually are significantly higher.
medical conditions. As a result, access to benefits Finally, of course, health insurance coverage has
in the workplace is a significant determinative of an incalculable value to covered individuals because
coverage. it protects them against economic loss from both
Employer-sponsored coverage has been referred foreseeable and unforeseeable healthcare expendi-
to as the “accidental system,” because its origins tures. Traditional notions of insurance would limit
can be traced to a decision to exclude employer coverage to losses related to unanticipated events,
such as serious illness or injury, but it is also is limited to persons who are poor enough to
customary for employer-sponsored plans to cover qualify for Supplemental Security Income (SSI),
at least some level of preventive and primary-care where earnings are at or below approximately
health benefits, such as well-child care, screening 75% of the federal poverty level.
mammography, and immunizations. Employer- As a matter of federal law, the legal authority
sponsored plans, in essence, function as tax-free for the regulation of insurance, including health
means of supplementing family income. insurance, rests with the individual states. The fed-
In light of the tangible and intangible benefits eral law that established this authority in states is
that flow from employer-sponsored health plans, the McCarran-Ferguson Act of 1945. At the same
health insurance reform has been difficult to time, ERISA, which was passed in 1974, essentially
achieve. The nearly 162 million persons who have upends this proposition to a considerable extent
coverage value it highly, as measured in numerous without actually overturning the McCarran-
public opinion surveys; likewise, employers con- Ferguson Act.
sider health benefits to be an important dimension
of their employee compensation policies and an
The States’ Role in Health Insurance
important means of attracting and retaining a
competent workforce. Allegiance to employer- Responding to a 1945 U.S. Supreme Court deci-
sponsored coverage thus has remained consider- sion subjecting the insurance industry to federal
able, even as the nation has witnessed a decline in regulation, the U.S. Congress moved rapidly to
coverage over the past generation. Between 1994 restore the primacy of states in insurance regula-
and 2005 alone, the proportion of U.S. residents tion through the passage of the McCarran-
with employer coverage declined from 69% to Ferguson Act. By the mid-1970s, all states to some
63% in the case of the total population, and from degree regulated health insurance. State regula-
66% to 58% in the case of children under 18 years tory structures reached the financial aspects of
of age. insurance, such as plan capitalization and reserves,
Table 1 illustrates the skewed nature of health and the financial aspects of plan operations. State
insurance coverage in the United States, chiefly as law also regulated marketplace conduct, prohibit-
a result of a system that treats health insurance as ing certain types of deceptive marketing practices.
an aspect of employee compensation. Finally, state laws regulated the content of insur-
Uninsured persons show patterns that are essen- ance coverage through an increasing number of
tially the inverse of those evident among persons benefit mandates, including the requirement for
with health insurance coverage. Uninsured per- coverage of at least a certain amount of inpatient
sons, as well as their family members, are signifi- mental health treatment.
cantly more likely to be low-income workers. These express state laws were aimed at the insur-
Most uninsured persons are uninsured for rela- ance industry and its nature, structure, and opera-
tively lengthy periods of time, usually a year or tions of insurance contracts. Numerous other state
more. Compensating public insurance benefits for laws reached insurer behavior too. For example,
lower-income uninsured persons generally are state civil rights and human rights statutes prohibit-
available under the Medicaid program only in the ing discrimination in the workplace were interpreted
case of selected subgroups of low-income persons: to prohibit employee benefit plans from reducing or
low-income children under 18 years of age; low- eliminating disability coverage in the case of women
income pregnant women; and single parents of whose disability was related to pregnancy. Similarly,
children under 18 years of age, who are below by the late 1970s, many states had laws that permit-
50% of the federal poverty level. Public coverage ted persons alleging injuries caused by the deliberate
through Medicare and/or Medicaid may be avail- and unfair claims denial practices of insurers to
able in the case of persons who are sufficiently bring suit for “bad faith breach of contract” and to
physically or mentally disabled. Medicare is seek compensatory and noneconomic damages as
restricted to persons whose employment history part of their remedy. A few states, most notably
meets the 40-quarter minimum work requirement California, recognized that insurers could be sued
contained in the Social Security Act, while Medicaid for corporate medical negligence in cases in which
Table 1 U.S. Private Health Insurance Coverage Through the Workplace Among Persons Under Age 65, by
Percentage and Selected Characteristics, 2005
Personal Characteristics Percentage of the Population
Total population treatment 63.1

Under 18 years of age 58.2
18–44 years of age 61.7
45–64 years of age 70.3
White only 65.6

Black/African American only 50.2
Hispanic or Latino 39.9
Below 100% of the federal poverty level 17.7
200% or more of the federal poverty level 78.3
Geographic region
Northeast 70.2
Midwest 69.6
West 59.6
South 57.6
Source: Health United States 2007, Table 137.
prospective utilization of substandard management uniform, national standards for the regulation of
systems and procedures could be shown to be a pension plans. Prior to ERISA’s enactment, employ-
proximate cause of injury or death. ers and unions had enormous discretion over the
In sum, even as ERISA moved to establish uni- structure and operation of pensions, and state
formity within the world of pension plans, a broad regulation of pension plans varied from weak to
body of state law not only regulated the structure nonexistent. Following a series of spectacular pen-
and content of insurance contracts, as well as con- sion plan failures, the U.S. Congress enacted legis-
tract administration, but also created rights and lation that established a unified federal approach
remedies for injuries arising from the maladminis- to the vesting, funding, and operation of pension
tration of health insurance coverage in connection plans, a mechanism for guaranteeing pensions to
with prospective utilization review. secure pension rights, and a strict fiduciary stan-
dard against which to measure the legality of pen-
sion plan administration.
Requirements of ERISA
The enactment of ERISA involved virtually no
Enactment of ERISA in 1974 fundamentally discussion of health benefits, which simply were
altered the regulatory landscape. It also affected classified as a part of employer-sponsored “welfare
regulations following profound shifts in the health benefits” and thus were to be subject to the terms
benefits marketplace, including the spread of proof the statute. Unlike its pension provisions, how-
spective and concurrent utilization review and the ever, ERISA established virtually no substantive
growth of plans that effectively merge coverage statutory terms where welfare plans were con-
and care through networked provider arrange- cerned, and the intervening years have seen the
ments that give plans considerable control over enactment of very little in the way of statutory
actual access to care. minimums with respect to health plan content and
ERISA, which applies to all private employers, structure, health plan operations, and patient and
had as its central purpose the establishment of consumer protections.
ERISA Reforms most, used postclaims review procedures to deter-

mine medical necessity.
While the original legislation did not include many Outside these few examples and a handful of
statutory terms for health plans, one notable additional minor requirements, ERISA is effec-
exception is the continuation of health insurance tively devoid of structural requirements related to
coverage, which was established as part of the fed- the structure or administration of health benefit
eral Consolidated Omnibus Budget Reconciliation plans offered by employers. Despite this fact,
Act of 1985 (COBRA). Continuation of coverage however, an obscure provision of ERISA, known
applies to employers with 20 or more full-time as the preemption statute, allows federal law to
employees and requires employer health plans to override state regulations by preempting state
permit persons who lose their health plan partici- laws that “relate to” employer-sponsored benefit
pant or beneficiary status as a result of certain plans.
qualifying reasons (e.g., the death of the covered
worker, loss of job, divorce) to continue to pur-
chase group health insurance coverage on a full- Preemption Under ERISA
premium, unsubsidized basis. Under the preemption statute of ERISA, laws are
The Health Insurance Portability and considered preempted if they attempt to compel
Accountability Act of 1996 (HIPAA) also provides plan design or place a direct burden on plan admin-
limited health insurance protections. Portability istration; on the other hand, laws that create indi-
permits individuals who amass creditable coverage rect economic burdens, such as a tax on healthcare
under one employer, and who meet certain other services, are not considered to relate to plans for
conditions, to change jobs without having to sat- purposes of preemption.
isfy preexisting requirements and waiting periods In addition, the ERISA preemption statute
under a subsequent employer plan. These rights “saves” state laws that regulate insurance. However,
also permit movement by individuals into the indi- self-insured health benefit plans, which account
vidual insurance market following exhaustion of for over half of all persons with employer-spon-
their COBRA benefits, without being subject to sored coverage, are not considered to be insurance.
the preexisting-conditions exclusions that charac- Thus, they are shielded from state insurance laws
terize individual policies. Portability does not, that apply to the health insurance industry and
however, address the basic affordability of indi- regulate the insurance contract.
vidual coverage or its postcoverage limitations. The preemptive effects of ERISA do not end
A third example of ERISA reform concerning with the so-called preemption statute. ERISA also
health benefits came in 2000, during a period of establishes an exclusive means by which individu-
intense and ultimately unsuccessful legislative als can challenge wrongful plan conduct. As noted,
debate over patients rights in managed-care when a claim arises involving benefits that alleg-
arrangements. That year, the U.S. Department of edly are due to a patient under the terms of the
Labor promulgated regulations that added consid- plan, the patient can seek a full and fair review by
erable rigor to the obligations of health plans when the plan and can go to court to secure his or her
individuals appeal decisions denying or terminat- benefits or to enjoin a future wrongful plan con-
ing benefits. In addition, the 2000 “full and fair” duct. But ERISA’s remedial provisions contemplate
hearing regulations established important limita- no means for recovering damages in the event of
tions on the amount of time that plans can take in injury. When an employer-sponsored plan, whether
making coverage determinations, in recognition of a large self-insured plan or a smaller plan that pur-
the adverse effect that prospective and concurrent chases state-regulated insurance and delegates
utilization review can have on healthcare access. administrative powers to the insurer, makes a bad-
Prospective utilization management was essentially faith or negligent coverage decision that results in
unheard of at the time of ERISA’s enactment in injury or death, claimants are cut off from all avail-
1974, as was the use of network-style health insurable damage remedies under state law. In effect,
ance. At the time, 90% of the insured workforce ERISA shields employer-sponsored health plans
was covered by indemnity insurance plans that, at from the consequences of negligent or wrongful
conduct, a fact that the U.S. Congress has attempted and health plans. It has many implications in the
to address by means of legislative amendments. health insurance marketplace, and its modifica-
ERISA’s shielding powers came to light in a his- tion becomes a crucial consideration in national
toric case involving the death of an infant after the health reform, particularly in the case of reform
mother’s health plan refused to preapprove her plans that contemplate a strong state role in the
inpatient admission prior to delivery so that her establishment or regulation of employee health
high-risk pregnancy could be managed more appro- benefit plans. Similarly, ERISA determines the
priately. Despite the fact that state law would have extent to which individuals who allege injury as a
given her the right to seek economic and noneco- result of substandard plan administration in the
nomic damages arising from the loss of her baby, area of coverage determinations have access to eco-
the federal courts ruled that ERISA’s exclusive nomic or noneconomic damages. A better under-
remedial provisions served to preempt all state rem- standing of ERISA and its interpretations will help
edies other than those specified in the ERISA statute inform any future reform efforts.
itself. Although the plan’s decision directly impli-
cated the woman’s access to healthcare itself, the Sara Rosenbaum
conduct was held to be a function of plan adminis- See also Access to Healthcare; Healthcare Reform;
tration, since prospective utilization review is simply Health Insurance; Health Insurance Coverage; Public
an aspect of modern health insurance operations. Policy; Regulation; State-Based Health Insurance
At the same time, this shield has its limits. In Initiatives; Uninsured Individuals
those situations in which an injured person can
demonstrate to a court that the injuries arise out
of the quality of care, as in the performance of a Further Readings
health professional or hospital in a health plan’s
Bronsteen, John, Brendan S. Maher, and Peter K. Stris.
provider network, the courts consider this type of
“ERISA, Agency Costs, and the Future of Health
claim to be one that seeks damages for the quality
Care in the United States,” Fordham Law Review
of the care furnished rather than for benefits that
76(5): 2297–2332, April 2008.
allegedly are owed under the terms of the plan.
Polvino, Kathlynn, Mazda K. Antia, and Jeremy P.
Despite this exception for quality claims, as Burnette. “ERISA as an Obstacle to Fair Share
well as the limits of preemption in the case of Legislation and Other State Initiatives to Expand
state laws that have only an indirect economic Coverage to the Uninsured and Underinsured,”
impact on ERISA health benefit plans, ERISA is Journal of Health and Life Sciences Law 1(1): 99,
understood to have a broad sweep, prohibiting 101–26, 2007.
state health reforms that compel certain types of Schneider, Paul J., and Brian M. Pinheiro. ERISA: A
health plan conduct. For example, a state cannot Comprehensive Guide. 3d ed. Frederick, MD: Aspen,
compel an employer to offer health benefits. The 2008.
State of Hawaii does so pursuant to an express Wooten, James A. The Employee Retirement Income
waiver of ERISA, granted in consideration of the Security Act of 1974: A Political History. Berkeley:
fact that the Hawaii law predated ERISA and was University of California Press, 2004.
immediately overturned following the federal Ziesenheim, Ken. Understanding ERISA: A Compact
enactment. Similarly, it would appear that a state Guide to the Landmark Act. Ellicott City, MD:
cannot compel an employer to either offer a Marketplace Books, 2002.
health benefit plan or pay into a pool, although
the legality of such an approach has not yet been
definitively addressed by the U.S. Supreme Web Sites
Court. America’s Health Insurance Plans (AHIP):
http://www.ahip.org
Employee Benefit Research Institute (EBRI):
Future Implications
http://www.ebri.org
The enactment of ERISA in 1974 sought to pro- ERISA.COM: http://www.erisa.com
tect participants in employee-sponsored pension U.S. Department of Labor (DOL): http://www.dol.gov
Enthoven, Alain C. 363
well as the Paul Ellwood Award for Efforts in

Enthoven, Alain C. Health Care Accountability from the Foundation
for Accountability (FACCT).
Alain C. Enthoven is a leading figure in the field Enthoven was a Rock Carling Fellow with the
of health economics and is regarded as the father of Nuffield Trust of London from 1998 to 1999 and
managed competition. He was also a cofounder is a former Rhodes Scholar. He is also an elected
of the Jackson Hole Group in Teton Village, member of the National Academy of Sciences,
Wyoming, a healthcare reform policy think tank, Institute of Medicine (IOM), and a fellow of the
which was composed of medical, public policy, American Academy of Arts and Sciences.
and business leaders committed to improving the Throughout his career, Enthoven has been deeply
nation’s healthcare system. Enthoven is currently involved with healthcare policy at both the state
the Marriner S. Eccles Professor of Public and and federal levels. In 1977, while serving as a con-
Private Management, emeritus, at the Stanford sultant to President Jimmy Carter, he proposed a
Graduate School of Business, and a core faculty at plan for universal health insurance, called Consumer
the Center for Health Policy/Center for Primary Choice Health Plan, the basis of which was man-
Care and Outcomes Research at Stanford. aged competition. He also has served as Chairman
Enthoven was born in 1930 in Seattle, of the Health Benefits Advisory Council for the
Washington. He received his bachelor’s degree California Public Employees Retirement System
from Stanford University in 1952, his master’s and was appointed Chairman of the California
degree from Oxford University in 1954, and a Managed Care Health Improvement Task Force,
doctorate degree from the Massachusetts Institute which was charged with the responsibility of study-
of Technology in 1956—all in economics. From ing healthcare issues created by managed care.
1956 to 1960, Enthoven worked as an economist Enthoven has published widely on issues related
at the RAND Corporation. Following this, he to the economics, management, and public policy
worked at the U.S. Department of Defense, which of healthcare, both in the United States and in the
ultimately culminated in his appointment by United Kingdom. The major focus of Enthoven’s
President Lyndon B. Johnson as assistant secretary research has been to examine the root causes of the
of defense for systems analysis in 1965. In 1969, rapid escalation in healthcare costs and national
Enthoven entered the corporate world, taking a health expenditures and to investigate strategies to
position as vice president of economic planning for mitigate these increases while improving the quality
Litton Industries, and in 1971 he became the of care. He is currently developing a proposal for a
president of Litton Medical Products. In this posi- market-based universal health insurance system.
tion, he began his work in health economics. In
1973, Enthoven became a professor at Stanford Alyssa Howell
University, where he currently remains.
During his distinguished career, Enthoven has See also Cost of Healthcare; Ellwood, Paul M.;
Healthcare Reform; Health Economics; Health
received numerous awards, appointments, and
Insurance; Managed Care; National Health Insurance;
recognitions for his accomplishments in the field of
Public Policy
economics. President John F. Kennedy presented
Enthoven with the President’s Award for
Distinguished Federal Civilian Service in 1963.
Enthoven also received the Baxter Health Services Further Readings
Research Prize from the Association for University Enthoven, Alain C. “The History and Principles of
Programs in Health Administration (AUPHA) in Managed Competition,” Health Affairs 12(Suppl. 1):
1994 for his work on managed competition. In the 24–48, 1993.
same year, he was awarded the Clifton J. Latiolais Enthoven, Alain C. “Market Forces and Efficient Health
Honor Medical from the American Managed Care Care Systems,” Health Affairs 23(2): 25–27, 2004.
Pharmacy Association. Enthoven also received the Enthoven, Alain C., and Victor R. Fuchs. “Employment-
Board of Directors Award from the Healthcare Based Health Insurance: Past, Present, and Future,”
Financial Management Association (HFMA) as Health Affairs 25(6): 1538–47, 2006.
364 Epidemiology
Enthoven, Alain C., and Richard Kronick. “A used to evaluate therapeutic and preventive health
Consumer-Choice Health Plan for the 1990s: measures, such as determining the effectiveness
Universal Health Insurance in a System Designed to and safety of health-screening programs, new
Promote Quality and Economy: Part 1,” New drugs, and vaccines. Public policymakers, govern-
England Journal of Medicine 320(1): 29–37, 1989. ment agencies, health insurance companies, hospi-
Enthoven, Alain C., and Richard Kronick. “A tals, physicians, and others increasingly rely on
Consumer-Choice Health Plan for the 1990s: epidemiology as the foundation for making sound
Universal Health Insurance in a System Designed to decisions to protect the public’s health.
Promote Quality and Economy: Part 2,” New
The field of epidemiology is highly interdisci-
England Journal of Medicine 320(2): 94–101, 1989.
plinary. It relies heavily on the concepts, knowl-
Enthoven, Alain C., and Laura A. Tollen, eds. Toward a
edge, and theories of disciplines such as biology,
21st Century Health System: The Contributions and
pathology, and physiology in the health and
Promise of Prepaid Group Practice. San Francisco:
Jossey-Bass, 2004.
biomedical sciences, as well as the disciplines of
anthropology, psychology, and sociology in the
behavioral and social sciences. Epidemiology is
Web Sites
also very closely tied to the discipline of statistics,
particularly biostatistics. Within the basic disci-
Stanford Center for Health Policy, Center for Primary pline of epidemiology, there are several core sub-
Care and Outcomes Research, Faculty Profile: http:// fields that have emerged over time. For example,
healthpolicy.stanford.edu/people/alaincenthoven scientific progress in the field of molecular genet-
ics has spawned a relatively new area of study
called genetic epidemiology. Epidemiologists
focusing their efforts in this area are concerned
Epidemiology with determining how newly discovered genes
interact with the host and environment to pro-
The term epidemiology is derived from the Greek duce complex disease. Other subfields within
roots epi meaning on or upon, demos meaning the epidemiology include infectious disease epidemi-
common people, and logy meaning the study of. ology, chronic disease epidemiology, cancer epide-
Epidemiology is defined as the study of diseases in miology, occupational epidemiology, and social
human populations, their causes, and their means epidemiology.
of prevention. The term disease in the definition
refers to a broad array of health and medical
History
problems, including disability, injury, and death.
Epidemiology differs from clinical medicine in a Epidemiology is a relatively new science that
number of ways. It studies groups of people, not emerged in the 19th century. However, its historical
just individuals. Epidemiology also studies both development spans thousands of years and is best
well people and people with disease to identify the described as slow and unsteady. Over the centuries,
crucial differences between those who are stricken many individuals have contributed to the establish-
and those who are spared. These differences are ment of the modern field of epidemiology.
compared to identify the underlying causes or eti- The first important individual was the Greek
ologies of disease. While the goal of clinical medi- physician Hippocrates (428–347 BCE), who is tra-
cine is to diminish pain, restore function, and bring ditionally regarded as the father of Western clinical
the patient back to full health, the main goal of medicine. Hippocrates wrote the first epidemio-
epidemiology is to understand the causes of dis- logic texts Epidemic I, Epidemic III and On Airs,
eases in order to prevent them from occurring. Waters, and Places. In these works, he was the first
Epidemiology addresses many areas of public person to attempt to explain the occurrence of dis-
health. For example, it studies the natural history ease on a rational rather than a supernatural basis.
and prognosis of disease. It is used to measure the Since Hippocrates recognized disease as a mass
extent and burden of disease within communities, phenomenon as well as one affecting individuals,
states, and nations. Epidemiology is also frequently he is recognized as the first epidemiologist.
Epidemiology 365
Another figure of importance was the English system. His most important contribution to epide-
statistician John Graunt (1620–1674). Graunt was miology was the establishment of a sophisticated
the first person to analyze the Bills of Mortality, system for classifying the causes of death. This
which recorded the weekly count of births and enabled the comparison, for the first time, of mor-
deaths in London. In 1662, Graunt published the tality rates among different demographic and
results of his findings in Natural and Political occupational groups. Farr’s classification system
Observations Made Upon the Bills of Mortality. still forms the basis of the International Classification
He found that male births consistently outnum- of Disease and Related Health Problems (ICD)
bered female births yet males no longer outnum- that is in use today.
bered females by the time they reached childbearing Another great pioneer in the field of epidemiol-
age because males experienced higher mortality ogy was John Snow (1813–1858). Snow, a con-
rates. Graunt also constructed the first life table, a temporary of William Farr, was a well-respected
statistical table that uses death rates of a cohort of London physician who specialized in obstetric
persons to determine the group’s average life anesthesiology. One of his patients was Queen
expectancy. Victoria, whom he assisted in the delivery of two
James Lind (1716–1794), a Scottish naval sur- of her children. Snow became interested in the
geon, also helped establish epidemiology. Lind cause and spread of cholera epidemics that peri-
studied the great sea plague scurvy. On long naval odically occurred in London. In 1854, when a
voyages, scurvy often killed two thirds of a ship’s severe cholera epidemic once again struck the city,
crew. To prevent scurvy, Lind conducted the first Snow undertook an investigation. At the time,
planned controlled clinical trial, supplementing the most physicians attributed the disease to miasma
diet of a small number of sailors with fresh citrus or “bad air” formed from decaying organic mat-
fruit and lemon juice (the experimental group). He ter. Snow, however, held the radical view at the time
then compared the incidence of scurvy among that cholera was caused by drinking fecal-contami-
these men with that of other sailors on the same nated water. Snow started his investigation by plot-
ship who ate the normal vitamin-poor naval diet ting the geographic location of all cholera deaths in
(the control group). Finding that citrus fruit pre- London. When he found a large number of deaths
vented the disease, Lind recommended dietary (more than 500 in a 10-day period) clustered around
changes for all sailors, which ultimately resulted in a public water hand pump on Broad Street in the
the eradication of scurvy from the British navy. Soho District of west London, he informed the local
Hence, British sailors are still referred to as authorities, along with his hunch as to the cause.
“limeys.” Although the authorities were skeptical, the next
Edward Jenner (1749–1823), a British surgeon day they had the pump disabled by removing its
who practiced medicine in the small village of handle. Immediately, new cases of cholera started to
Berkeley in Gloucestershire, England, observed dwindle and then disappear. However, because
that milkmaids who developed cowpox (a mild cholera deaths were already declining in the city,
disease) never contracted the severe and often dis- Snow was unable to attribute the end of the out-
figuring and deadly disease smallpox. Using matter break directly to the removal of the pump handle.
drawn from the lesions of cowpox on the hand of Snow doggedly continued his investigation of chol-
a milkmaid, Jenner performed the first vaccina- era and conducted what he called his Great
tion. In time, the practice of vaccinating for the Experiment. To conduct the “Experiment,” Snow
prevention of smallpox became widespread. Today, painstakingly documented the cholera deaths
smallpox is the only disease to ever be totally (nearly 1,400) among the subscribers of London’s
eradicated from nature. And vaccination is a two independent private water companies.
widely used method to prevent the occurrence of The Southwark and Vauxhall Company (which
many diseases. supplied more than 40,000 homes) drew its water
William Farr (1807–1883), a British physician from the sewage-polluted lower Thames River,
who worked as the first compiler of scientific while the Lambeth Company (which supplied
abstracts at the Registrar General’s Office in more than 25,000 homes) obtained its water
London, helped shape England’s vital statistics farther upriver. Snow conclusively showed that the
366 Epidemiology
number and rate of cholera deaths were much physical environment (e.g., precipitation, tempera-
higher for residents in homes served by the ture, and weather conditions), or the biological
Southwark and Vauxhall Company, which sup- environment (animals and plants). To illustrate the
plied the polluted water. Using meticulously gath- epidemiologic triad, consider a case of lung cancer.
ered data and the power of statistics, Snow brought The host is the person who developed lung cancer.
about the beginning of the end of cholera in He or she may have had the habit of smoking for
Britain. Because of his study methods and insights, many years. The agent is the smoke, tars, and toxic
Snow is generally regarded as the father of modern chemicals contained in the tobacco. Environment
epidemiology. may have been the workplace where smoking on
the job was permitted and cigarettes or other
tobacco products were readily available.
Basic Concepts and Tools
Epidemiologists classify the type of disease cases
Epidemiology has two fundamental assumptions. and frequency of disease occurrence within a popu-
First, disease does not occur at random. Second, lation as being either endemic or epidemic. Endemic
disease has causal and preventive factors. is defined as the usual occurrence of a disease
Epidemiologists often use models to explain within a population. In contrast, an epidemic is the
the occurrence of disease. One commonly used occurrence of disease, often developing suddenly,
model views disease in terms of susceptibility and that is clearly in excess of the level that normally
exposure factors. Specifically, for individuals to occurs within a population. It may also be the first
develop disease, they must be both susceptible to occurrence of an entirely new disease. A special
the disease and exposed to it. For example, for a type of epidemic is the pandemic, which is a rap-
person to develop measles (rubeola), a highly idly emerging outbreak of a disease that affects a
infectious viral disease that was once very com- wide range of geographically distributed popula-
mon among children, he or she must both be tions. Many pandemics are worldwide in scope. To
exposed to a person who is shedding the measles illustrate these terms, a small number of people
virus (an active case) and be susceptible to mea- develop the flu (influenza) in a large city through-
sles because of lack of immunity to it. Immunity out the year, and these would be endemic cases of
to measles may be derived from either previously the disease. In contrast, the number of people con-
having the disease or from being vaccinated tracting the flu in the same city may increase enor-
against it. mously in the fall, and these would represent
Another commonly used model, the epidemio- epidemic cases. Last, if a new variety of flu emerges
logic triad, views the occurrence of disease as the and people throughout the world get sick from it,
balance among the host, agent, and environmental they would be pandemic cases. An example of a
factors. The host is the actual or potential recipient pandemic is the great influenza outbreak of 1918,
or victim of the disease. Hosts have characteristics which spread throughout the world, killing an esti-
that either predispose them to or protect them mated 20 to 40 million people.
from disease. These characteristics may be biologi- Epidemiologists study the morbidity and mortal-
cal (e.g., age, sex, and degree of immunity), behav- ity caused by acute and chronic diseases. Morbidity
ioral (e.g., habits, culture, and lifestyle), or social is defined as the state of illness, symptoms, or
(e.g., attitudes, norms, and values). The agent is a impairments produced by a disease, while mortality
factor whose presence or absence is necessary for a is death caused by a particular disease. Acute dis-
particular disease to occur. Agents may be biologi- eases are those that strike and disappear quickly,
cal (e.g., bacteria, fungi, and viruses), chemical within a month or so (e.g., chicken pox, colds, and
(e.g., gases and toxic agents), nutritional (e.g., car- the flu), while chronic diseases are those that are
bohydrates, fats, and food additives), or physical long-term or lifelong diseases, many of which are
(e.g., electricity and ionizing radiation). The envi- incurable (e.g., cancer, diabetes, and HIV/AIDS).
ronment includes all external factors, other than One of the most important measurement tools
the host and agent, that influence health. The envi- of epidemiology is the use of morbidity and mor-
ronment may be categorized as the social environ- tality rates. Epidemiologists use rates so that
ment (e.g., economic, legal, and political), the the number of disease cases and deaths can be
Epidemiology 367
compared with a certain number of people at risk years). Basically, adjusted or standardized rates
in a population. Although strict use of the term allow for comparison of populations that have dif-
rate is not always observed, a rate is a special type ferent demographic characteristics. To calculate
of proportion that includes a specification of time. adjusted rates, summary adjusted rates are used to
Thus, a rate indicates the proportion of people in remove age, sex, or race differences in populations.
a population who experience an event during a For example, in the United States, the population
specified period of time. Rates can be expressed in of Florida (a state where many people go to retire)
any form that is convenient (e.g., per 100 per is much older than the population in Alaska. Thus,
week, per 1,000 per year, per 10,000 per year, per it would be inappropriate to compare the mortality
100,000 per month). Infant mortality rates, for rates of the two states without adjusting for the
example, are often expressed per 1,000 live births, differences in their age structures.
while cancer rates are often expressed per 100,000 Two measures that epidemiologists frequently
population. Any meaningful number may be used use to describe the occurrence of disease include
in the denominator, however. incidence and prevalence. Incidence measures the
The following example illustrates the important rapidity at which new cases of a disease are occur-
role rates play in making epidemiological compari- ring in a population over a specified period of
sons. Assume that City A has 10 cases of a disease time. Since incidence always includes a specified
while City B has 50 cases. Although in terms of period of time during which new cases occur, it is
absolute numbers City B has five times more cases another type of rate. The incidence rate is an
of the disease than City A, the differences may be important measure for evaluating disease control
due to the underlying population size of the two programs; an example incidence rate could be
cities. To compare the occurrence of disease in the stated as follows: 10 new cases of Disease X per
cities on a unit population basis, rates must be cal- 100 people per year. Epidemiologists in health
culated. If City A has a population of 10,000 and departments, for example, study the incidence
City B has a population of 50,000, the disease rates rates of HIV/AIDS to determine if the disease is
per 1,000 people would be the same for both cities. spreading and whether AIDS prevention programs
City A’s disease rate is (10/10,000) × 1000 = 1.0 are working.
case per 1,000 population, and City B’s disease Prevalence measures the total number of exist-
rate is (50/50,000) × 1000 = 1.0 case per 1,000 ing cases of a disease in a population at a given
population. Of course, a valid comparison here point of time (“point prevalence”) or sometimes
also presumes that disease occurrence is being mea- within a period of time (“period prevalence”).
sured over the same amount of time. Prevalence can be a useful indicator of the burden
Rates may be crude, specific, or adjusted. Crude of disease on the medical and social systems of a
rates use the total number of disease cases and the geographic region. Prevalence is often expressed as
entire population in their calculations. For exam- a proportion. For example, if 100 people in a small
ple, the above rates for City A and City B are crude town of 1,000 people had hypertension at a par-
disease rates. Specific rates differentiate cases and ticular point in time, then the prevalence of hyper-
populations into age, sex, race, or other subgroups. tension in the population would be 0.1, or 10%.
For example, if the rates for City A and City B were Epidemiologists at the World Health Organization
for persons with disease who were 25 to 34 years (WHO), for example, use prevalence measures to
of age divided by the total number of people in describe the medical, economic, and social burden
each city who were 25 to 34 years of age, the rates of AIDS in developing countries.
would be age-specific disease rates. Specific rates There is a relationship between incidence and
can be applied to very narrowly defined segments prevalence. Prevalence directly varies with both
of a population. For example, one could calculate the incidence and the duration of disease. If the
an age/sex/race-specific disease rate (e.g., the num- incidence of a disease is low but the duration of
ber of persons with disease who are African the disease is long, such as with chronic diseases, the
American, male, and aged 25–34 years divided by prevalence will be large in relation to the incidence.
the total number of people in the population who Conversely, if disease prevalence is low because of
are African American, male, and aged 25–34 short duration due to migration, death, or quick
368 Epidemiology
recovery, then prevalence will be small relative to characterizes the distribution of disease within a
incidence. population. It describes the person, place, and
time characteristics of disease occurrence. It spe-
cifically asks the questions “Who is getting the
Sources of Epidemiological Data
disease? Where is the disease occurring? When is
Epidemiologists use primary and secondary data the disease occurring?”
sources to calculate disease measures and con- A typical example of descriptive epidemiology
duct studies. Primary data are the original data is an investigation whereby the health status of a
collected for a specific purpose by or for an inves- population is determined via the administration of
tigator. For example, an epidemiologist may col- a health survey. Through detailed interviews, medi-
lect primary data by interviewing people who cal examinations, and the extraction of data from
became ill after eating at a restaurant, to identify medical records, the epidemiologist may be able to
which foods they ate. Collecting primary data is determine a variety of characteristics of the popula-
expensive and time-consuming, and it usually is tion, such as who suffers from diabetes, hyperten-
undertaken only when secondary data are not sion, heart disease, cancer, disability, and so on.
available. Secondary data are data that have Using these data to develop hypotheses about the
already been collected for another purpose by environmental causes of disease may be possible.
other individuals or organizations. Examples of These data might also be used to help policymakers
secondary data commonly used by epidemiolo- decide on how to distribute resources that could
gists include birth and death certificates, popula- best serve the population living in the area.
tion census records, hospital and clinic patient Analytical epidemiology, on the other hand,
medical records, data from disease registries, tests hypotheses to determine if statistical associa-
insurance claim forms and billing records, public tions exist between suspected causal factors and
health department case reports, and surveys of disease occurrence. It also tests the effectiveness
individuals and households. and safety of therapeutic and medical interventions.
An important source of secondary data is the To accomplish these tasks, analytical epidemiology
Centers for Disease Control and Prevention (CDC). uses four major types of research study designs:
The CDC, which is an agency of the U.S. cross-sectional studies, case-control studies, cohort
Department of Health and Human Services, con- studies, and controlled clinical trials. Each of these
sists of 12 centers, institutes, and offices. The types of studies has strengths and weaknesses.
various centers collect a wide array of epidemio- Cross-sectional studies examine the relationship
logical data on problems such as birth defects and between disease and other variables of interest as
developmental disabilities, chronic diseases, infec- they exist in defined populations at one particular
tious diseases, injuries, work-related injuries, and time. For example, a cross-sectional study investi-
sexually transmitted diseases. Within the CDC, gating whether residential exposure to the radioac-
the National Center for Health Statistics (NCHS) tive gas radon increases the risk of lung cancer may
conducts, publishes, and widely disseminates the examine the current level of radon gas in lung can-
results of numerous health surveys of individuals cer patients’ homes. Cross-sectional studies have
and healthcare organizations. Examples of NCHS the advantage of being inexpensive and simple to
surveys include the National Health Interview conduct. However, their main disadvantage is that
Survey, the National Health and Nutrition they may not establish causality because exposures
Examination Survey, the National Hospital are only measured once disease has already occurred.
Discharge Survey, and the National Nursing Home To establish causation, it would be important to
Survey. measure exposure over a period of time prior to
the onset of disease so that exposure status could
be measured and contrasted among those who did
Descriptive and Analytical Epidemiology
and did not develop the disease.
The field of epidemiology can be divided into two Case-control studies start with people who already
broad categories: descriptive epidemiology and have a particular disease (cases) and a suitable
analytical epidemiology. Descriptive epidemiology control group without the disease and then compare
Epidemiology 369
the exposures that have occurred among the cases safety. Controlled clinical trials compare the out-
and controls. If an exposure is truly related to devel- comes of new drugs or interventions given to an
opment of the disease of interest, then it will have experimental group versus another group (control)
occurred more frequently among the cases than the that does not receive the same drugs or interven-
controls. These types of studies are most useful for tions. To minimize bias, individuals involved in
ascertaining the cause of rare events, such as certain clinical trials may be randomly assigned to the
cancers. For example, to determine whether the use experimental and control groups. For example, to
of cellular telephones causes head cancers, a group determine whether a new drug to treat breast can-
of head cancer patients (cases) would be compared cer is more effective than another drug, breast
with a group of individuals without head cancers cancer patients would be assigned randomly into
(controls). The two groups would then be compared either an experimental group that receives the new
with respect to the proportion that used cellular tele- drug or the control group that receives the other
phones and their level of exposure (i.e., how many drug. The outcomes of the two groups (e.g., the
minutes they talked over the telephone per day). number of remissions and increase in survival time)
Case-control studies have the advantages of being would then be compared. In the United States, and
quick to conduct and inexpensive, and they may many other countries, all new therapeutic drugs
require only a small number of cases and controls to are subjected to rigorous controlled clinical trials
determine an association. However, their main dis- before they can be provided to the public. The
advantage is that they rely on recall or some estimate main advantage of controlled clinical trials is they
of an exposure that has already occurred in the past. provide unbiased results. However, their main
These can lead to misleading and biased results. disadvantage is that they are very expensive to
Cohort studies are observational studies in conduct.
which a defined group of people (the cohort) is
followed over time and outcomes are compared
Future Implications
for individuals who were exposed or not exposed
to different levels of some factor. Cohorts can be During the past several decades, the field of epide-
assembled in the present and followed into the miology has greatly expanded in size, scope, and
future (a prospective cohort study) or identified influence. The number of epidemiologists has
from past records (historical or retrospective cohort grown rapidly along with epidemiology programs
study). An example of a cohort study is the in schools of public health and medicine. Today,
Framingham Heart Study. The Framingham study epidemiologists investigate the outbreaks of acute
is the longest ongoing epidemiological study in the diseases, such as food-borne epidemics. They also
United States. Starting in 1948 with an original investigate the outbreaks of new emerging diseases
cohort of 5,200 adult volunteers from Framingham, such as SARS and reemerging older diseases such
Massachusetts, the study has followed the volun- as tuberculosis. At the same time, epidemiologists
teers and their offspring to identify the risk factors study the underlying causes of many chronic dis-
associated with developing heart disease (e.g., cho- eases such as cancer, heart disease, and stroke.
lesterol levels, smoking, obesity, and diabetes). To They also study the causes of psychiatric disor-
date, the results from this landmark cohort study ders, substance abuse, and social problems such as
have been published in more than 1,000 scientific violence. Since the recent terrorist attacks in the
papers. The main advantage of cohort studies is United States, Europe, and Japan, many epidemi-
that they can establish the timing and directional- ologists are involved in planning and implement-
ity of events. However, their main disadvantages ing health surveillance programs to detect and
are that they require large sample sizes and a long prevent possible bioterrorism attacks. Epide
follow-up time and they are not typically suitable miologists are also just beginning to examine the
for investigating rare diseases unless extremely determinants of health at the molecular and genetic
large populations are studied. levels. They are studying how individual genes
Controlled clinical trials are studies that test influence the risk of developing chronic conditions
therapeutic drugs or other health or medical such as Alzheimer’s disease. And epidemiologists
interventions to assess their effectiveness and are beginning to develop new molecular
370 E-Prescribing
markers to improve the measurement of indi- International Epidemiological Association:

vidually specific exposure and susceptibility http://www.dundee.ac.uk/iea
factors. Society for Epidemiologic Research:
http://www.jhsph.edu/Publications/JEPI/ser.html
Daniel K. Roberts
See also Acute and Chronic Diseases; Disability; Disease;

Health; Morbidity; Mortality; Public Health; Risk
E-Prescribing
Further Readings E-prescribing or electronic prescribing systems
Adami, Hans-Olov, David Hunter, and Dimitrios include the ability of entering prescription data
Trichopoulos, eds. Textbook of Cancer intended for ambulatory use into a computer
Epidemiology. New York: Oxford University Press, system and then either printing a copy of the
2002. prescription or, as a preferred mechanism, com-
Bhopal, Raj. Concepts of Epidemiology: An Integrated municating the data elements of the prescription
Introduction to the Ideas, Theories, Principles and directly to the filling pharmacy’s computer sys-
Methods of Epidemiology. New York: Oxford tem. These systems, whether in the hospital as
University Press, 2002. part of an automated medication order entry pro-
Gerstman, B. Burt. Epidemiology Kept Simple: An cess or in the ambulatory environment through
Introduction to Traditional and Modern the use of a handheld technology device, provide
Epidemiology. 2d ed. New York: Wiley-Liss, 2003. benefits to both clinicians and patients. They pro-
Gordis, Leon. Epidemiology. 3d ed. Philadelphia: vide a quicker way for prescription data to be in
Elsevier Saunders, 2004. the pharmacy, thereby eliminating delays in pre-
Greenberg, Raymond S., Stephen R. Daniels, W. Dana scription processing caused by illegible handwrit-
Flanders, et al. Medical Epidemiology. New York: ing and data entry. This results in a reduction in
Lang Medical Books/McGraw-Hill, 2001. medication errors and, ultimately, should reduce
Koepsell, Thomas D., and Noel S. Weiss. Epidemiologic overall medication costs for the patient through
Methods: Studying the Occurrence of Illness. New better drug use.
Typically, e-prescribing systems permit the clini-
Last, John M., ed. A Dictionary of Epidemiology. 4th ed.
cian to use the extensive drug resources supplied
New York: Oxford University Press, 2000.
by software companies in order to confirm drug
Nelson, Kenrad E., Carolyn Masters Williams, and Neil
information, including drug availability, dosing,
M. H. Graham. Infectious Disease Epidemiology:
indications, contraindications, and drug interac-
Theory and Practice. Sudbury, MA: Jones and
Bartlett, 2004.
tions, and have access to monograph and journal
Rothman, Kenneth J. Epidemiology: An Introduction. article references. In more comprehensive systems,
New York: Oxford University Press, 2002. clinicians can check intended medications against
Szklo, Moyses, and F. Javier Nieto. Epidemiology: the patient’s current medication profile and/or
Beyond the Basics. 2d ed. Sudbury, MA: Jones and insurance company drug formulary, all at the point
Bartlett, 2007. of care. Additionally, clinicians may benefit by
using the software to stay current with informa-
tion on new medications, pharmacokinetics, and
Web Sites other treatment protocols.
American College of Epidemiology:

http://www.acepidemiology.org Background
http://www.cdc.gov The Medicare Prescription Drug, Improvement,
Epidemiology.net: http://www.epidemiology.net and Modernization Act (MMA) of 2003 had a
Epidemiology Virtual Library: profound legislative and regulatory impact on
http://www.epibiostat.ucsf.edu/epidem/epidem.html e-prescribing. The act provides a prescription drug
E-Prescribing 371
benefit (under Part D) to Medicare enrollees and software without an automated prescription writ-
also includes the requirement for standards to be ing capability. In Level 2, the clinician uses a
adopted for the voluntary use of e-prescribing as stand-alone prescription writer without integrated
well as proposed relief to antikickback laws that access to the patient’s clinical data or supporting
may support various e-prescribing arrangements. medication history. In Level 3, the clinician has
Additionally, the act tasked the National the ability to access the patient’s supporting data,
Committee on Vital and Health Statistics with such as demographic, allergy, formulary, and/or
recommending appropriate messaging standards payer information prior to generating a prescrip-
for the exchange of e-prescribing data. The com- tion from a stand-alone prescription writer. In
mittee developed an initial set of recommenda- Level 4, the clinician has the ability to manage the
tions for e-prescribing data standards in September patient’s drug treatment by tracking and monitor-
2004, and they have been through the regulatory ing the patient’s medication history and current
process, with a final rule issued in November medication usage. In Level 5, the clinician has the
2005. ability to communicate prescription data with
pharmacies, payers to check drug formularies,
pharmacy benefit managers who submit claims
Utility of the Systems data, and other intermediaries. Finally, in Level 6,
the clinician has full integration with a complete
There are several major factors that affect the util-
electronic health record that includes the ability to
ity of e-prescribing systems in actual practice.
order and prescribe medications.
Specifically, the data in the systems must be accu-
rate. Clinicians will be making decisions based on
the data; thus the source systems must provide Barriers
accurate data through working interfaces. Second,
While there is great potential for e-prescribing, the
the software must be reliable. Clinicians must be
nation’s healthcare industry has seen only limited
confident that the software works as intended.
adoption of these systems. According to the
Medication and patient data must be readily avail-
e-Health Initiative, in 2004, less than 20% of phy-
able at the point of care when the clinicians intend
sicians used e-prescribing. Given the fact that
to make decisions. Third, since clinicians often use
there are more than 3 billion prescriptions written
acute care for discharge and emergency department
annually in the United States, other studies have
prescriptions, uniform standards in both acute care
suggested that the national savings from the uni-
and ambulatory environments must exist. The
versal adoption of e-prescribing systems could
HL7 interface standard is currently used in most
save as much as $25 to $30 billion. Some of these
acute-care systems while the National Council for
savings are from prevention of adverse drug
Prescription Drug Programs data and transmission
events, reduced hospitalizations and ambulatory
standards are used in most retail pharmacy sys-
visits, use of generic drugs, and formulary compli-
tems. There is a need for cross-communications to
ance, with an overall reduction in the use of pre-
promote full interoperability of systems. Finally,
scription drugs.
the systems must be maintained with regular
This limited adoption is the result of barriers
updates. Clinicians must be confident that all data
that have been reported when implementing
content is regularly updated as scheduled.
e-prescribing systems, which have prevented the
full realization of their benefits. Specifically, seven
major barriers have been identified.
Levels of Usage
First, e-prescribing systems are perceived to be
According to the e-Health Initiative, there are six slower than other manual systems, and clinicians
graduated levels of e-prescribing usage. The levels complain of lower productivity. The increased time
go from the basic (Level 1) to the most compre- clinicians take to use electronic prescribing requires
hensive (Level 6). In Level 1, the clinician uses a them to spend more time with each patient, which
handheld hardware unit for basic electronic refer- decreases the number of patients who can be seen
ence data, usually provided by drug reference per unit of time, thus potentially reducing overall
372 Equity, Efficiency, and Effectiveness in Healthcare
income. Clinicians have had substantial experience overly concerned about another experimental tech-
manually writing prescriptions in a matter of sec- nology being used.
onds, and most physicians will continue to hand- Finally, many clinicians question their invest-
write prescriptions because it is perceived to be ment into e-prescribing products that do not inte-
quicker than using a computer. In spite of the qual- grate with existing systems and expect that better
ity and other benefits to be realized from electronic products will be introduced into the marketplace
prescribing, until the automated process is deemed in the near future.
quicker, this barrier will be cited.
Second, lack of connectivity with other provid- Lawrence M. Pawola
ers, particularly retail pharmacy outlets, is limiting See also Adverse Drug Events; Clinical Decision Support;
the full utilization of e-prescribing. Many times, Health Insurance; Medical Errors; Medicare Part D
handheld e-prescribing systems do not integrate Prescription Drug Benefit; Patient Safety; Pharmacy;
with all pharmacy computer systems, resulting in Quality of Healthcare
manual entry for some cases and the increased pos-
sibility of medication errors in spite of the clinician’s
best intentions. While many of the retail pharma- Further Readings
cies are working hard to become e-prescribing
Fincham, Jack E. E-Prescribing: The Electronic
certified, this is a difficult and slow process.
Transformation of Medicine. Sudbury, MA: Jones and
Third, the purchase of e-prescribing technology is
Bartlett, 2009.
often not the only capital investment under consider-
Hollingworth, William, Emily Beth Devine, Ryan N.
ation in most ambulatory medical practices and
Hansen, et al. “The Impact of e-Prescribing on
hospitals. In an environment of decreasing reim- Prescriber and Staff Time in Ambulatory Care Clinics:
bursements, many clinicians and hospitals feel that A Time-Motion Study,” Journal of the American
there is limited capital and few successful business Medical Informatics Association 14(6): 722–30,
models in the literature to make this capability a high November–December 2007.
priority when considering other major projects. Kirkman, Kirk Paul. “The Five Foundations of Successful
Fourth, there is confusion about the available e-Prescribing Programs: The Right Combination of
functionality of these systems in the minds of many Technology, People, Process and Commitment Drive
buyers. The e-prescribing systems marketplace is Success for Electronic Prescribing,” Health
still evolving, and many suppliers in this market Management Technology 26(4): 32–33, April 2005.
segment are striving to make their software sys-
tems appear to be the best. This has created confu-
sion among clinician buyers, who may not have Web Sites
the full opportunity or the time to assess all avail-
able options. A variety of wrong decisions have
http://www.cms.hhs.gov/eprescribing
been made, resulting in less than optimal integra-
eHealth Initiative: http://www.ehealthinitiative.org
tion and usage. National Committee on Vital and Health Statistics
Fifth, the cost of purchasing and implementing (NCVHS): http://ncvhs.hhs.gov
e-prescribing has become a major barrier for many National Council for Prescription Drug Programs
clinicians in private practice. Estimates for the hard- (NCPDP): http://www.ncpdp.org
ware and software costs of low-level e-prescribing
systems range from $1,500 to almost $5,000 per
clinician. Estimated costs for higher-level systems
with advanced capabilities, including complex Equity, Efficiency, and
alerts and reminders, are almost $30,000 per clini-
cian in the 1st year and can be as high as $5,000 Effectiveness in Healthcare
to $10,000 annually.
Sixth, in today’s healthcare environment, most Healthcare providers are increasingly under pres-
clinicians have had negative experiences with other sure to prove that their services are being deliv-
information technology projects and have become ered in an efficient and effective manner. Those
Equity, Efficiency, and Effectiveness in Healthcare 373
funding healthcare services—both third-party is the extent to which these services, especially
payers and consumers—are demanding more publicly funded services, are provided to the same
accountability. And policymakers are seeking people, to similar groups of people, or to constitu-
measures that are objective and based on empiri- encies. “Sameness” is at the heart of a standard that
cal evidence. focuses, for example, on whether individuals or
The reason for this pressure for greater account- groups receiving healthcare services funded by the
ability is that policymakers recognize that health- same health insurance plan (e.g., Medicaid) receive
care providers have an obligation to demonstrate the same quantity and quality of services. To the
that what they are doing is having some specific extent that they are, then equity has been achieved.
effect. In other words, it is possible to document To the extent that they are not, then there are
outcomes from particular service delivery models documented disparities, and equity has not been
or programs. achieved.
With rising healthcare costs squeezing profits
and the growing numbers of people without health
insurance pushing costs even higher, many employ- Efficiency
ers are beginning to highlight healthcare costs and Another standard that can be used to assess the
benefits as one of the most important issues to be delivery of healthcare services is the extent to
addressed. At the same time, employees faced with which particular services have been delivered at
increased cost sharing, the increased cost of health the least possible cost to the public or to a different
insurance, and the growing numbers of people third-party payer. When the least possible cost has
without any kind of insurance are also pointing to been identified, it is assumed that this represents
healthcare as a “crisis.” efficiency. The standard of efficiency is most rele-
Healthcare policymakers are concerned with vant when the policymaker’s goal is to compare
whether it is possible to develop measures to docu- alternatives for the investment of resources and to
ment improvement or change for particular medical select the alternative that is the least costly. This
conditions. They raise a number of questions. For standard is focused on the least costly method to
example, what should be the standard for assessing achieve a particular objective.
whether a consumer/patient has gotten better or
worse as a result of a given treatment or service
Effectiveness
delivery model? What specific outcome or set of
outcomes is a treatment aimed at? It should be noted In contrast to efficiency, another standard
that the state of the art in terms of measuring medi- focuses on particular goals or outputs that are to
cal outcomes is not such that one can be particularly be achieved. Alternative programs or methods are
precise about the results that have been achieved. compared that achieve the same output or out-
How does one, for example, compare four units of come. In other words, this form of accountability
wellness with two or three units? Can an outcome involves specifying an objective or a level of desired
such as wellness really be measured at interval levels output and identifying alternative methods that
where one assumes that each additional unit of well- succeed in reaching the desired goal.
ness has the same value as another unit? By identifying all alternative methods that suc-
More specifically, healthcare policymakers at ceed in reaching a desired level of output or out-
the national, state, and local levels have demon- come, policymakers may also be identifying a
strated an increasing concern for equity, efficiency, range of costs that are associated with this level of
and effectiveness of healthcare. success. Consequently, an effective outcome may
or may not be an efficient outcome. By employing
effectiveness as a standard, policymakers may also
Definitions be identifying inefficient options.
This discussion of different standards highlights
Equity
the fact that if policymakers are looking to make
One of the standards used to assess the delivery health services programs more accountable, it is
of healthcare services for purposes of accountability crucial to be clear as to what question is being
asked. If a policymaker is mainly interested in and in driving the development of accountability

measuring quality or a particular outcome or a set measures. As recently as 1960, consumers paid
of outputs, then a range of alternatives for achiev- most healthcare expenditures as out-of-pocket
ing success may be identified that, in turn, have a expenses. In 1960, 55% of all healthcare costs
range of costs associated with these options. were paid out of pocket, but by 1998, that number
However, this assessment would not necessarily had dropped to less than 20%. It may not be coin-
provide any information about which of these cidence that healthcare expenditures, measured as
alternatives is the least costly. It is only when one a percentage of the nation’s gross domestic product
poses the challenge of identifying the least possible (GDP), have risen in line with this increase in third-
cost that one is analyzing efficiency. party payment. It is also worth noting that prior to
From a health policy perspective, without con- 1965 and the passage of Medicare and Medicaid,
sidered attention to the efficiency dimension, the the public healthcare delivery system was limited
results of an analysis may be counterproductive to state public health departments and some public
in that inefficient options are invested in as if hospitals and there was no broad insurance scheme
they were the best available. It is also clear that for any segment of the population.
an analysis of neither efficiency or effectiveness The system of third-party payment, especially in
will necessarily identify options that produce the form called fee-for-service insurance, contains
equity. very little incentive for cost control. Neither the
provider nor the patient is at financial risk in mak-
ing healthcare decisions. In economic terms, the
Context
marginal cost to either of these participants in the
These measures or standards of accountability transaction was very low, usually zero. However,
should be placed in the context of a changing the marginal benefit of extra healthcare expendi-
health services delivery and policy landscape. By tures, while diminishing, was certainly positive.
understanding how the service delivery systems Since benefits exceeded private costs, it was “ratio-
and models have changed, it will be possible to nal” for the physician to order more services and
also understand where the demands for account- tests. However, it is unlikely that benefits exceeded
ability have come from. the overall costs to society. Regardless, the result
In the early 1990s, the dominant model for was ever-increasing expenditures on healthcare;
health insurance financing and delivery in the and from the mid-1960s through the early 1980s,
United States was the fee-for-service system. healthcare expenditures rose by more than 10%
Managed care was beginning to grow in impor- per year. Much of the changes in the healthcare
tance but still had a smaller market share. In 1994, arena in the recent past can be traced to changes in
50.5 million Americans were enrolled in health laws and regulations related to healthcare. While
maintenance organizations (HMOs), and in 1993, some of this legislation has helped constrain
preferred provider organizations (PPOs) had healthcare costs, some of it has also contributed to
approximately 60 million enrollees. By 2006, more rising costs in a variety of ways.
than 70 million Americans were enrolled in HMOs, In the 1990s, growth of managed care coincided
and almost 90 million were part of PPOs. with a sharp reduction in the growth of healthcare
An area where this shift to managed care has costs. National data from that period suggest that
been particularly influential has been in Medicaid. managed care organizations (MCOs) have been
In 1991, 2.7 million Medicaid recipients were substantially more efficient than traditional indem-
enrolled in some form of managed care; by 2004, nity plans in controlling costs. The sweeping
27 million Medicaid recipients were enrolled in changes in the American healthcare system in the
managed care. A total of 63% of all Medicaid past 15 years, such as the slowdown in the rising
recipients in the nation were enrolled in managed rate of healthcare costs, cutbacks at hospitals, and
care in 2005. the merger of hospitals and drug companies, can
The design of the American healthcare system is be attributed in large part to the spread of man-
such that third-party payers for health coverage are aged care. While a great deal of the cost savings
a driving force in shaping the healthcare system can be attributed to discounted prices negotiated
by MCOs, the literature also suggests that in these Despite the fact that managed-care plans did
organizations there has been a significant decrease succeed in controlling costs without decreasing
in the use of more costly tests, which has contrib- quality, there was a significant backlash from
uted to reduced total spending. There is certainly a consumers and providers to this new form of
general consensus that managed care was success- healthcare service delivery. This strong public
ful in reducing the rate of healthcare cost growth, backlash has been driven by claims that managed
and it remains a powerful tool for controlling care has not reduced costs or increased efficiency,
the rate of increase. In other words, MCOs have it has led to patient dissatisfaction, and its man-
reduced healthcare expenditures in three ways: agement techniques have resulted in adverse
(1) by reducing the quantity of services used, (2) by medical outcomes.
reducing payments to providers, and (3) by select- This dissatisfaction came to a head in the late
ing healthier patients. 1990s and early 2000s, when a series of so-called
The controversy surrounding managed care anti-managed-care regulations were passed at the
stems from the question of what methods were federal and state levels and a series of lawsuits
used to achieve this level of cost control. The gen- against HMOs put the question of managed-care
eral answer is that managed care brought new organization liability on the top of the health pol-
constraints to the decision making of both con- icy agenda. Between 1996 and 2002 alone, nearly
sumers and healthcare providers. As indicated 900 bills introducing some form of regulation of
above, a system of fee-for-service compensation MCOs were introduced in legislatures across the
has built-in incentives for overutilization as ser- nation, and at least one provision was enacted in
vices were provided beyond the point of effective- every state. By 2001, all but four states had some
ness or even appropriateness. Managed care type of comprehensive patients’ bill of rights or
brought in a new set of incentives. The “managed” patient protection act.
part of the term meant that there would be more In sum, this picture of the healthcare service
attention paid to medical utilization reviewing landscape documents that the demands for account-
procedures as well as to provider contracts. In this ability are directly related to concerns over cost
managed-care system, a greater emphasis on com- control, quality, and consumer dissatisfaction.
petition was injected into the healthcare market-
place. Insurers were able to successfully negotiate
Measures
terms with hospitals and other providers that
resulted in significant slowdown in the rapid rise In the public sector, standards emerged out of the
of health insurance premiums. However, these new Medicare program and a desire by policymakers
incentives created concerns about the quality of to effectively document and control costs while
care being provided by providers who were sud- maintaining high-quality services. The first mea-
denly forced to become more cost conscious. sures were developed in the inpatient sector. These
This quality controversy was fueled throughout measures became known as the Medicare pay-
the 1990s by media horror stories and a number of ment systems.
lawsuits alleging that managed-care plans were The impact of the Medicare payment systems on
guilty of medical malpractice. Despite the public the nation’s hospital sector has been substantial and
perception that managed care might reduce qual- widespread since it introduced its prospective pay-
ity, the available evidence suggests that there has ment system (PPS) in 1983. The PPS is divided into
been no clear change in the quality of care pro- an inpatient system (IPPS), which is based on
vided under managed care, even in areas that have Diagnosis Related Groups (DRGs) payments, and
been specifically targeted for regulation, such as an outpatient payment system (OPPS), which was
maternity care. At worst, the evidence about the implemented in 2000 and is based on ambulatory
quality of care provided under managed care has payment classifications (APCs) related to the epi-
been mixed, with analyses reviewing more than sode of care. The PPS, which replaced the previous
100 primary studies finding nearly equal numbers cost-based reimbursement system, is designed to
of examples of managed-care arrangements that create financial incentives for hospitals to become
increased quality as those that decreased quality. more efficient in providing services for each episode
of care provided to Medicare beneficiaries. Medicare own reimbursement policies. The result of this
administrators believed that such a system would development is that Medicare reimbursement pol-
create a more competitive, market-like environ- icy not only affects the prices of medical care for
ment in the hospital sector. The theory was that Medicare beneficiaries, but it also creates a stan-
hospitals that successfully implemented improve- dard for medical care pricing for the entire health-
ments in efficiency under the PPS would become care industry, both public and private.
more competitive vis-à-vis their counterparts who The nature of the hospitals with which private
were unable to achieve efficiency gains. insurance companies contract can affect the
First adopted by Medicare in 1983, DRGs are insurance companies’ ability to compete with one
now used by health systems internationally as a another. For example, insurance plans’ marketabil-
method to control costs. Under the DRG system, ity to employers and employees depends not only
medical conditions are classified into approxi- on the price of the coverage they offer but also on
mately 500 groups. DRGs (and the similar APCs the number of hospitals where coverage is offered
used in the outpatient setting) represent predeter- and on the quality, accessibility, and desirability of
mined payments based on the average cost of pro- those hospitals. Being a must-have hospital may
viding a given healthcare service, including all the confer a significant competitive advantage to such
ancillary services necessary to perform the service. a hospital in contract negotiations with private
The payments are weighted based on the median insurance companies.
cost of providing the service in a given geographic The Centers for Medicare and Medicaid Services
area. Services provided within a given DRG are (CMS), the federal agency that administers the
expected to incur similar healthcare costs and use Medicare program, clearly has a profound effect
a similar amount of hospital resources and are on the competitive environment in which hospitals
therefore used to set standard Medicare reimburse- operate, but this is primarily an indirect effect
ment rates. through its price-setting authority. It does not, for
Proponents argue that DRG reimbursement example, have the ability to use competitive bid-
systems have contained hospital costs, saving ding or selective contracting mechanisms to exert
nearly $18 billion in their 1st year of implementa- direct control of the providers with which it nego-
tion. Critics say that low reimbursement rates tiates. And there is virtually no way for Medicare
provide an incentive for private physicians to reject to encourage nonprice competition between pro-
Medicare patients and place an undue fiscal strain viders. This is what recent pay-for-performance
on hospitals. The costs are then passed on to other initiatives would attempt to do by inserting quality
insured hospital patients, raising healthcare costs and outcome measures into the payment policy,
overall. but such initiatives are in their infancy.
One of the goals of introducing the PPS was to Hospital pricing in the United States is deter-
encourage a shift of some hospital services to less mined by four primary factors: (1) the amount of
expensive outpatient settings and thereby reduce bulk purchasing by insurance companies, (2) price
the overall costs of inpatient hospital care. There discrimination between different buyers of ser-
are numerous examples of this goal having been vices, (3) cost shifting between consumers, and
borne out empirically, including the fact that the (4) cross subsidies between types of services. Bulk
average hospital inpatient length of stay declined purchasing typically involves large insurance com-
rapidly after the introduction of the PPS. Within panies negotiating discounted pricing for some or
the first few years of the PPS, the number of inpa- all services in exchange for a guaranteed volume.
tient cataract surgeries declined by more than Price discrimination may result from different
65%, and the number of outpatient cataract sur- negotiations with different insurance companies
geries increased by almost 130%. and involves charging different prices for the same
The PPS also had a profound but indirect, and services to different payers. Cost shifting occurs
largely unintended, consequence. In many cases, when a hospital raises prices for one group of pur-
private payers have modified the PPS for their own chasers while lowering the price for another group.
purposes or used outright the Medicare DRGs Cross subsidizing is similar to cost shifting in that
payment structures as reference pricing for their one group is charged more for certain services; but
in this case, the excess revenue is used to subsidize been limited to 15% of the approved charge. As a
the price of those services for another group. result, many providers have been reducing the
There is controversy about whether hospitals number of patients on Medicare that they will
increase prices to private payers in response to accept or are reducing the range of services that
reductions in payment rates from public programs— they will provide to Medicare enrollees. This pat-
whether they engage in cost shifting. Cost shifting tern increases when Medicare’s budget is cut, and
has its roots in community-rated insurance, which this reduces the access of Medicare beneficiaries to
depends on “overpayments” relative to underlying certain healthcare providers. The effect is to reduce
healthcare costs incurred by youthful and less sick the choice of providers for those in the program.
populations. These payments cover “underpay- Successive budget reductions have operated to
ments” relative to the healthcare costs incurred by reduce the number of providers who are willing to
older and sicker populations. This form of cost see Medicare patients without limitation.
shifting was an outgrowth of hospitals’ and physi- Cost shifting and cross-subsidization tend to be
cians’ charging practices before health insurance minimized in a highly competitive market, and
was generally available. Most discussion of cost the U.S. Congress has recognized certain areas in
shifting now centers on hospitals, where, to vary- which there is perceived social value in maintain-
ing degrees, public payers and self-pay patients ing hospitals’ ability to continue to provide those
have paid less than their costs. The financial losses services. It has been estimated that U.S. hospitals
incurred by hospitals in providing care to these incur costs of $25 billion to $50 billion annually
populations have generally been cross-subsidized in providing community service, primarily in the
by revenue surpluses generated by the privately form of health professions education and standby
insured. costs. In the case of hospitals with significant
The practice of direct hospital rate setting by teaching functions and those whose patient base is
states has undergone a significant reduction since substantially poorer than average, Medicare pro-
the introduction of managed care. In the 1970s and vides a direct subsidy to support those functions.
1980s, it represented an experiment that fascinated These subsidies total more than $10 billion in
health policy analysts and enjoyed wide application direct payments annually.
in 30 states by 1980. However, currently it is only Both for-profit and not-for-profit hospitals
applied in Maryland and West Virginia. According receive support from Medicare for activities related
to one source, the decline reflects the development to medical education. Large academic medical cen-
of managed care and capitation as alternative ters as well as many community-based hospitals
means to control the growth in health spending. receive Medicare payments proportional to the
This trend represents both an evolution in prospec- number of trainees (medical interns, residents, and
tive payment methodology and a renewed prefer- fellows, and allied health professional trainees)
ence for private- over public-sector price controls. who are working in their system. These payments
Studies indicate that rate-setting systems were help defray the costs of medical education that
effective in controlling costs per hospital admis- these hospitals bear, which often involves incurring
sion but ineffective in controlling healthcare costs greater than average uncompensated-care costs
overall. These systems did not control the number because teaching hospitals tend to be in low-in-
of hospital admissions, nor did they regulate outcome areas with higher than average populations
patient costs. With the rise of managed care and its of uninsured patients. Not including charity care,
broader potential to contain healthcare costs, most the cost of health professions education has been
states turned to market-based strategies and aban- estimated to be $20 billion to $25 billion annually,
doned regulatory initiatives. and as noted above, Medicare pays a substantial
Prior to 1993, some healthcare providers (phy- portion of this subsidy to hospitals. This amount is
sicians) chose not to participate in the Medicare calculated as part of Medicare payments to sup-
program in an effort to bypass Medicare’s man- port graduate medical education and includes the
dated payment rates. But since 1993, the maxi- indirect costs of operating the hospitals as well as
mum amount that a nonparticipating provider can the direct costs of salaries and benefits for trainees
charge over Medicare’s approved charge rate has and attending physicians.
378 Ethics
Some hospitals also receive additional funding Liu, Xingzhu. Policy Tools for Allocative Efficiency of
from the Medicaid program to support the com- Health Services. Geneva, Switzerland: World Health
munity benefit role they perform serving low-in- Organization, 2003.
come populations. This Disproportionate Share Muennig, Peter. Cost-Effectiveness Analysis in Health: A
Hospital (DSH) program helps defray the costs of Practical Approach. 2d ed. San Francisco: Jossey-
providing uncompensated, or charity, care, which Bass, 2008.
many hospitals in low-income areas provide, and O’Donnell, Owen A. Analyzing Health Equity Using
it represents a significant additional government Household Survey Data: A Guide to Techniques and
Their Implementation. Washington, DC: World Bank,
input into the hospital sector. In 2002, hospitals
2008.
reported a total of $22.3 billion in uncompensat-
Oliver, Adam J., ed. Equity in Health and Healthcare:
ed-care expenses, and the DSH program payments
Views from Ethics, Economics, and Political Science:
amounted to $15.2 billion.
Proceedings From a Meeting of the Health Equity
Network. London: Nuffield Trust, 2003.
Wallace, Barbara C., ed. Toward Equity in Health: A
Future Implications
New Global Approach to Health Disparities. New
Overall, accountability issues focus on the need York: Springer, 2008.
to be able to measure outcomes (acceptable or
not) and the ability to measure costs, appropri-
ately defined. While cost measurement poses few Web Sites
theoretical barriers, the ability to measure out- AcademyHealth: http://www.academyhealth.org
comes and to determine what is an acceptable Agency for Healthcare Research and Quality (AHRQ):
outcome poses serious problems. This is why it is http://www.ahrq.gov
critical to understand the healthcare policy land- American Society of Health Economists (ASHE):
scapes well as some of the initiatives developed http://healtheconomics.us
by the Medicare and Medicaid programs. Not International Society for Equity in Health (ISEqH):
only are outcome measures not well developed, http://www.iseqh.org
they are also not uniformly adopted or applied. World Health Organization (WHO): http://www.who.int
There is a definite need for further development
of the concepts of equity, efficiency, and effective-
ness along with measures that are employed using
these concepts.
Ethics
Robert F. Rich
Ethics is a branch of philosophy that studies moral
See also Cost of Healthcare; Evidence-Based Medicine values and principles. It identifies right and wrong
(EBM); Health Disparities; Health Insurance; Hospitals; behaviors of individuals and members of a profes-
Managed Care; Outcomes Movement; Public Policy sion. While discussing ethics in healthcare, many
distinctions have to be made. There is the growing
field of bioethics, at the intersection of moral
Further Readings inquiry and progress in the life sciences. The
Aday, Lu Ann, Charles E. Begley, David R. Lairson, et
original field of medical ethics has been all but
al. Evaluating the Healthcare System: Effectiveness, swallowed by this newer cousin. Many commen-
Efficiency, and Equity. 3d ed. Chicago: Health tators make a distinction between bioethics and
Administration Press, 2004. the smaller, but no less important, field of public
Ellis, Phillip. Research on the Comparative Effectiveness health ethics. There is a nascent literature on the
of Medical Treatments. Washington, DC: U.S. social ethics of health, looking at the moral values
Congressional Budget Office, 2007. that play a role in health and healthcare policy-
Hollingsworth, Bruce, and Stuart Peacock. Efficiency making. Organizational or business ethics is a
Measurement in Health and Healthcare. New York: burgeoning field. There is also the growing list of
Routledge, 2008. professional organizations that have felt the need
Ethics 379
to develop and promulgate codes of ethical avoid the injustice of these actions, perpetrated on
conduct. Most university courses and publications an underprivileged minority; justice demands that
in health ethics spend quite a bit of their efforts on those who might bear the risks of an experiment
standards for the ethical conduct of research. This be among those who could benefit from the results.
entry identifies some of the major topics being These four principles—autonomy, beneficence,
examined within each of these fields and addresses nonmaleficence, and justice—form the basis of
some of the more pressing issues. It also assesses most contemporary discussions about the need to
the differences and similarities between these protect human subjects involved in health-related
fields of study. experiments.
In 1974, the U.S. Department of Health,
Education and Welfare formed the National
Protection of Human Subjects
Commission on the Protection of Human Subjects
For practitioners of health services research, prob- of Biomedical and Behavioral Research. The com-
ably the most important ethical questions have to mission held a series of meetings at the Smithsonian
do with how to conduct their work without vio- Institution’s Belmont Conference Center, and the
lating customary or legal standards of behavior. In report that was issued in 1979 was forever referred
evaluating health services outcomes, it would be to as the Belmont Report. The report identified
useful to be able to randomly assign patients to three principles that need to be considered when
treatment and control groups, but this cannot be designing and carrying out research involving
done without due consideration given to the rights human subjects: respect for persons (encompassing
of the people involved. The study of best practices autonomy), beneficence (including nonmalefi-
would benefit from being able to observe the cence), and justice.
natural history of diseases, but society does not The report also recommended practical guide-
allow this to be done without the informed con- lines for achieving informed consent, assessing the
sent of those being observed. risks and benefits of the research, and selecting the
There are certain touchstones that need to be subjects. Under informed consent, the report dis-
acknowledged if one is interested in understand- cussed the following: the amount and accessibility
ing the history of protection of human subjects of information that was available to potential sub-
of research. Among these are the Tuskegee syph- jects, the subjects’ ability to comprehend the infor-
ilis study and the Belmont Report. In the 1930s, mation presented to them about the nature of the
a group of researchers from the U.S. Public risks, and the extent to which the subjects volun-
Health Service (PHS) decided that they would tarily undertook the risks from the research.
closely observe a group of African American men The Belmont Report recommends that the
diagnosed with syphilis to determine the natural nature of the risks to the human subjects should be
history of the disease in Black men. The men fully understood and the magnitude and the distri-
were not offered treatment, even when, a few bution of the risks and benefits of the research
decades into the study, modern antibiotics should be commensurate. In trying to achieve the
became available. proper balance between protecting human subjects
Today, society looks aghast at this violation of and encouraging needed research, the report states
the dignity of these men, treated as not much more that research on human subjects must be “justifi-
than animals to be observed rather than patients to able” and identified a number of factors that must
be served. Failing to discuss the goals of the study be considered in assessing justifiability. It states
and secure the participants’ permission was a vio- that “brutal or inhumane treatment” of human
lation of the men’s autonomy, their right to deter- subjects is never justifiable. Risks to participants
mine their own future. The researchers did not should be kept as low as possible, and the more
treat these men, thereby failing to provide them the significant the risk of serious impairment, the more
beneficence that is the hallmark of healthcare. closely reviewing committees must scrutinize the
Deciding to do without life-saving treatment when research protocol. If participants are drawn from
it became available was an obvious violation of the vulnerable populations, the committee should con-
value of nonmaleficence. And it is impossible to sider involving them at all. In any case, researchers
380 Ethics
and review committees should balance the relative institutes, centers, university courses, and books
risks and benefits to study participants and make on the subject.
sure that information on them be adequately con- A place to begin understanding the breadth of
veyed in the informed consent documents. this field is the Web site of the Kennedy Institute
Finally, the report states that the principle of for Ethics at Georgetown University, Washington,
justice requires that there be “fair procedures and D.C., aptly subtitled “Where Bioethics Research
outcomes in the selection of research subjects.” Begins.” The institute offers “quick bibliogra-
The application of this principle, states the report, phies” on topics of bioethics concerns. The list for
must occur not just at the level of the subjects the 100 most recent bibliographic citations in the
themselves, making sure that selection procedures institute’s database gives a useful overview of the
are equitable, but also at the societal level, where enormously wide range of topics that bioethicists
researchers should take into account the social address. There are ethical issues involving the
justice implications of having too much of the bur- practice of healthcare, such as advanced directives,
den fall on isolated sectors of the community—for patient relationships, and terminal care. There are
instance, where vulnerable populations are tar- social problems, such as abortion (subdivided into
geted as research subjects due to their relative lack legal aspects, moral and religious aspects, and
of power or status. social aspects), chemical and biological warfare,
The U.S. Department of Health and Human and cloning. The fact that bioethics is an extraor-
Services (HHS) has issued federal regulations that dinarily inclusive rubric is evidenced by items on
establish the baseline requirements for programs this list such as codes of ethics, informed consent
to protect human subjects of research. These (both for treatment and for research), and resource
regulations are overseen by the Office for the allocation.
Protection of Research Risks. This regulation
empowers an institutional review board (IRB) to
Public Health Ethics
review all proposals to ensure that human sub-
jects are granted the maximum protection possi- Public health ethics is a relatively new concern.
ble. While certain types of research are exempt Much of the discussion in the field is focused on
from these rules, it is common to use an IRB as the research ethics questions discussed above,
the body that determines the exempt status of some of it involving health services research,
proposed research. Hence, health services some of it involving epidemiological research
researchers must, inevitably, become adept at and randomized controlled trials. A point of
understanding the federal and state rules that view has been expressed attempting to separate
govern their work, as well as the policies and public health ethics from bioethics, on the basis
procedures set by their employers or cooperating that public health ethics is more properly con-
institutions. cerned with the use of societal power and its
potentially coercive impact. The most commonly
cited books in the field usually reflect the aca-
Bioethics
demic preparation of their authors, such as law
In addition to having ethical concerns in the con- or philosophy.
duct of their work, health services researchers may Another emphasis is on developing codes of eth-
be called on to do work that educates the difficult ics for administrators of local health departments.
decisions faced by health professionals, organiza- Some of the people in this field also argue that a
tions, and policymakers at the intersection of full view of public health ethics has to include a
moral inquiry and progress in the life sciences. discussion of how normative or social ethics edu-
Once referred to as medical ethics, this field is cates public health decision making.
now more broadly known as bioethics.
The number of university-based programs in
Normative or Social Ethics
bioethics has risen exponentially in the past decade.
In addition, there are many government commis- Normative ethics is the study of what is right and
sions, journals, blogs, international conventions, what is wrong. Social ethics is less clearly defined
Ethics 381
but usually refers to a discussion of how commu- administrator has a duty to report known viola-
nities or bodies politic can achieve the “good.” tions of the code. As with many of these organiza-
The trajectories of social ethics and health services tional efforts, the ACHE also includes a frequently
research might be seen as skewed lines, since updated list of policy documents addressing spe-
social ethics wishes to answer just the sort of nor- cific ethical problems faced by administrators. It is
mative questions that scientifically oriented health not clear how successful these codes are in consis-
services researchers eschew. However, most of all tently producing ethical behavior, a potentially
the problems that concern social ethicists, issues interesting area for health services researchers to
such as rights and justice and fairness, are inextri- investigate.
cably linked with the public policy issues that AcademyHealth, the professional society for
health services research hopes to illuminate with health services researchers, does not appear to
its objective work. And facts, reliable conclusions, have a complete code of ethics. In 2004, the orga-
careful analyses, are all critical inputs into norma- nization issued a thorough report titled Ethical
tive decision making. Guidelines for Managing Conflicts of Interest in
Social ethics attempts to understand the nature Health Services Research. The organization’s
of human rights and what those ideas say about Ethical Guidelines Committee focused on three
the distribution of healthcare in the United States values that guided their development of the policy:
or around the world. Is healthcare a birthright that (1) maintaining the integrity of health services
attaches to every child born? If so, then research- research, (2) providing consistency between the
ing market-oriented health systems may be greatly ethical values of health services research and those
missing the point. But even if healthcare is a birth- of other health-related research, and (3) ensuring
right, society can never guarantee an unlimited that practitioners are aware of and adhere to the
amount of it to everyone, everywhere, and at all ethical guidelines of the multiple disciplines that
times. Society’s decisions on what is “best” to do, are involved in health services research. This state-
what priorities to set, and how quickly to effect ment recognizes that health services researchers
change, must all be informed by sound research. are doing inherently interdisciplinary work and
will bring with them the ethical practices of the
disciplines in which they were trained. This pres-
Codes of Ethics
ents a problem for newer educational programs
Many of the professions, such as law, medicine, focusing specifically on health services research, as
and dentistry, have early on in their development their ethics education will need to be drawn from
recognized the benefits of having a code of eth- a variety of other sources. Certainly, such pro-
ics. For example, the American Medical grams will need extensive coverage of the “whys”
Association (AMA) has a recommended code of and “why nots” and the “dos” and “don’ts” of
ethics for physicians dating back more than 150 research ethics, but they may also need to identify
years. This approach is becoming popular in the ways in which the ethical issues raised by
other venues. The American Nurses Association health services research differ from the ethics of
(ANA) has a much more recent code. The other types of health-related inquiry.
American Public Health Association (APHA) The AcademyHealth document does contain 14
also recently adopted a code of ethics. And the guidelines for the ethical conduct of health services
American College of Healthcare Executives research, albeit with a focus on how they relate to
(ACHE) has a code of personal and organiza- preventing conflicts of interest. These guidelines
tional ethics for its members. emphasize that ethical concerns can arise in every
The ACHE code identifies the ethical responsi- phase of the researcher’s work, in initiating the
bilities that healthcare administrators owe to research, in conducting the research, and in report-
patients served, to the administrator’s coworkers ing on the research.
and employees, to their organization, to their pro- So not only does the health services researcher
fession, and to the larger community and society need to understand the mandated protections of
that they ultimately serve. It includes a section dis- human subjects, but he or she must also confront the
cussing under what circumstances a healthcare fact that the outcome of his or her work may very
382 Ethics
well cost a lot of people a lot of money. Any time wrong.” While this may not be an area of inquiry
large and powerful organizations can be affected, in which the health services researcher is trained,
positively or negatively, by a researcher’s work, the he or she would do well to understand the nature
researcher must be vigilant against the influence that of this ongoing social dialogue, the role that health
those large and powerful organizations have on the services research might play in informing that dia-
research agenda or the conduct of its efforts. To do logue, and the role that this dialogue plays in shap-
otherwise could be considered disingenuous. ing the future of health services research.
Daniel Swartzman
Lessons
See also Health Insurance Portability and Accountability
Health ethics is a very broad topic. At best, this Act of 1996 (HIPAA); Informed Consent; Public
entry has offered a list of key words to use when Policy; Randomized Controlled Trials (RCTs);
exploring less limited venues and then put those Rationing Healthcare; Regulation; U.S. Food and Drug
key words into some perspective. Administration (FDA); Vulnerable Populations
If a health services researcher were just start-
ing to look at the ethical issues involved in his
or her work, he or she would do well to start Further Readings
with a thorough investigation of the ethics of
AcademyHealth. Ethical Guidelines for Managing
doing research. If there was any part of the field
Conflicts of Interest in Health Services Research.
of ethics that every health services researcher
Washington, DC: AcademyHealth, 2004.
must know about, it is the ethical concerns of Bayer, Ronald, Lawrence O. Gostin, Bruce Jennings,
doing work: involving human subjects and et al. eds. Public Health Ethics: Theory, Policy and
where powerful interests stand to gain or lose Practice. New York: Oxford University Press, 2007.
lots of money as a result of the work’s conclu- Beauchamp, Tom L., and LeRoy Walters, eds.
sions. IRBs and conflict of interest reviews Contemporary Issues in Bioethics. 6th ed. Belmont,
should be the starting point. And the interdisci- CA: Thomson/Wadsworth, 2003.
plinary nature of health services research creates Mappes, Thomas A., and Jane S. Zembaty. Social Ethics:
an added responsibility for the researcher to Morality and Social Policy. 7th ed. Boston: McGraw
understand multiple perspectives. Hill, 2007.
Health services researchers should understand Mazur, Dennis. Evaluating the Science and Ethics of
the larger arena in which they are operating, and Research on Humans: A Guide for IRB Members.
they should become more familiar with the spread- Baltimore: Johns Hopkins University Press, 2007.
ing field of bioethics. One way to look at the rela- Murphy, Timothy. Case Studies in Biomedical Research
tionship between bioethics and health services Ethics. Cambridge: MIT Press, 2004.
research is that the latter is merely one category of Smith, Marie, and Emma Williamson. Researchers and
the former. If that is so, then health services Their “Subjects”: Ethnic, Power, Knowledge and
researchers are an integral part of the bioethics Consent. Bristol, UK: Policy Press, 2004.
field and need to understand the terrain of their
work. However, many health services researchers
do not see themselves fitting neatly into bioethics, Web Sites
but the two worlds are multiple and complexly AcademyHealth: http://www.academyhealth.org/ethics/
linked. Bioethics is, at least, the context of health index.htm
services research and so ought to be studied by any American College of Healthcare Executives (ACHE):
health services researcher who has an expansive http://www.ache.org/ABT_ACHE/code.cfm
view of his or her research agenda. American Medical Association (AMA):
Discussions about health are not easy to sepa- http://www.ama-assn.org/ama/pub/category/2498.html
rate from discussions about moral decision mak- American Nursing Association (ANA), Center for Ethics
ing. The word health has as its Indo-European and Human Rights: http://www.nursingworld.org/ethics
origin the same root as holy. It is not possible to Kennedy Institute for Ethics:
discuss health ethics without addressing “right and http://kennedyinstitute.georgetown.edu
Ethnic and Racial Barriers to Healthcare 383
that minority groups generally receive lower qual-

Ethnic and Racial ity of care than nonminorities, even after consid-
Barriers to Healthcare ering access to care, insurance status, and income.
The report also noted that the causes of these dis-
Ethnic and racial minorities, including African parities are widespread and complex, requiring
Americans, Hispanics/Latinos, Native Americans systemic changes at many levels by various
and Alaskan Natives, Asian and Pacific Islanders, actors.
and Native Hawaiians, comprise approximately
25% of the United States population. It has been Potential Barriers to Healthcare
well documented in research studies that ethnic
and racial minorities face barriers to the healthcare In addition to the biases present in the nation’s
system due to a variety of factors, including socio- healthcare system, ethnic and racial minorities
economic, healthcare coverage, geographic, cultural may face hardships in terms of finances, transpor-
differences, and decreased access and availability tation, and child care to get to regular healthcare
to healthcare providers. The ethnic and racial visits as well as encounter possible difficulties in
barriers to healthcare have in turn resulted in navigating the complicated healthcare system.
health disparities or differences in health out- Generally speaking, ethnic and racial minorities
comes and health status across racial and ethnic are of lower socioeconomic status and have lower
subgroups. education levels, which are correlated with poorer
health outcomes. Furthermore, many ethnic and
racial minority groups may be at greater risk of
being exposed to certain environmental condi-
Overview
tions that may adversely affect their health. Ethnic
The historical injustices that ethnic and racial and racial minorities may also have greater geo-
minorities have endured in the United States are graphic impediments by traveling farther distances
significantly intertwined with the issue of racial to see a healthcare provider. As a result, ethnic
and ethnic barriers to healthcare. For example, and racial minorities often encounter greater bar-
Native Americans were left to care and fend for riers when accessing the healthcare system.
themselves after smallpox and yellow fever were A 2001 study by the National Center for Health
brought over by the early Europeans settlers. Statistics (NCHS) indicated that 27% of Hispanics
Additionally, this group has been historically mar- did not visit a healthcare provider over a period of
ginalized. Within the African American commu- 1 year. Additionally, 21.4% of Native Americans
nity, there remains great mistrust of the healthcare and Alaskan Natives, 20.8% of Asians, and 16.4%
system due to the Tuskegee studies, where African of Blacks did not receive any healthcare over the
American males participated in research studies same time period compared with 14.3% of Whites.
without any informed consent and were denied Additionally, the lack of health insurance cover-
proper treatment for syphilis with penicillin. The age poses a significant barrier to many ethnic and
history of segregation of African Americans still racial minorities in receiving appropriate health-
runs deep in this community, and it has created care. Although nearly 74% of Whites are privately
social barriers. There are similar injustices that insured, only about 45% of Hispanics/Latinos are
Hispanics/Latinos, Asian and Pacific Islanders, privately insured. Furthermore, Medicaid covers
and Native Hawaiians have endured that provide approximately 20% of African Americans, while
some context and background to the racial and only about 10% of Whites are covered through
ethnic barriers to healthcare. this publicly sponsored program. Compared with
There is a large body of literature documenting the 12% of Whites who are uninsured, about 33%
the inequities and disparities in the treatment that of Hispanics/Latinos, 33% of Native American
patients receive based on their race or ethnicity. A and Alaskan Natives, 20% of African Americans,
2003 national Institute of Medicine (IOM) report and 17% of Asian Americans were uninsured. The
Unequal Treatment: Confronting Racial and reason for the disparities in terms of healthcare
Ethnic Disparities in Health Care acknowledges coverage between these groups is primarily due to
384 Evans, Robert G.
employment status, where ethnic and racial minor- Bierman, Arlene S., Nicole Lurie, Karen Scott Cullins,
ities are unemployed, employed in a job that does et al. “Addressing Racial and Ethnic Barriers to
not offer health insurance, or are unable to afford Effective Health Care: The Need for Better Data,”
the health insurance coverage offered. Health Affairs 21(3): 91–102, May–June 2002.
There may also be differences in cultural beliefs Chen, Judy Y., Sarah A. Fox, Clairessa H. Cantrell, et al.
that preclude certain ethnic and racial groups “Health Disparities and Prevention: Racial/Ethnic
from seeking healthcare in addition to the histori- Barriers to Flu Vaccination,” Journal of Community
cal mistrust of the healthcare system, resulting in Health 32(1): 5–20, February 2007.
Mead, Holly, Lara Cartwright-Smith, Karen Jones, et
minority groups having less satisfaction with their
al. Racial and Ethnic Disparities in U.S. Health
medical care. Furthermore, certain ethnic and
Care: A Chartbook. New York: Commonwealth
racial groups may not believe in Western medici-
Fund, 2008.
nal practices. There may also be linguistic barriers
Smedley, Brian D., Adrienne Y. Stith, and Alan R.
to receiving culturally appropriate healthcare. Nelson, eds. Unequal Treatment: Confronting Racial
Due to this recognition, the concept of cultural and Ethnic Disparities in Health Care. Washington,
competence, training health professionals to deliver DC: National Academies Press, 2003.
culturally competent healthcare, has become a pop- Williams, Richard Allen, ed. Eliminating Healthcare
ular notion as an effective means of reducing some Disparities in America: Beyond the IOM Report.
of the barriers faced by ethnic and racial minorities. Totowa, NJ: Humana Press, 2007.
Cultural competency training has been used to make
providers aware of disparities in health status and to
improve provider-patient relationships by delivering Web Sites
tailored and appropriate care.
Aetna: http://www.aetna.com
Commonwealth Fund: http://www.commonwealthfund.org
Future Implications Robert Wood Johnson Foundation (RWJF):
http://www.rwjf.org
It is estimated that by the year 2050, ethnic and
racial minorities will outnumber the current White
majority. As the ethnic and racial minority popu-
lation continues to grow, it is paramount that
barriers to healthcare be properly identified and
Evans, Robert G.
addressed. Proactive efforts should be made to
eliminate ethnic and racial barriers to healthcare Robert G. Evans is a leading Canadian health
in addition to eliminating health disparities. economist. His comparative studies of healthcare
Cultural competency programs are a step in the systems and funding strategies have greatly influ-
right direction of making this a tangible reality. enced the Canadian federal and provincial govern-
ments. He also has served as a consultant to many
Richard H. Sewell governments and public agencies in the United
States, Europe, Asia, and the South Pacific.
See also Access to Healthcare; Child Care; Cultural Evans is a senior faculty member and professor
Competency; Economic Barriers to Healthcare; Health of economics at the University of British Columbia
Disparities; Medicaid; Transportation; Vulnerable in Vancouver, Canada. Evans is a fellow at the
Populations Canadian Institute for Advanced Research. He
was previously the director of the Institute’s
Population Health Program from 1987 to 1997.
Further Readings Born in 1942, Evans earned a bachelor’s degree
Aaron, Kaytura Felix, and Carolyn M. Clancy. in political economy from the University of Toronto
“Improving Quality and Reducing Disparities: and a doctorate degree in economics from Harvard
Toward a Common Pathway,” Journal of the University. While in graduate school, Evans was a
American Medical Association 289(8): 1033–34, research staff member of the Ontario Committee
February 26, 2003. on Taxation (the summers of 1964 and 1965) and
Evidence-Based Medicine (EBM) 385
at the Bank of Canada (the summers of 1966 and received the Health Services Research Advancement
1967). He returned to the Ontario Committee on Award from the Canadian Health Services Research
Taxation in 1967 and the Bank of Canada in 1968 Foundation (CHSRF).
on a part-time basis. He also worked part-time
at the Ontario Hospital Services Commission in Amie Lulinski Norris
1969. After graduating from Harvard, Evans See also Canadian Association for Health Services and
became an assistant professor at the University of Policy Research (CAHSPR); Canadian Health Services
British Columbia. He quickly rose through the Research Foundation (CHSRF); Canadian Institute of
academic ranks of the university, becoming associ- Health Services and Policy Research (IHSPR); Health
ate professor in 1973 and professor in 1978. Economics; Health Services Research in Canada;
Throughout his career, Evans has served on the International Health Systems; Public Policy
boards of numerous healthcare, research, and
policy organizations. He was the president of the
Canadian Health Economics Research Association; Further Readings
member of the National Health Research and
Barer, Morris L., Robert G. Evans, Matthew Holt, et al.
Development Program, Main Advisory Committee; “It Ain’t Necessarily So: The Cost Implications of
member of the expert advisory panel on National Health Care Reform in the United States,” Health
Health Expenditures, Canadian Institute of Health Affairs 13(4): 88–99, Fall 1994.
Information; member of the Commonwealth Fund Evans, Robert G. Strained Mercy: The Economics of
Commission on Elderly People Living Alone; Canadian Health Care. Toronto, Ontario, Canada:
member of the executive board of directors of the Butterworth, 1984.
International Health Economics Association Evans, Robert G. “New Bottles, Same Old Wine: Right
(iHEA); and board member of the Association for and Wrong on Physician Supply,” Canadian Medical
Health Services Research (now AcademyHealth). Association Journal 158(6): 757–59, March 24, 1998.
Evans has authored or coauthored more than Evans, Robert G. “The Blind Men, the Elephant and
230 scholarly articles and books. Two of his books the CT Scanner,” Healthcare Policy 1(3): 12–18,
are considered classics: Strained Mercy: The 2006.
Economics of Canadian Health Care and Why Are Evans, Robert G., Morris L. Barer, and Theodore R.
Some People Healthy and Others Not? The Marmor, eds. Why Are Some People Healthy and
Determinants of Health of Populations. He is a Others Not? The Determinants of Health of
frequent commentator in the journal Healthcare Populations. New York: Aldine de Gruyter, 1994.
Policy. And he serves on the editorial boards of
Annals of Internal Medicine, International Journal
of Technology Assessment, ISUMA Canadian Web Sites
Journal of Policy Research, Journal of Health University of British Columbia, Centre for Health
Economics, and Journal of Health Politics, Policy Services and Policy Research (CHSPR):
and Law. http://www.chspr.ubc.ca
Evans has received many awards and honors in
recognition of his work. He is an honorary life
member of the Canadian College of Health Services
Executives and the Canadian Health Economics
Research Association, and he is a member of the
Evidence-Based
National Academy of Social Insurance in the Medicine (EBM)
United States. He also was a member of the British
Columbia Royal Commission on Health Care and Evidence-based medicine (EBM) is a fairly recent
Costs in 1990, and the National Forum on Health concept in the field of medicine, and it represents
from 1994 to 1997. He was awarded the Baxter a major paradigm shift from the reliance exclu-
International Health Services Research Prize in sively on clinical expertise in healthcare decision
2001 by the Association of University Programs in making. EBM involves the integration of the
Health Administration (AUPHA). In 2002, he also best available research evidence with clinical
386 Evidence-Based Medicine (EBM)
experience and patient preferences. By combining first published randomized controlled trial (RCT)
these three components, the goal of EBM is to reported in 1948 by the Medical Research Council
provide the best possible healthcare and obtain in London. Archibald L. Cochrane (1909–1988),
the best patient outcomes possible. whose work would lead to the Cochrane Colla-
EBM involves five steps: (1) generating an boration, published what is considered a classic
answerable clinical question; (2) conducting a work titled Effectiveness and Efficiency: Random
search to find the best research studies available Reflections on Health Services in 1972. This text
that can answer the question; (3) critically evaluat- had a profound effect on medical practice and
ing the studies found for validity (closeness to the evaluation with its stress on the importance of
truth), impact (size of the effect), and applicability RCTs in evaluating the effectiveness of treatments.
to clinical practice; (4) integrating the research The Cochrane Collaboration, which was named
evidence with the clinician’s expertise and experi- in his honor, is known worldwide for its develop-
ence and the patient’s values; and (5) evaluating ment, evaluation, and synthesis of RCTs in all
the efficiency and effectiveness of conducting Steps areas of medicine.
1 to 4 for potential improvements the next time The momentum for what was to become EBM
they are implemented. Each of these steps is dis- began in the 1970s. Research was increasingly
cussed in more detail below. showing a wide variety of practice patterns among
While it is believed that by applying findings physicians, challenging the assumption that clinical
from research studies as evidence to the applica- judgment or the art of medicine was sufficient. It
tion of clinical practices will result in improved was deemed that medical decisions were far too
decision making and patient outcomes, EBM has complex for a physician to have all the information
received mixed reactions by clinicians and academ- needed to make decisions in this manner. It was
ics. In real-world clinical practice, it is very diffi- also found that there was a gap between clinical
cult for clinicians to keep up-to-date with the rapid research and what was occurring in clinical prac-
expansion of healthcare information being pub- tice. The evidence was lacking for many important
lished. When faced with clinical questions con- practices. As practices were studied through clini-
cerning a diagnosis, prognosis, treatment, or cal trials, it was found that many of those being
general care, the answer is typically needed rap- used by physicians were ineffective. Greater empha-
idly. With the volume of published information, sis began to be placed on RCTs. However, it still
most clinicians will only have time to read a small took years for physicians to put the results of the
portion of what is available on a regular basis. The trials into practice. In addition, with the rising cost
hope of EBM is that in the case of some of the of healthcare, a solution needed to be found.
more pertinent clinical questions, the evidence may The term evidence-based medicine first appeared
have already been found, critically analyzed, and in the 1990s. David L. Sackett, is widely regarded
packaged in a format that is readily accessible to as one of the originators of EBM. Sackett devel-
the busy clinician. Ultimately, the goal is to have oped the concept when he was a faculty member at
patients, clinicians, healthcare managers, and poli- McMaster University in Canada. After working at
cymakers have available to them healthcare McMaster for decades, Oxford University in the
research that is scientifically valid and readily United Kingdom created a chair for Sackett allow-
applicable to clinical situations. ing him to establish the first center in EBM.
The original definition of EBM stressed the
need for a systematic approach to analyze pub-
History
lished research to be used for clinical decision
There are accounts of evidence being used to making. Sackett later refined the definition in 1996
change medical practices as far back as the 1700s. to stress a more evaluative and conscientious use
In more recent times, Sir Richard Doll (1912–2005), of current research in caring for individual patients.
a world famous English epidemiologist, described In 1997, the Agency for Healthcare Research and
evidence for medical practice in 1937 with the use Quality (AHRQ) created the Evidence-Based
of case studies as guides. The use of evidence Practice Center program, which collects and syn-
became more scientifically controlled with the thesizes evidence.
Steps best information from the resources. The types of

questions might be categorized as clinical findings,
The practice of EBM constitutes a five-step
differential diagnosis, diagnostic tests, therapy,
process: (1) formulating a question, (2) finding the
prevention, prognosis, cause/etiology, cost-
evidence, (3) critically appraising the evidence,
effectiveness, harm/risk, or quality of life.
(4) integrating evidence with clinician judgment
The type of information that would answer the
and patient values, (5) and conducting a self-
question will depend on the type of question. While
evaluation of the process. A description of each of
RCTs have been considered the gold standard of
these steps is given below.
scientific evidence in healthcare, a range of research
methodologies, including quasi-experimental and
Step 1: Formulating a Question qualitative research methods, which have been bor-
rowed from the social sciences, may be considered
A good question must be answerable. Sackett appropriate evidence depending on the type of
makes a distinction between what he calls back- question. Questions involving patient satisfaction
ground and foreground questions. When a clini- or quality of life would involve qualitative evi-
cian’s experience with a condition or disorder is dence, whereas the best evidence about a therapy
limited, most questions will tend to be background might tend to be more systematically gathered and
questions. As clinical experience and responsibility involve quantitative evidence. Hierarchies or levels
grow, questions increasingly become foreground of evidence are often constructed in a pyramid,
questions but still with the need for background showing the strongest to the weakest form of evi-
knowledge. Background questions involve asking dence for a particular type of question. In the
for general knowledge about a disorder by using a medical model, the type of study that would be
question root (who, what, when, where, how, considered the strongest form of evidence is the one
why) with a verb and a disorder or an aspect of it. based on RCTs. Alternatively, a systematic review
Foreground questions ask for specific knowledge or meta-analysis, synthesizing the results of a num-
about a given disorder and contain four essential ber of RCTs, would be even stronger evidence. The
components: patient and/or problem, intervention, quickest and potentially the most efficient way to
comparison intervention (as needed), and clinical find the best evidence is to use an evidence-based
outcomes. In contrast, foreground questions often clinical practice guideline. However, there may not
arise as central issues in clinical work, involving be one available that matches a specific clinical
clinical findings, etiology, clinical manifestations of issue, and these guidelines, which are often devel-
the disease, differential diagnosis, diagnostic tests, oped by panels of experts, may contain more bias
prognosis, therapy, prevention, patient experience than a systemically controlled study. Where the
and meaning, and self-improvement. strongest forms of evidence are not available, one
would move down the hierarchy to less robust
forms of evidence, such as nonrandomized clinical
Step 2: Finding the Evidence
trials, cohort studies, prospective studies, and so
To make informed decisions or influence change, on. Under some circumstances, the best form of
formulating an answerable question and then evidence available may be case reports, which do
starting the process of information seeking is not have the rigor and strength of evidence of a
essential. Given the multitude of scientific and controlled research study but nevertheless may pro-
medical research articles that are now published vide helpful information. Studies and other forms
annually, it is helpful to take a systematic approach of evidence may be found in various databases (i.e.,
to finding the best available evidence for the type MEDLINE, CINAHL, and PsycInfo), catalogs, or
of question being asked. Some researchers suggest free resources on the Internet in the form of journal
looking at five areas as a guide: type of question, articles, trial and research registries, bulletins and
type of information that would answer the ques- newsletters, published reports, gray literature, con-
tion, type of study that would provide the informa- ference proceedings, and Web sites. It is critical that
tion, types of information resources that would the literature be carefully evaluated for its strength
give access to the best studies, and extracting the and applicability to the question at hand.
388 Evidence-Based Medicine (EBM)
Step 3: Critically Appraising Studies Found dropping out of the study without follow-up,
people changing their behavior because they are
On finding a journal article that includes poten-
being observed, or investigators treating groups
tially useful evidence, the next step is to evaluate
differently.
its quality. Three key issues to address include
When analyzing studies, it is important to look
validity, results, and the relevance of results.
at the strength of the association between vari-
In health services research, most studies include
ables. Estimates of strength can be reported as
six major components by which a study can be
relative risk, which compares the potential for one
analyzed—sampling, assignment to groups, assess-
group having the same outcome as another group
ment, analysis, interpretation, and extrapolation
with the presence or absence of an experience or
to large groups, as outlined by the National
exposure to a condition or treatment. A relative
Information Center on Health Services Research
risk of 5.0 is considered very significant. However,
and Health Care Technology (NICHSR). Each of
risks in epidemiological studies tend to be lower
the six components is discussed below.
(i.e., 2.0). This has caused some concern and con-
Sampling troversy about the value of the relative risk statis-
tic. Statistical significance relates to characteristics
Health services research questions require data of the larger population. From studying the results
from large groups of people as recommendations from a sample of the population, one can infer
for things such as reimbursement rates, screening, what is happening with the population.
or surgical options that apply to the larger popula- The p value is used to measure statistical sig-
tion. A sample of the population is studied and nificance, with a value less than .05 indicating a
applied to the larger group. Based on statistical less than 5% chance of the results occurring if
methods, an appropriate sample size of people to there is no relationship to the larger population.
study can be obtained, from which the results can A value of .01 has the same meaning at 1% prob-
be applied to the larger group. Descriptions of the ability. Either of these values generally results in
specific type of sampling used in the study should the conclusion that there is a relationship to the
appear in the methods section of a journal article. larger population, which, however, is not the same
as cause and effect. Finally, looking at adjustment
Assignment
is important. When differences between two
People in the sample are assigned into prespeci- groups being studied may influence the results,
fied groups, such as smokers and nonsmokers, to these factors are called confounders. Confounders
observe differences based on health behaviors and may be analyzed using the statistical tools of
other characteristics. Alternatively, people may be stratification and regression analysis. Factors
randomly assigned to different groups to investi- other than those targeted for study may have
gate the effects of different treatments on different influenced and therefore confounded the results
groups. Regardless of study design type, the people of the study. These factors are often noted in the
in the experimental group must be alike except for discussion of a journal article. To understand the
the factor being studied so that the results may be analysis, it is necessary to have some training in
attributed to the factor and not to differences in the area through readings, coursework, or consul-
the people. Tables in a study showing the profiles tation with a statistician.
of the people in each group should be reviewed for
similarity in factors such as age, gender, ethnicity Interpretation
and race, socioeconomic status, and health status. A study is concluded by interpreting the results
from the analysis to draw conclusions about indi-
Assessment
viduals in the study. An assessment is made of the
The means by which people or factors are strength of the association between the variables
measured is of considerable importance to the being measured and the cause-effect relationship
value of the study. Some potential errors in mea- between them. Factors that may support more
surement include inaccurate instruments, people confidence in assuming a cause-effect relationship
are if the risk factor occurs more often in people Selected Resources for Locating Evidence
with the specified outcome, if it precedes the effect,
There are numerous resources available on the
or if changes in the risk factor produce the effect.
Internet for learning about or finding evidence to
Causation may also be determined by looking at
be used in clinical or policy situations. Many are
the strength of association between factors as mea-
based in Canada, the United Kingdom, and the
sured by relative risk, determining the consistency
United States. Some of the main resources are
of the association when the study of different
highlighted below.
groups in different settings results in similar out-
comes, determining that a specific factor caused an
outcome due to biologic plausibility in a clinical Evidence-Based Practice Reports
study, and a dose-response relationship in which
The AHRQ awards 5-year contracts to organi-
higher levels of a risk factor contribute more than
zations in the United States and Canada to be
lower levels to an outcome.
Evidence-Based Practice Centers (EPCs). These
centers thoroughly review the relevant scientific
Extrapolation
and medical literature in areas of clinical, behav-
Before adopting a study as evidence for a clini- ioral, organization of, and financing of healthcare
cal or administrative need at hand, one must deter- to produce evidence reports and technology assess-
mine if the study is applicable to the situation in ments. In addition, they conduct research on the
question. For example, is the population under methodology of systematic reviews.
study similar according to characteristics that were
controlled for in the selection of people? Can one
generalize the results to another group, form of National Guideline Clearinghouse
treatment, higher or lower dose of medication, and This comprehensive database is a project of the
so on? AHRQ in partnership with the American Medical
Association (AMA) and America’s Health Insurance
Plans (AHIP). It provides structured abstracts and
Step 4: Integrating Research Evidence With links to full-text guidelines, where available, or for
Clinician Expertise and Patient Values ordering information for print copies.
Once the found evidence has been critically
appraised, in clinical practice it is important along
Cochrane Collaboration Database
with the best available evidence to take the client’s
of Systematic Reviews
values and preferences into account as well as the
professional judgment and experience of the clini- A major product of the Cochrane Collaboration,
cian before making a healthcare decision. Clearly, this database provides access to quarterly produced
the process and outcome of this step occurs on a systematic reviews. The Cochrane Collaboration is
case-by-case basis. a nonprofit organization that produces and dis-
seminates systematic reviews related to healthcare
worldwide and promotes the search for evidence
Step 5: Self-Evaluation in the form of RCTs. Access to the Cochrane
Library is available by subscription online, on
The final step involves evaluating oneself to
CD-ROM, or by PDA, and is free in various parts
determine how well the process was carried out
of the world through sponsorships by various
in Steps 1 to 4. Where problems have occurred,
organizations.
one or more steps of the process may need to be
repeated to find the best available evidence. There
may also be a need for the individual to engage in
Health Services Technology Assessment Text
further education about any of the steps involved
in order to ensure greater success when seeking The Health Services Technology Assessment
evidence the next time. Text (HSTAT) is a free resource on the Internet
390 Eye Care Services
that provides links to full-text evidence documents Web Sites

to support healthcare decision making. It is avail- Agency for Healthcare Research and Quality (AHRQ):
able through the U.S. National Library of Medicine http://www.ahrq.gov
(NLM). Centre for Evidence-Based Medicine (CEBM):
http://www.cebm.net
Cochrane Collaboration: http://www.cochrane.org
PubMed/MEDLINE
Evidence-Based Medicine Resource Center:
The database MEDLINE is freely accessible http://www.ebmny.org
worldwide on the Internet using the PubMed inter- National Guideline Clearinghouse:
face maintained by the NLM. Evidence can be http://www.guideline.gov
found by using the EBM limit. More options and PubMed Home: http://www.ncbi.nlm.nih.gov/pubmed
instructions for finding specific forms of evidence
are available from the Search for the Evidence Web
site, a joint project between the New York Academy
of Medicine (NYAM) and the New York Chapter
of the American College of Physicians (ACP).
Eye Care Services
Barbara Nail-Chiwetalu Studying the organization and delivery of eye care
services is important to the field of health services
See also Agency for Healthcare Research and Quality research. Vision disorders and eye diseases affect
(AHRQ); Clinical Decision Support; Clinical Practice the quality of life for tens of millions of Americans,
Guidelines; Cochrane, Archibald L.; Meta-Analysis; and the resulting visual impairment or blindness
National Guideline Clearinghouse (NGC); Randomized
significantly increases the economic burden to
Controlled Trials (RCTs); Sackett, David L.
society. Undiagnosed and untreated visual disor-
ders and eye diseases particularly affect children
and the elderly. Childhood visual disorders have
Further Readings the potential to impede learning, and adult age-
Cochrane, Archibald L. Effectiveness and Efficiency: related eye diseases constitute a large percentage
Random Reflections on Health Services. London: of preventable blindness in the United States.
Nuffield Provincial Hospitals Trust, 1972. Analysis by health service researchers of eye care
Drummond, Rennie, ed. User’s Guide to the Medical services can lead to increasing the nation’s visual
Literature: A Manual for Evidence-Based Clinical and ocular health.
Practice. New York: McGraw-Hill Medical, 2008.
Eden, Jill. “Committee on Reviewing Evidence to Identify
Highly Effective Clinical Services.” Knowing What Organization of Care
Works in Healthcare: A Roadmap for the Nation.
Three types of medical practitioners provide eye
care services in the nation: ophthalmologists,
Guyatt, Gordon, Rennie Drummond, Maureen Meade,
optometrists, and opticians. Ophthalmologists are
et al., eds. User’s Guide to the Medical Literature: A
physicians who specialize in the medical and sur-
Manual for Evidence-Based Clinical Practice. 2d ed.
New York: McGraw-Hill Medical, 2008.
gical management of the eyes and the visual sys-
Higgins, Julian, and Sally Green, eds. Cochrane
tem. They provide a spectrum of care, including
Handbook for Systematic Reviews of Interventions. the examination of the visual system to prescribe
Hoboken, NJ: Wiley Sons, 2008. eyeglasses and contact lenses, as well as the diag-
Melhorn, J. Mark, and William E. Ackerman, eds. Guides nosis and medical or surgical management of eye
to the Evaluation of Disease and Injury Causation. disorders and diseases. In addition, many ophthal-
Chicago: American Medical Association, 2008. mologists further specialize in a particular section
Sackett, David L., Sharon E. Straus, W. Scott of the eye or disease. Ophthalmologists are medi-
Richardson, et al. Evidence-Based Medicine: How to cal doctors (MD) or doctors of osteopathy (DO).
Practice and Teach EBM. 2d ed. New York: Churchill Optometrists, also called doctors of optome-
Livingstone, 2000. try (OD), diagnose and treat vision problems,
Eye Care Services 391
prescribe eyeglasses and contact lenses, diagnose Access to Eye Care

and treat eye diseases, and prescribe medications
Many factors affect the accessibility to eye care
to treat eye disorders. They do not perform
services. As with most healthcare services, afford-
surgery, but they often provide patients with
ability and availability of medical and vision
pre- and postsurgical care. Sometimes ophthal
insurance can limit access to needed eye care.
mologists and optometrists work in the same
With few exceptions, traditional health insurance
practice and comanage patients.
coverage, including Medicare and Medicaid, does
An optician manufactures and fits eyeglasses
not cover well-eye examinations, preventive ser-
and, in some states, contact lenses. Many states
vices, or the component of the examination for the
require opticians to be licensed to deliver these
determination of eyeglasses or contact lenses. Eye
services. Some opticians manufacture eyeglass
examinations must have a medical diagnosis that
lenses and contact lenses from raw materials in the
includes the use of the International Classification
laboratory. Office-based opticians cut the labora-
of Diseases (ICD) codes to be eligible for reim-
tory-created lenses to fit into the eyeglass frame.
bursement. All well-eye examinations, or exami-
Opticians then take eye measurements to ensure
nations for the determination of eyeglasses and
proper lens placement in the eyeglass frame and
contact lenses, are covered by a separate vision
verify accuracy.
care benefit policy. The U.S. Bureau of Labor
Since there is some overlap in the scope of care
Statistics (BLS) reports that only 26% of full-time
offered by ophthalmologists and optometrists,
employees and 9% of part-time employees work-
there is no defined organization of eye care deliv-
ing in medium and large private companies in the
ery. An efficient and effective model is a verti-
nation have a vision care benefit. Without a sepa-
cally integrated system with optometrists being
rate vision care benefit, the cost of eye care ser-
the primary entry point into the system with
vices may keep away individuals who would
referral to ophthalmologists for more advanced
benefit from preventive services and correction of
medical care or surgical treatment. This design is
refractive error.
widely recognized in studies as showing an
Health disparities exist in eye care services and
enhancement in both eye care delivery and cost-
contribute to the lack of accessibility. Race, income,
effectiveness of care.
and educational level all have an effect on access to
There are an estimated 17,000 practicing oph-
eye care. Lack of understanding of the eye and
thalmologists and 33,000 practicing optometrists
visual system also limits eagerness to seek out
in the nation. Eye care services provided by them
needed eye care. The Centers for Disease Control
represents more than 5% of the total Medicare
and Prevention’s Behavioral Risk Factor Surveillance
Part B payments, or $4.5 billion in 2005. The
System (BRFSS) identified “no reason to go” and
National Ambulatory Medical Care Survey
“cost or insurance” as the top two reasons for not
(NAMCS), conducted by the National Center for
seeking eye care services. In response, Healthy
Health Statistics (NCHS), reported an estimated
People 2010 includes 10 objectives for vision care.
47.3 million outpatient visits to ophthalmologists
Having access to a regular provider of eye care as
in 2004. This number does not include hospital-
well as receiving a physician referral for eye care
ized patients or visits to optometrists. The current
increases the likelihood that a patient will have
supply of eye care providers meets the patient
access to these services.
demand; however, the demand for eye care services
is artificially low. The demand significantly
increases when the number of patients in whom
Children Services
eye care is indicated but not requested is consid-
ered. Of the population that is determined to be at Children’s access to comprehensive eye care ser-
high risk of serious vision loss, and which should vices is particularly important. At birth, a child’s
have yearly eye examinations, less than half have visual system is not completely developed, and the
had a complete eye examination in the past year. eye and neuronal pathways associated with vision
This shortfall in the provision of eye care services continue to develop during childhood. Children’s
highlights the lack of access to needed care. visual systems have plasticity during a brief period
of time between birth and approximately 5 to identify visual disorders. In addition to no agree-
9 years of age. It is during this time that the visual ment regarding the content of school vision
system develops the ability to discern fine detail. screenings, there is also no consensus as to which
During the time of plasticity, abnormalities of the agency should oversee the screenings and who
eye or visual system that are not corrected can should administer these vision screenings, which
result in permanent uncorrectable visual disorders can range from an untrained teachers aid to a
into adulthood. Amblyopia, commonly referred to physician. Also, there are no nationwide man-
as lazy eye, is an example of a visual disorder that dates for when school vision screenings should
is present at birth or early childhood and has the take place. Only 15 states require vision screen-
potential of being reversed if treatment is received ings for preschool age children. Parents of chil-
during this time of plasticity of the visual system. dren who fail school vision screenings are issued
However, many disorders of the visual system that a letter, which explains that the child needs a
are present in infants and children are undiag- comprehensive eye examination, by an ophthal-
nosed due to the lack of an eye examination. This mologist or optometrist. However, due to the lack
primarily occurs because of the lack of articula- of access to eye care services and parents not
tion of symptoms by children and the signs of the understanding the scope of the vision problem,
visual disorder going unnoticed by parents. If dis- many children do not receive follow-up care after
orders of the visual system are not treated by the the screenings. Moreover, many parents view
age of approximately 9, the visual deficit may school vision screenings as a substitute for a com-
become permanent. prehensive eye examination. Parents of children
Vision disorders in children can have lasting who pass school vision screenings may have a
effects. It is estimated that 80% of learning is false sense of assurance that no vision problems
assimilated through the visual system, and 60% of exist with their child. Due to variability in the
children who are identified as problem learners content and administration of school vision
have undetected vision disorders. The American screenings, as well as the sensitivity of detecting
Optometric Association (AOA) reports that 25% visual disorders through the screening modality, a
of children in the nation have significant visual debate exists over the cost-effectiveness of vision
disorders that impede learning. Some of these screening versus comprehensive eye examinations
vision problems can persist into adulthood and can for children. A small number of states currently
have implications as to which career choices are require a comprehensive eye examination, pre-
available to them. An example of this would be formed by an ophthalmologist or optometrist, to
untreated childhood amblyopia, which results in be completed before a child enters into public
one eye, or both eyes, with poor vision as an adult. kindergarten. However, this can create a financial
Adults with amblyopia cannot pursue careers that barrier to a free public education if parents do not
would require binocular, or stereo, vision. Careers have health insurance or lack the financial means
that require good binocular vision are (but are not to afford the examination.
limited to) airplane pilots, commercial vehicle
drivers, and surgeons. This limitation of career
Adult Services
choice into adulthood can translate into economic
implications for society. As the nation’s average life expectancy increases,
School vision screenings have been imple- age-related eye diseases and disorders will increase
mented in an effort to identify children with in prevalence. This increase is compounded by
visual impairment. However, the implementation the aging of the baby boomer generation, those
of school vision screenings is controversial. There born between 1946 and 1964. Many age-related
is no universal standardized approach for the eye diseases can lead to vision impairment and
administration or content of school vision screen- blindness. The Eye Diseases Prevalence Research
ings. The components of vision screenings vary Group at the Wilmer Eye Institute of Johns
widely, and there is no consensus regarding which Hopkins University estimates that more than 3.5
components are the most sensitive and specific to million Americans are affected by blindness or
Eye Care Services 393
visual impairment. However grim this statistic Eye Institute Visual Functioning Questionnaire
may appear, many age-related eye diseases are (NEI-VFQ) was developed to identify and quan-
preventable, or may be reduced in severity, with tify vision-related difficulties that are experienced
early diagnosis and treatment. Diabetic retinopa- by the visually impaired. The results of the col-
thy, cataracts, macular degeneration, and glau- lected data, from the NEI-VFQ pre- and post-
coma are the leading causes of preventable treatment, measure the benefits of treatments
blindness in the United States. As with pediatric that restore visual ability. A modified and shorter
visual disorders, adult-age-related eye diseases version of the survey, the VFQ-25, has been
may be asymptomatic in the early, most treat- developed to measure changes in the difficulty
able, phase. Issues such as lack of health insur- of associated tasks after vision rehabilitation.
ance coverage, lack of patient and provider Outcome measurement of various eye-related
education and understanding, as well as afford- interventions is useful in establishing the overall
ability impede access to adult eye care services. effect of the intervention. These outcome mea-
Increased assess to eye care services would reduce surements are also useful when comparing, and
the number of Americans living with blindness, justifying, the cost interventions.
which could have been prevented if timely diag-
nosis and treatment had been given. A 2006 Gregory S. Wolfe
study by David Rein and colleagues of the eco- See also Access to Healthcare; Cost of Healthcare;
nomic burden of major adult visual disorders in Disability; Health Insurance; National Institutes of
the nation’s population 40 years of age or older Health (NIH); Preventive Care; Public Health; Quality
estimated that the total government budgetary of Life, Health-Related (HRQOL)
impact was $13.7 billion, and the economic bur-
den, including total direct medical costs, total
direct nonmedical costs, and total productivity
Further Readings
losses, was $35.4 billion. Another study by Kevin
Frick and colleagues of the economic impact of Colman, Shoshana S., R. David Jones, Christian L.
visual impairment and blindness in the nation Serdahl, et al. “The Impact of Managed Eye Care on
estimated the loss of 209,000 quality-adjusted Use of Vision Services, Vision Costs, and Patient
life years. Both of these studies highlight the sig- Satisfaction,” Value in Health 7(2): 195–203, March–
nificant economic burden of blindness and visual April 2004.
impairment. Increasing access to eye care services Frick, Kevin D., Emily W. Gower, John H. Kempen,
and the understanding of age-related eye diseases et al. “Economic Impact of Visual Impairment and
is paramount in attempting to reduce the total Blindness in the United States,” Archives of
economic burden. Ophthalmology 125(4): 544–50, April 2007.
Kimel, Linda S. “Lack of Follow-Up Exams After Failed
School Vision Screening an Investigation of
Outcome Measures Contributing Factors,” Journal of School Nursing
22(3): 156–62, June 2006.
Until recently, there has not been a reliable and
Lee, Paul P., H. Dunbar Hoskins, and David W. Parke.
valid survey instrument to measure the outcome
“Access to Care: Eye Care Provider Workforce
effect of interventions related to eye care services. Considerations in 2020,” Archives of Ophthalmology
Health-related quality of life (HRQOL) is con- 125(3): 406–10, March 2007.
sidered an important outcome measure for Rein, David B., Ping Zhang, Kathleen E. Wirth, et al.
healthcare. The National Eye Institute (NEI) “The Economic Burden of Major Adult Visual
devised a survey instrument to measure changes Disorders in the United States,” Archives of
in HRQOL caused by eye diseases and their Ophthalmology 124(12): 1754–60, December 2006.
treatment. The NEI contracted with the RAND Zhang, Xinzhi, Jinan B. Saaddine, Paul P. Lee, et al. “Eye
Corporation to develop a vision-specific HRQOL Care in the United States: Do We Deliver to High-Risk
survey instrument to measure the outcomes People Who Can Benefit Most From It?” Archives of
of eye disease clinical trials. The National Ophthalmology 125(3): 411–18, March 2007.
Web Sites American Optometric Association (AOA):

http://www.aoa.org
American Academy of Ophthalmology (AAO):
National Eye Institute (NEI): http://www.nei.nih.gov
http://www.aao.org
Prevent Blindness America:
American Academy of Optometry (AAOPT):
http://www.preventblindness.org
http://www.aaopt.org
F
In 1849, there was a major outbreak of cholera
Farr, William in London that killed nearly 15,000 people.
London, at the time, was one of the most populous
William Farr (1807–1883) had a major impact on cities in the world due to early industrialization,
the emergence of British social statistics, epidemi- and as a result, the River Thames was heavily pol-
ology, and demography in the mid-19th century luted with untreated sewage. While Farr was ini-
and is considered to be a founder of medical sta- tially a proponent of the miasmic theory of disease,
tistics. Born in Shropshire, England, in 1807 to the theory that diseases were airborne, his detailed
poor parents, Farr was effectively adopted by a mapping of disease incidence in London, including
local squire, Joseph Pryce, after his family moved data on social class and elevation, laid the ground-
to Dorrington. He was able to afford his medical work for much 19th-century public health research.
education, receiving a licentiate from the Society Although Farr was unconvinced by John Snow’s
of Apothecaries, through the inheritance from efforts to show that cholera was of water-borne
several benefactors. Farr married in 1833 and origin, he provided Snow with data on individual
opened a medical practice in Fitzroy Square in deaths from that disease, and his geographically
London. His wife died in 1838 of tuberculosis, based orientation toward disease incidence helped
and he later remarried and had eight children. lay the groundwork for the acceptance of Snow’s
During the 1820s and 1830s, Farr became inter- theory of water-borne transmission.
ested in public health and medical statistics, and in Farr’s contributions to demography are less
the early 1840s, he played a key role in the devel- well-known to epidemiologists. By linking accurate
opment of a system of reporting the causes of vital statistics to the 1841 British census, he was
death by medical personnel and the collection of able to show how cross-sectional measures like the
these reports for local areas. Farr was also inter- census could be linked to dynamic measures of
ested in comparative methods of classification of population processes derived from age-specific
disease and causes of death; his work included birth and death rates. Lewis credits him with origi-
comparisons of such methods in other European nating the net reproduction ratio (NRR), a sum-
nations. mary measure of the rate at which a population is
Farr served for many years as the Compiler of reproducing itself net of the mortality rate. Farr’s
Abstracts of the Office of the Registrar General, a work in improving the accuracy of British popula-
post that enabled him to serve as the major statisti- tion and vital statistics led succeeding generations
cian of vital statistics for Great Britain. He was of demographers to see these as a dynamic system.
also a census commissioner for the 1861 and 1871 This led to the development of the linked equations
British censuses and served as president of the of general population theory and the theory of
Statistical Society. stable populations (by Lotka and Dublin in the
395
396 Feder, Judith
1920s). The fact that their mathematical model of D.C. Feder is a national leader and recognized
population dynamics could be easily demonstrated expert on healthcare policy. Her areas of expertise
by population dynamics in late-19th-century include national healthcare reform, the uninsured,
Britain led to its widespread acceptance by demog- Medicare, Medicaid, and long-term care. She fre-
raphers. These models also led to the influential quently testifies on Capitol Hill about various
computer simulations of population processes of healthcare policy issues.
Coale and Demeny (the families of model popula- Born in Brooklyn, New York, Feder went on to
tions) and the development of quasi-stable popula- earn a bachelor’s degree from Brandeis University
tion models. Farr’s work in showing how accurate, (1968) and a master’s (1970) and a doctoral degree
age-specific cause-of-death statistics could be linked (1977) in government from Harvard University.
to census tabulations provided epidemiologists She started her career working at the Brookings
with the ability to measure risks of incidence and Institution and the Urban Institute before joining
death in different population groups. the faculty of Georgetown University in 1984.
Feder has occupied a number of key leadership
Richard E. Barrett positions in both the U.S. Congress and the Execu
tive Branch of the federal government. In 1989,
See also Acute and Chronic Diseases; Epidemiology; Health
Services Research, Origins; Mortality; Public Health she was the staff director of the congressional U.S.
Bipartisan Commission on Comprehensive Health
Care, more commonly known as the Pepper
Further Readings Commission. The commission addressed national
long-term care policy issues.
Eyler, John M. Victorian Social Medicine: The Ideas and Feder is widely recognized for setting the stage
Methods of William Farr. Baltimore: Johns Hopkins for the national healthcare reform debate of the
University Press, 1979. 1990s. She served as a senior official in the Clinton
Lewis, F. M. M. “A Note on the Origin of the Net administration. Feder was the healthcare director
Reproduction Ratio,” Population Studies 38(2):
of President-Elect Clinton’s Transition Team. After
321–24, 1984.
President Clinton’s inauguration, she was appointed
Lilienfeld, D. E. “Celebration: William Farr
the principal deputy assistant secretary for plan-
(1807–1883): An Appreciation on the 200th
ning and evaluation in the U.S. Department of
Anniversary of His Birth,” International Journal of
Health and Human Services. In that position, she
Epidemiology 36(5): 985–87, 2007.
Gertsman, B. B. “Comments Regarding ‘On Prognosis’
was primarily responsible for developing the
by William Farr (1838), With Reconstruction of His Clinton Health Security Act and chairing the work-
Longitudinal Analysis of Smallpox Recovery and ing groups for the President’s Health Reform Task
Death Rates,” Soz-Praventivmed 48: 285–89, 2003. Force. She also helped shape the administration’s
Morabia, Alfredo, ed. A History of Epidemiologic healthcare policy by working intensively with
Methods and Concepts. Basel, Switzerland: members of Congress and the national media.
Birkhauser, 2004. After serving in the Clinton administration, she
returned to Georgetown University in 1995. She
became the dean of the university’s Public Policy
Web Sites Institute in 1999.
In 2006, Feder decided to take her policy exper-
London School of Hygiene and Tropical Medicine
tise to politics and ran for Congress as the Demo
(LSHTM): http://www.lshtm.ac.uk
cratic nominee in Virginia’s 10th District. Despite
her eventual defeat, Feder’s campaign garnered
national attention and gave the 13-term Republican
representative Frank Wolf his closest race in nearly
Feder, Judith 25 years.
Feder is a widely published scholar. Specifically,
Judith Feder is professor and dean of Georgetown she has authored or coauthored five books on
University’s Public Policy Institute in Washington, healthcare policy and over 60 articles in various
Federally Qualified Health Centers (FQHCs) 397
peer-reviewed journals, including the New England and linguistically diverse populations, in collabo-
Journal of Medicine, the Journal of the American ration with other community providers.
Medical Association, the Milbank Quarterly, FQHCs must provide a specific array of services
Health Services Research, and Health Affairs. to a community in which the population is found
She is a past chair and board member of to be suffering from a lack of access to essential
AcademyHealth. Feder is also a member of the healthcare providers and services. They must be
National Academy of Sciences’ Institute of Medicine organized as public or private nonprofit entities.
(IOM), the National Academy of Public Admini They also must be governed by an independent
stration, and the National Academy of Social board of directors, the majority of whom are cur-
Insurance. She is a senior advisor to the Kaiser Family rent consumers of healthcare from the organiza-
Foundation’s Commission on Medicaid and the tion who are representative of the community
Uninsured and a member of the Commonwealth served by the FQHC.
Fund Task Force on the Uninsured. The broad values ensconced in the construct of
an FQHC include the following: comprehensive
Ross M. Mullner primary healthcare, focus on the changing needs
See also AcademyHealth; Equity, Efficiency, and
of individuals throughout the life cycle, evidence-
Effectiveness in Healthcare; Healthcare Reform; based medicine, responsiveness to the health
Health Insurance; National Health Insurance; Public status and needs of the community, and communi-
Policy; Uninsured Individuals; Vulnerable ty-dominated governance. Specific program expec-
Populations tations are extensive and are set forth by the
Bureau of Primary Health Care of the U.S. Public
Health Service (PHS). Areas covered include the
Further Readings following: mission and strategy, approaches to
underserved populations, cultural competency,
Feder, Judith. “Why Truth Matters: Research Versus
strategic positioning, needs assessment and con-
Propaganda in the Policy Debate,” Health Services
tinuous quality improvement and performance,
Research 38(3): 783–87, June 2003.
Feder, Judith, Harriet L. Komisar, and Marlene Niefeld.
clinical program, organization of the system of
“Long-Term Care in the United States,” Health
care, service delivery models, contracting for
Affairs 19(3): 40–56, May–June 2000. health services, healthcare planning, clinical staff,
Feder, Judith, and Karen Pollitz. “Reform’s Three Essential consumer bill of rights and responsibilities, and
Elements: To Be Effective, Insurance Coverage Must Be clinical systems and procedures; and governance,
Adequate, Affordable, and Available,” Health Progress compliance with board composition, governing
88(3): 30–31, May–June 2007. board functions and responsibilities, and network
and affiliations.
The key benefits of meeting the requirements
Web Sites and gaining FQHC status include enhanced
Medicare and Medicaid reimbursement, eligibility
Georgetown Public Policy Institute:
for Section 330 and other specific federal grants
http://gppi.georgetown.edu
and programs, medical malpractice coverage
through the Federal Tort Claims Act, eligibility to
purchase prescription and nonprescription medica-
Federally Qualified tions for outpatients at reduced cost through the
340B Drug Pricing Program, access to the National
Health Centers (FQHCs) Health Service Corps, and access to the Vaccine for
Children Program.
A federally qualified health center (FQHC) is a
type of organized healthcare provider defined by
Development
the Medicare and Medicaid statutes. FQHCs are
intended to expand access to quality healthcare The health center movement that led to the devel-
services for underserved and vulnerable, culturally opment of FQHCs began with the creation of the
398 Federally Qualified Health Centers (FQHCs)
migrant health center program in 1962. The programs (Section 330H), and public housing
federal Migrant Health Act was enacted by Public primary-care programs (Section 330I). While the
Law 87–692, which added Section 310 to the funding opportunities and sources vary, these, as
Public Health Service Act (now currently autho- well as school-based health centers (funded
rized under Section 330G of the act). The Migrant through the Healthy Schools, Healthy Communities
Health Center program provides a broad array of Program) and FQHC look-alikes, are all related
medical and support services to migrant and sea- in that they all must meet the same standards and
sonal farm workers and their families. expectations set out for health centers under
The initial success of the Migrant Health Centers Section 330.
was followed by the neighborhood health center Among the many federal initiatives that have
demonstration projects initiated in 1965 as part of been aimed at the problem of access to healthcare
President Johnson’s War on Poverty program. It services, the health center family of initiatives has
was recognized that by addressing the untreated enjoyed the widest and most persistent support.
health problems of the poor, the economic burden Throughout more than four decades of changing
of these communities could be reduced. social, economic, and political environments,
Health centers were envisioned as comprehen- health centers have continued to receive growing
sive health services programs oriented toward the federal support and attention. From their begin-
needs of vulnerable and underserved populations. ning as a component of President Johnson’s War
They made great strides in eliminating barriers to on Poverty program to the commitment from
healthcare for the poor and underserved, ensuring President George W. Bush, health centers have
continuity and quality of care, promoting the use been viewed as an effective and appropriate means
of preventive services, and increasing community for extending the benefits of healthcare to the poor
participation. Health centers also served as an eco- and uninsured.
nomic engine for their economically disadvantaged In FY2002, President Bush proposed a multi-
communities by generating jobs in the local econ- year initiative for the Federal Consolidation Health
omy. Health centers were unique in providing Center Program authorized under Section 330 of
access to a wide range of medical and nonmedical the Public Health Service Act. The President’s ini-
services and in their mission to serve all regardless tiative seeks to substantially expand and strengthen
of their ability to pay. the safety net for those most in need by extending
Despite major growth and numerous challenges the availability of primary healthcare services to
over the past 40 years, the mission of health cen- new and existing patients served by community
ters has remained the same—the provision of high- health centers. In 2007, the federal Office of
quality primary and preventive healthcare services Management and Budget (OMB) ranked the health
to people in rural and urban medically underserved center program as one of the 10 most effective
areas. federal programs.
FQHCs include all organizations receiving
grants under Section 330 of the Public Health
Current Status
Service Act, certain tribal organizations, and
FQHC look-alikes. An FQHC look-alike is an By 2006, there were more than 1,000 FQHCs in
organization that meets all of the eligibility require- the nation. They operated in each of the 50 states
ments of an organization that receives a Public as well as Puerto Rico and the District of Columbia.
Health Service 330 grant but does not receive They provided nearly 60 million healthcare
grant funding. encounters to more than 15 million individuals.
Section 330 of the Public Health Service Act More than 5 million of those individuals were
defines federal grant funding opportunities for covered under Medicaid programs, and nearly 6
organizations to provide care to underserved million more of the patients had no insurance. In
populations. Types of organizations that may this endeavor, the health centers employed more
receive 330 grants include community health than 97,000 full-time-equivalent employees.
centers (Section 330E), migrant health centers Health centers served approximately 12% of all
(Section 330G), healthcare for the homeless the uninsured individuals (providing about 22%
Fee-for-Service 399
of the uninsured ambulatory-care visits) in the See also Access to Healthcare; Centers for Medicare and
nation and about 15% of the nation’s population Medicaid Services (CMS); Ethnic and Racial Barriers
living below the federal poverty level (FPL). The to Healthcare; Health Professional Shortage Areas
majority of patients (59%) served were Latino or (HPSA); Medicaid; Medicare; Uninsured Individuals;
Vulnerable Populations
African American. The average medical cost per
patient was $117.
The National Association of Community
Further Readings
Health Centers (NACHC) proposes that the ser-
vices of FQHCs provide great potential for sub- Cook, Kakela, LeRoi S. Hicks, A. James O’Malley, et al.
stantial cost savings throughout the nation’s “Access to Specialty Care and Medical Services in
healthcare delivery system. FQHCs are particu- Community Health Centers,” Health Affairs 26(5):
larly effective in addressing access issues that 1459–68, September–October 2007.
often drive patients to hospital emergency depart- Falik, Marilyn, Jack Needleman, Robert Herbert, et al.
ments with noncritical health needs. This is a “Comparative Effectiveness of Health Centers as
significant problem operationally and financially. Regular Source of Care: Application of Sentinel
Studies have estimated the annual cost of “wasted” ACSC Events as Performance Measures,” Journal of
or unnecessary emergency department visits in the Ambulatory Care Management 29(1): 24–35,
nation to be in excess of $18 billion. A recent January–March 2006.
study analyzing Medicaid claims data in four Falik, Marilyn, Jack Needleman, Barbara L. Wells, et al.
“Ambulatory Care Sensitive Hospitalizations and
states concluded that Medicaid recipients relying
Emergency Visits: Experiences of Medicaid Patients
on health centers for usual care are 19% less
Using Federally Qualified Health Centers,” Medical
likely to use an emergency department for ambu-
Care 39(6): 551–61, June 2001.
latory-care-sensitive conditions than recipients
Lefkowitz, Bonnie. Community Health Centers: A
using outpatient and office-based physicians for Movement and the People Who Made It Happen.
usual care. A 2004 study estimated savings to New Brunswick, NJ: Rutgers University Press, 2007.
Medicaid programs of nearly $1,000 per year per
patient served in health centers as compared with
other sources of care. Web Sites
Overall, when compared with Medicaid
patients treated elsewhere, health center Medicaid Centers for Medicare and Medicaid Services (CMS):
patients are between 11% and 22% less likely to http://www.cms.hhs.gov/center/fqhc.asp
be hospitalized for avoidable conditions; are FQHC Forum: http://www.fqhc.org
19% less likely to use hospital emergency depart- Health Resources and Services Administration (HRSA):
ments for avoidable conditions; and have lower http://bphc.hrsa.gov
hospital admission rates, lower lengths of hospi-
http://www.kff.org
tal stays, less costly admissions, and lower outpa-
tient and other care costs. A 2006 study estimated
(NACHC): http://www.nachc.com
savings of 30% to 33% in total costs per
Medicaid recipient.
Future Implications Fee-for-Service

The effectiveness of FQHCs and the popularity of
the community governance model within which Under fee-for-service payment mechanisms, the
they operate continue to make them a highly val- healthcare provider’s income increases each time
ued option in federal plans for addressing prob- he or she renders a service. As with any form of
lems of healthcare access and the uninsured provider payment, a decision to pay providers on
population. a fee-for-service basis affects utilization, cost, and
population health. Many healthcare policymakers
Benn J. Greenspan and researchers argue that fee-for-service payment
400 Fee-for-Service
mechanisms provide a strong economic incentive Hospitals

to overprovide services, many of which are costly,
The problem of potential overprovision of ser-
unnecessary, and may actually decrease the qual-
vices is perhaps most acute for hospital-based
ity of patient care.
medical care because the patient typically has less
ability to assess the costs and benefits of this type
Economic Theory of service than in the case of prescription drugs,
diagnostic tests, or office visits. In addition,
A healthcare provider who is paid on a fee-for-
hospital-based medical care is also more likely to
service basis and who ignores patient preferences
be covered by the patient’s health insurer than
will provide services up to the point at which the
other types of medical care. While insurance
fee just matches the cost of providing the service
reduces the patients’ incentives to economize on
one more time. For example, as long as the fee
hospital-based services, fee-for-service reimburse-
paid for an additional dental examination exceeds
ment reduces hospitals’ incentives to control
the cost incurred by the dentist for providing the
costs: As they are fully reimbursed for the cost
examination, the dentist will provide, and bill for,
they report, hospitals can pass on to insurers all
additional dental exams.
fluctuation in cost.
Whenever the fee does not reflect the value
Medicare, the federal health insurance pro-
that a fully informed patient would place on
gram for the elderly in the United States, used a
receiving the service, the level of service provided
fee-for-service payment system until 1982, which
will be either inefficiently low or inefficiently
encouraged hospitals to compete for patients and
high. In markets for medical services, the fee
physicians by investing in expensive technologies,
might not reflect the patient’s valuation because
even if their clinical value had not been demon-
of ignorance or intermediation. Patients often do
strated. This “medical arms race” led to sharp
not know all the clinical risks and benefits of the
increases in utilization and cost without commen-
services offered by providers, and they typically
surate benefits in health outcomes. In an attempt
do not pay providers for their services directly
to slow the increase in the cost of hospitalizations
but through an insurer. Lack of information may
among the elderly, in 1983, the Medicare pro-
lead patients to underestimate the benefits of a
gram switched from a fee-for-service payment
service such as preventive care, prompting them
system to a prospective payment system (PPS),
to demand too little care, while intermediation,
according to which hospitals receive a lump sum
such as copayments and coinsurance, insulates
for each patient’s hospital stay. This lump sum
patients from the full cost of the service, prompt-
varies with the patient’s classification into a
ing them to demand too much care. By exposing
Diagnosis Related Group (DRG) but does not
patients to the full cost of a larger fraction of
vary with the hospital’s actual resource use to
services than under traditional insurance, health
treat the patient. Thus, the hospital is fully
savings accounts (HSAs) aim to eliminate the dis-
exposed to all fluctuation in cost and now has an
torting effects of intermediation. The distorting
incentive to minimize the resource use associated
effects of patient ignorance can be mitigated by
with each hospitalization.
education.
If the fee exceeds the patient’s valuation of the
Physicians
service, providers will be tempted to overprovide
services (supplier-induced demand), in the sense For physicians, the counterpart of prospective
that a fully informed patient who paid out of payment is a fixed monthly payment per enrollee
pocket would have purchased a lower volume of (capitation payment). While capitation payment
the service than the provider is rendering. Nonprice encourages physicians to avoid patients who are
mechanisms, such as implementation of treatment anticipated to require many visits or costly and
protocols, utilization review, and employment of time-consuming tests and procedures, physicians
gatekeepers to control the use of medical special- who are paid on a fee-for-service basis have the
ists, are designed to prevent the overprovision of opposite incentive, namely, to attract patients
services. such as the chronically ill or those with special
Flat-of-the-Curve Medicine 401
needs, who are expected to require many sepa- Robinson, James C. “Theory and Practice in the Design
rately billable services. To increase revenue from of Physician Payment Incentives,” Milbank Quarterly
fees, physicians paid by fee-for-service also have 79(2): 149–77, 2001.
an incentive to underrefer patients to a colleague Wallack, Stanley S., and Christopher P. Tompkins.
whose services they can perform themselves “Realigning Incentives in Fee-For-Service Medicare,”
instead, even if the colleague would be a better Health Affairs 22(4): 59–70, July–August 2003.
match. Fee-for-service also creates an incentive to
overrefer patients to specialty facilities in which
the referring physician has a financial stake and to Web Sites
establish new physician-owned specialty hospitals, American Dental Association (ADA): http://www.ada.org
ambulatory surgical centers, and imaging centers. American Medical Association (AMA):
For patients who are expected to remain with http://www.ama-assn.org
their physician for a long time, capitation payment Centers for Medicare and Medicaid Services (CMS):
encourages physicians to manage their patients’ http://www.cms.hhs.gov
health proactively by providing sufficient preven- Healthcare Financial Management Association (HFMA):
tive and primary-care services to reduce the inci- http://www.hfma.org
dence of disease and thus reduce costly future visits
and treatment. By the same token, however, physi-
cians paid on a capitation basis will be reluctant to
test for diseases that, once diagnosed, raise the Flat-of-the-Curve Medicine
patient’s number and service intensity of future
visits. Physicians paid on a capitation basis will Flat-of-the-curve medicine refers to applications
also attempt to minimize the resources spent on of healthcare resources yielding no discernable
treating a patient’s existing medical conditions. or valuable health benefits. It is a level of inten-
Recognition that physicians paid by capitation sity of healthcare that provides no incremental
might underdiagnose and undertreat diseases, benefit. In health economic terms, it is the con-
especially chronic conditions such as asthma, dia- sumption of medical care resources to a point
betes, depression, and cancer, has led some insur- that the marginal (added) benefit relative to the
ers to carve out of their capitation payments marginal (added) cost is at or near zero. Flat-of-
fee-for-service schedules for select diagnostic pro- the-curve medicine is of concern because it
cedures, under which physicians’ pay increases for affects the cost and quality of healthcare with-
each performance of a qualifying procedure or out improving health and medical outcomes. It
examination (pay-for-performance). also has implications for issues of access, financ-
ing, reimbursement, and the organization of
Lorens A. Helmchen healthcare. Understanding this concept, why it
occurs, and how it might be addressed is benefi-
See also Capitation; Healthcare Financial Management; cial to health services researchers and healthcare
Health Economics; Medicare; Pay-for-Performance; policymakers.
Payment Mechanisms; Prospective Payment;
Variation in the use of healthcare and health
Supplier-Induced Demand
outcomes in the United States is ubiquitous.
Variation in the amount of healthcare delivered
has been noted many times in seemingly compa-
Further Readings rable patients in terms of their health status and
Gosden, T., F. Forland, I. S. Kristiansen, et al. “Impact of social demographic characteristics and the type
Payment Method on Behavior of Primary Care and depth of health insurance coverage. This
Physicians: A Systematic Review,” Journal of Health observation has persisted over time. Concern has
Services Research and Policy 6(1): 44–55, January 2001. been expressed that patients receiving costly high-
Pham, Horngmai H., and Paul S. Ginsburg. “Unhealthy intensity healthcare often do not have better
Trends: The Future of Physician Services,” Health health outcomes than those receiving cheaper
Affairs 26(6): 1586–98, November–December 2007. low-intensity care. This finding is not confined to
402 Flat-of-the-Curve Medicine
the United States. The same phenomenon has Issues and Implications
been observed in other highly developed nations.
Flat-of-the-curve medicine raises many healthcare
This has led some researchers to conclude that
policy issues with many implications. In the above
differences in the intensity of healthcare play, at
example, flat-of-the-curve medicine does not nec-
most, a minor role in explaining cross-sectional
essarily imply that there is no benefit with each
differences in health outcomes. Many health ser-
inpatient day. But it does suggest that the marginal
vices researchers and healthcare policymakers
benefit, if any benefit at all, comes at a higher
have termed this phenomenon flat-of-the-curve
marginal cost. Issues can arise at any point along
medicine.
the curve. At the point where the curve becomes
flat, there are no additional benefits from any
What Is Flat-of-the-Curve Medicine? combination of inputs. It may even be possible for
the curve to bend lower at the tail end, as in the
Popularized by health economists such as Alain
case of a poorer outcome. In that instance, addi-
Enthoven, Robert Evans, and Victor Fuchs, the
tional costs would be associated with a worse
concept underlying flat-of-the-curve medicine is
outcome, as in the case, for example, of a hospi-
analogous to the economic law of diminishing
tal-acquired infection or a terminally ill patient.
marginal returns; that is, as inputs are applied
Flat-of-the-curve medicine raises the issue of
to a production process in successively larger
the amount and value of the benefit relative to the
amounts, there will be successively smaller
units of input, often measured by the common
increases in outputs. At some point, additional
unit of dollars. How valuable the additional ben-
inputs may result in zero or even negative outputs.
efit is at any point along the curve is often subjec-
Used frequently in economics, this law has been
tive and debatable in absolute or relative terms.
applied in many instances to the production of
Medical practice often is subjective. Diagnoses are
many goods and services, environment, energy
subject to uncertainty. There is often a range of
production, national defense, and medicine.
possible treatments, with none being “the best”
Figure 1 shows a theoretical curve to explain
with certainty. Differing opinions also may be
the concept of flat-of-the-curve medicine. An
expressed among physicians, patients, families, or
example would be the length of an inpatient hos-
payers. Benefits may include added days of life;
pital stay for a patient with a particular diagnosis.
reduced mortality, morbidity, or disability;
The horizontal x-axis in the figure reflects the
increased ability to function; reduced pain and
inputs—in this case, cost in dollars for each day.
suffering; or improvement in the overall quality of
These costs may be for personnel, equipment,
supplies, overhead, and so on. The vertical y-axis
reflects health outcomes depicted by improved
health status. Each letter (A, B, C, D, and E) rep- C D E
resents one inpatient hospital day. The first inpa-
tient day (A) is clearly beneficial. Likewise, the B
second inpatient day (B) is beneficial but less so.
Health outcomes
Inpatient Day C is beneficial but less so than

either of the previous days. That is, there is an A
added (marginal) benefit relative to the added
(marginal) cost after the first inpatient day, but
this benefit accrues at a diminishing rate. Finally,
Inpatient Day 4 (D) and Inpatient Day 5 (E) add
marginal costs but no discernable marginal bene-
fit. In this instance, the marginal benefit after the
third inpatient day relative to costs is zero.
Likewise, additional inpatient days beyond C Health costs
would add only costs without any concomitant
benefits. Figure 1 “Outcomes” and “Costs”
Flat-of-the-Curve Medicine 403
life. Some of the benefits are difficult to either Another possible explanation is that the standard
quantify or value. Some may occur at extremely of medical care in one area may be quite different
high marginal cost or may not occur at all. from that in another. The standard of medical
Sometimes one benefit may occur at the expense care in an area may be reflected by variations in
of others, as in the case of added days of life in a length of hospital stay, the number and frequency
state of extreme pain and with an overall deterio- of diagnostic tests, rates of surgical procedures,
rating quality of life. Benefits are not always easy and rates of other clinical procedures. The medi-
to calculate, much less translate into a common cal school a physician attended may play a role,
unit of measurement. Also, often there is signifi- since medical training varies. Medical students at
cant uncertainty in the anticipated benefit, espe- one institution may be trained to be more or less
cially when the patient is the unit of analysis. aggressive. The individual physician is a variable,
Widespread variation in health outcomes by treat- with some willing to go much further along the
ment is commonplace. curve than others. Attention to the interests of the
The issue of flat-of-the-curve medicine becomes patient, dedication to one’s profession, and pro-
an important consideration depending on the fessional expectations can influence clinical deci-
source of payment. Generally, there is little or no sions. Finally, financial considerations may
concern if the increased intensity or cost of influence the clinical decisions made by patients,
healthcare is knowingly borne by the individual, family members, physicians, administrators,
as expressed by his or her preferences, demon- third-party payers, and others. The widespread
strated by his or her out-of-pocket payment. use of third-party payment has led many to con-
Many individuals may not wish to get to the point clude that medical-care markets operate beyond
where the marginal cost is zero, since any addi- the point of maximum efficiency and perverse
tional cost would be entirely at their expense with incentives exist. Fully insured patients may want
no proportionate benefit. A greater level of con- care to the point of no incremental benefit.
cern may arise if the source of payment is a spouse Similarly, a physician may be inclined to provide
or other family member. A more difficult social care that provides no benefit for an insured
problem may arise if the payment is borne col- patient but not for an underinsured or uninsured
lectively through private or public health insur- patient. Also, self-interest on the part of the phy-
ance coverage. At this level, the scrutiny and sician may play a role, since one person’s health
expectation of benefit relative to cost may increase, spending is another person’s income. A legal
since the cost is no longer just borne by the indi- entitlement to a Medicare beneficiary or a
vidual beneficiary but by a third-party payer. An Medicaid recipient is a de facto entitlement to
individual may be much more willing to consume providers. Incentives associated with fee-for-ser-
medical care to a point where the marginal benefit vice practice or those associated with an owner-
is zero when payment is by a third-party payer, ship position in a medical facility may also cause
whether private or public. Some individuals may clinical decisions to differ from those made by
not have any effective choice if they are uninsured healthcare providers working under a capitation
or lack sufficient resources to pay regardless of or salary arrangement.
their condition.
Strategies to Deal With
Why Does Flat-of-the-Curve Medicine Occur? Flat-of-the-Curve Medicine
Several possible reasons for why flat-of-the-curve Several strategies have been implemented or sug-
medicine occurs have been suggested. The various gested to address flat-of-the-curve medicine. For
reasons may occur at the same time. Service vol- example, the nation’s Medicare program in 1983
ume may increase with an increase of healthcare changed its policy of paying hospitals from a cost-
providers in a geographic area. Or the presence based retrospective one, which created the incen-
of more medical specialists in an area may be tive for hospitals to provide more care because
reflected in a higher intensity of practice than is they were reimbursed for it, to a prospective pay-
found in areas with a lower concentration. ment system (PPS), which pays hospitals a lump
404 Flexible Spending Accounts (FSAs)
sum for treating a given medical condition. The

result was an immediate and sharp decline in the Flexible Spending
average length of hospital stays, with no apparent Accounts (FSAs)
adverse medical effect. Other strategies have
included increased utilization management and Flexible spending accounts (FSAs) are tax-
review, patient cost sharing, supply limits, aggre- sheltered programs established by employers.
gating the unit of payment (as in capitation), lump Employees contribute pretax wages to these
sum payments to hospitals for specific procedures, accounts and may use the funds to pay for quali-
global budgeting, and efforts to increase competi- fied healthcare expenditures. These expenditures
tion. Others have suggested that flat-of-the-curve include fees for uninsured physician or dental
medicine be addressed by the greater use of cost- care, for example, but may also include the
benefit or cost-effectiveness analysis and the con- copays or deductible payments associated with
trolled introduction of new clinical procedures otherwise insured medical expenses. In addition,
and medical technology backed by clear evidence the accounts may be used to pay for over-the-
of their benefits. counter medications and things such as contact
Thomas W. O’Rourke lens solution.
See also Cost Containment Strategies; Cost of Healthcare; Overview

Enthoven, Alain C.; Equity, Efficiency, and
Effectiveness in Healthcare; Evans, Robert G.; Fuchs, Flexible spending accounts are paid into with pre-
Victor R.; Geographic Variations in Healthcare; tax dollars by employees and can be used to pur-
Health Economics; Quality of Healthcare; Supplier- chase qualified healthcare-related expenses. The
Induced Demand Internal Revenue Service (IRS) defines what con-
stitutes a qualified healthcare expense in FSAs.
The IRS does not limit the amount of money that
Further Readings can be set aside in an FSA. Many employers, how-
ever, do set annual limits, often in the range of
Enthoven, Alain C. “Cutting Cost without Cutting the
$5,000 to $10,000, and any monies that are not
Quality of Care,” New England Journal of Medicine
298(22): 1229–38, 1978.
spent by the end of the year (or by March 15 of the
Enthoven, Alain C. Health Plan: The Only Practical
subsequent year, at the discretion of the employer)
Solution to the Soaring Cost of Medical Care. Menlo are lost to the employee. On the other hand, once
Park, CA: Addison Wesley, 1980. an employee’s FSA is created, he or she may spend
Fuchs, Victor R. “The Supply of Surgeons and the the entire annual amount to be deposited. For
Demand for Operations,” Journal of Human example, an employee may choose to set aside
Resources 13(Suppl.), 35–56, 1978. $100 per month in an FSA for an annual total of
Fuchs, Victor R., and Marcia J. Kramer. Determinants of $1,200. In January, the employee could spend the
Expenditures for Physicians’ Services in the United entire $1,200 on uninsured orthodontic care.
States, 1948–68. NBER Occasional Paper No. 117. Moreover, if the employee were to leave the
New York: National Bureau of Economic Research, firm later in the same year, he or she would not be
1973. required to pay into the FSA. Analogously, how-
ever, if an employee were to leave the firm with a
positive balance in his or her FSA account, those
Web Sites monies would be lost to the employee.
Evidence-Based Medicine (EBM): http://ebm.bmj.com The provisions of FSAs are in marked contrast
Institute for Healthcare Improvement (IHI): to health savings accounts (HSAs). Monies that
http://www.ihi.org/IHI are contributed to an HSA are owned by the
Cochrane Library—Evidence for healthcare decision- employee and remain with him or her upon sepa-
making: http://www.cochrane.org ration from an employer. More important, unspent
Dartmouth Atlas of Health Care: HSA balances roll over to the next year, whereas
http://www.dartmouthatlas.org an unspent FSA balance is forfeited annually. In
Flexible Spending Accounts (FSAs) 405
addition, while an individual may establish an Economic Theory

HSA, only an employer can establish an FSA.
Furthermore, HSAs require the holder individually Several testable hypotheses emerge from the eco-
or through his or her employer to have a qualified nomics of FSAs. The first is that households facing
health plan, usually a high-deductible plan. In con- a higher marginal income tax rate will be more
trast, a firm that establishes an FSA program for likely to participate in an FSA. Feldman and Shultz
its employees does not need to offer any health examined participation among 15 Minnesota
insurance plan. firms in 1998. Higher marginal tax rates were
associated with greater participation rates among
those with family coverage but not those with
Tax Savings
single coverage. An increase in the marginal tax
The tax savings associated with the use of FSAs rate from 15% to 28% resulted in a near doubling
can be substantial. For example, suppose an indi- of the participation rate. The marginal tax rate
vidual contributes $100 per month, or $1,200 per also increased the size of the FSA contribution.
year, in an FSA, these contributions are tax shel- James Cardon and Mark Showalter used data
tered. Additionally, suppose one has a marginal from a benefits consulting firm from 1996. They
federal income tax rate of 28%, pays Social concluded that participation increased with income
Security and Medicare payroll taxes of 7.65%, and was also higher for those living in states with
and faces a 5% state income tax rate. The indi- state income taxes. Interestingly, they also found
vidual or the family has a combined marginal tax that participants tended to spend out their accounts
rate of 40.65%. By putting $1,200 in the FSA and relatively early in the year, implying that the FSA
spending it on qualified health services that the effectively provided a no-interest loan for qualified
individual would have purchased anyway, the sav- healthcare expenditures.
ings would amount to $487.80 in taxes. Even if A second hypothesis is that tax-sheltered treat-
the individual does not spend the entire $1,200, as ment of employee premium contributions as a
long as a balance of less than $487.80 is forfeited, result of an FSA should reduce the premium elas-
the individual comes out ahead monetarily. ticity of demand for employer-sponsored health
A less well-known and appreciated feature of insurance. If an insurance plan has a $1,000
establishing an FSA is that it allows employee pre- annual employee premium contribution, the pres-
mium contributions to employer-sponsored health ence of a 40% marginal tax rate and an FSA
insurance to be paid with pretax dollars. Workers do effectively reduces the premium contribution to
not have to explicitly direct premium contributions $600. As a result, the same premium contribu-
to the FSA for this purpose, as it is simply a feature tion in an FSA will result in less plan switching
of establishing an FSA. Moreover, an employer can than in a firm with no FSA. Bryan Dowd and col-
set up a premium-only plan (POP) that allows leagues examined premium elasticities in a sam-
employee premium contributions to be paid with ple of large public employers and concluded that
pretax wages even without establishing an FSA. the presence of an FSA reduced elasticities by
Data on the extent to which employers offer over 50%.
FSAs and employees use them are not routinely Finally, one should expect FSAs to lead
collected. Offer rates appear to increase with firm to larger employee premium contributions.
size. William Jack and colleagues reported that Consider the premium contribution problem in
14% of small firms, 76% of large firms, and 83% the absence of FSA provisions. The exclusion of
of very large firms administered FSAs in 2003. employer-provided health insurance from fed-
Roger Feldman and Jennifer Schultz reported that eral and state income and payroll taxes means
among 15 Minnesota firms offering an FSA, 19% that the entire premium should be paid for by
of singles without dependents and 33% of those the employer in the form of lower money wages
with family coverage took coverage. The average to workers. This approach takes full advantage
annual contribution (converted to 2007 dollars) of the tax subsidy. However, employee premium
was $530 for those with single coverage and $988 contributions also serve to sort workers into
for those with family coverage. health plans that reflect their preferences for
406 Flexner, Abraham
coverage, with higher employee premium contri-

butions used to signal more generous plans. Flexner, Abraham
Thus, the tax incentives and the signaling incen-
tives work in opposite directions. The former Abraham Flexner (1866–1959) made enormous
provide incentives for little or no premium con- contributions to the quality of healthcare by
tributions, and the latter provide incentives for improving the education offered at medical schools
potentially large premium contributions. In the in the United States and Canada. As a result of
presence of an FSA, the employee premium con- this work, Flexner is considered one of the most
tribution is paid with pretax dollars, and the important health services researchers of the 20th
tax-induced incentive for small premium contri- century. His on-site assessment of medical schools
butions is removed; however, this hypothesis resulted in a landmark report, Medical Education
remains to be tested empirically. in the United States and Canada, which was pub-
lished by the Carnegie Institute for the Advancement
Michael A. Morrisey of Teaching in 1910. This report received wide
attention and acclaim. So critical was Flexner of
See also Coinsurance, Copays, and Deductibles;
Compensation Differentials; Consumer-Directed
poor-quality medical schools that many closed or
Health Plans (CDHPs); Health Economics; Health merged, while others were forced to implement
Insurance; Health Savings Accounts (HSAs) immediate improvements. In 1909, when Flexner
began his investigation, the United States had
approximately 150 medical schools; by 1915, the
number had dropped to 96.
Further Readings Born to German Jewish immigrant parents in
Cardon, James H., and Mark H. Showalter. “An Lexington, Kentucky, Flexner was one of eight
Examination of Flexible Spending Accounts,” Journal children. Flexner went to Johns Hopkins University,
of Health Economics 20(6): 935–54, November where he received his bachelor’s degree in 1886.
2001. After graduation, he returned to Lexington and
Dowd, Bryan, Roger Feldman, Matthew Maciejewski, worked for that city’s public school system as an
et al. “The Effect of Tax-Exempt Out-of-Pocket instructor. After 4 years, he formed his own col-
Premiums on Health Plan Choice,” National Tax lege preparatory school, where he had the free-
Journal 54(4): 741–56, December 2001. dom to try out certain theories of classroom
Feldman, Roger, and Jennifer Schultz. “Who Uses education, and there he became convinced of the
Flexible Spending Accounts: Effects of Employee value of progressive principles of education—
Characteristics and Employer Strategies,” Medical among them, small classes, tutoring rather than
Care 39(7): 661–69, July 2001. lecturing, and learning by doing, principles that
Jack, William, Arik Levinson, and Sjamsu Rahardja. later influenced him when he undertook his inves-
“Employee Cost Sharing and the Welfare Effects of
tigation of medical schools. After many years of
Flexible Spending Accounts,” Journal of Public
teaching, Flexner left Lexington and attended
Economics 90(12): 2285–2301, December 2006.
Harvard University, where he received a master’s
Morrisey, Michael A. Health Insurance. Chicago: Health
degree in 1906.
In 1908, Flexner’s book The American College:
A Criticism came to the attention of Henry S.
Pritchett, president of the Carnegie Foundation
Web Sites for the Advancement of Teaching. Pritchett was
America’s Health Insurance Plans (AHIP): impressed by Flexner’s critical ability and his force-
http://www.ahip.org ful manner as a writer, and he felt that Flexner
Employee Benefit Research Institute (EBRI): would be the ideal person for a new Carnegie
http://www.ebri.org project: a response to a request from the American
Federal Flexible Spending Account (FSAFEDS) Program: Medical Association’s Council on Medical
https://www.fsafeds.com/fsafeds/index.asp, Education to carry out a survey of medical
http://www.fsafed.com schools.
Flexner, Abraham 407
Although the Council on Medical Education dispensary patients and to clinical laboratories for
had completed its own survey in 1906, the results analysis and diagnosis. Flexner’s plan also included
were not widely published as there was reluctance a full-time medical faculty, standardized hospital
on the part of physicians to publicly criticize other record keeping, and control of a modern hospital
members of the profession. Pritchett recognized whenever possible.
the inherent bias in medical involvement in the After his field study, Flexner wrote his famous
survey and therefore favored hiring a competent report, Medical Education in the United States
outsider to manage the task. and Canada. Its findings were widely publicized.
The need for a survey of medical schools was Contrary to the popular notion that the report
widely felt. The dismal quality of many medical was a relentlessly harsh critique of medical
schools was generally known, and in the Progressive schools, unsparing in its condemnation of all
Era at the end of the 19th century and the begin- institutions, over half of the report is historical
ning of the 20th, the reform impulse was strong. background information, a discussion of Flexner’s
Medical schools were already feeling the heat of methods and findings, and recommendations for
that momentum when Flexner accepted the charge reform; the balance comprises school-by-school
and began his research. assessments.
What Flexner lacked in healthcare experience, The immediate reaction to the report by medi-
he made up for with his sound grasp of educa- cal schools that fared poorly was often dismissive
tional principles and his practical, clear-thinking, or antagonistic, but over time, in the wider com-
analytical mind. He also had the advantage of his munity, the consensus of opinion was highly favor-
employer’s august name as a calling card. Because able: Flexner had done a great service for medical
Flexner represented the Carnegie Foundation, a education. It was this view that held throughout
possible funding source, medical schools opened his long life. After his death, however, historians
their doors to him. have reassessed his report. Some now question
Flexner began his preparation for the project Flexner’s hastily formed judgments about the
with a review of medical education in the United medical schools. The closing of medical schools
States and Canada—its historical record—and the resulted in a loss of physicians to nearby communi-
available critiques of that education. He determined ties, however suspect their training might have
that the best scientific/clinical medical education been. Other historians fault the science-heavy cur-
could be found at the Johns Hopkins University riculum Flexner imposed on medical education,
medical school, which was based on European which minimized the balancing influence of human-
models, and he hypothesized that his survey of istic studies. Last, it has been argued that Flexner’s
medical schools would show that most would fall report was merely a catalyst that accelerated the
short of the high Johns Hopkins standard. pace of existing reform. And the standards he
During his 16 months of fieldwork, Flexner espoused were generally accepted well before his
visited 155 medical schools. He collected data report and were already reshaping the nation’s
from each on five key areas: (1) their admission medical education.
requirements, (2) the size and qualification of their After publishing his famous report, Flexner also
faculty, (3) the amount of funds available from the conducted surveys of medical education in England,
endowment and fees to support the school, (4) the France, and Germany. In 1912, he began working
quality of their laboratories and the training of for the General Education Board of the Rockefeller
their instructors, and (5) the connection of the Foundation as an assistant to the secretary, and in
school to clinical facilities (hospitals). 1914 he became a trustee. As a board member for
Flexner had a standard of excellence clear in his many years, Flexner had a say in the distribution
mind when he visited the medical schools. His of grants to colleges and universities as well as to
vision of medical education was an ambitious one, primary and secondary schools.
centered on higher admission requirements, Later in his life, Flexner was directly involved
expanded instruction in the laboratory sciences, in founding the Institute for Advanced Study in
and clinical instruction based on access both to a Princeton, New Jersey, the world’s first think
large number and wide variety of hospital and tank. He was the institute’s first director from
408 Focused Factories
1930 to 1939. Among his successes in bringing

distinguished scholars and researchers to the Focused Factories
Institute was his recruitment of Albert Einstein in
1933. C. Wickham Skinner first introduced the concept
Abraham Flexner died in 1959 at the age of 92. of “focused factories” in a 1974 article in the
During his long life, Flexner’s central interest— Harvard Business Review. In this seminal article,
embodied in his landmark research and criticism Skinner, a Harvard Business School professor,
and the recommendations of his famous 1910 applied the concept of focused factories to manu-
report—was in elevating and standardizing medi- facturers in the United States, which at the time
cal education and, ultimately, contributing to the were experiencing a productivity crisis. Skinner
improved quality of healthcare services for all believed that the nation’s manufacturers were no
Americans. This is his greatest legacy. longer competitive because they had very broad
missions and produced too many products. To
James Hill and Samuel Levey correct the situation, Skinner urged the manufac-
turers to focus each of their factories on a limited,
See also Academic Medical Centers; American Medical
Association (AMA); Association of American Medical
manageable set of products and markets. He
Colleges (AAMC); Health Services Research, Origins; argued that focusing each factory’s entire effort to
Physicians; Quality of Healthcare produce a particular product would lower costs,
especially overhead costs, and make each of the
factories a competitive weapon.
Further Readings
Bonner, Thomas Neville. “Abraham Flexner and the Focused Factories in Healthcare
Historians,” Journal of the History of Medicine and
In healthcare there have been few attempts to for-
Allied Sciences 45(1): 3–10, January 1990.
mally define the concept of focused factories, and
Bonner, Thomas Neville. Iconoclast: Abraham Flexner
no standard definition exists. Regina H. Herzlinger,
and a Life in Learning. Baltimore: Johns Hopkins
a Harvard Business School professor and a lead-
University Press, 2002.
Flexner, Abraham. The American College: A Criticism.
ing advocate of consumer-directed healthcare,
New York: The Century Company, 1908.
defines healthcare-focused factories as integrated,
Flexner, Abraham. Medical Education in the United multidisciplinary teams of health professionals
States and Canada: A Report to the Carnegie organized around the needs and treatments of
Foundation for the Advancement of Teaching. particular chronic diseases or disabilities. For
Bulletin No. 4. New York: Carnegie Foundation for example, she envisions diabetes-focused factories
the Advancement of Teaching, 1910. having teams of health professionals entirely
Flexner, Abraham. Abraham Flexner: An Autobiography. focused on treating and controlling that disease.
New York: Simon and Schuster, 1960. Such teams would include cardiologists, der-
Hiatt, Mark D. “The Amazing Logistics of Flexner’s matologists, endocrinologists, nephrologists,
Fieldwork,” Medical Sentinel 5(5): 167–68, 2000. podiatrists, behavioral support specialists, and
Starr, Paul. The Social Transformation of American others. Focused factories would deliver services
Medicine: The Rise of a Sovereign Profession and the wherever patients needed them—in their homes
Making of a Vast Industry. New York: Basic Books, and in pharmacies, community centers, and
1982. shopping malls, as well as in community and
Wheatley, Steven C. The Politics of Philanthropy: specialty hospitals. Focused factories also would
Abraham Flexner and Medical Education. Madison: provide the patients with all the medical informa-
University of Wisconsin Press, 1988. tion they wanted. Herzlinger views focused fac-
tories as an important component of
consumer-driven healthcare.
Web Sites Other researchers have empirically defined
Library of Congress, Abraham Flexner Papers: healthcare-focused factories as specialty hospi-
http://www.loc.gov/rr/mss/text/flexner.html tals, primarily facilities that specialize in cardiac,
Focused Factories 409
orthopedic, or surgical care. A few researchers and joint replacement surgery; Addis Ababa Fistula
also include ambulatory surgery centers as Hospital in Ethiopia, which specializes in obstetric
healthcare-focused factories. Most specialty hos- fistula surgery; and the Diagnostic Treatment
pitals are physician-owned, for-profit facilities. Centers in England, which specialize in elective
Physicians often establish specialty hospitals surgery.
because they want greater autonomy over treat-
ment decisions and the care environment, a
Controversy and Public Policy Issues
selected number of medical procedures having
relatively high profit margins, and a larger share The concept of healthcare-focused factories is
of the hospital’s profit margin to increase their highly controversial and raises a number of
incomes. Physicians may directly own and man- important public policy issues. Proponents of
age the specialty hospitals and be their sole pro- focused factories, such as Herzlinger, argue that
prietor, or they may indirectly own and not they provide a revolutionary promise of lowering
manage the hospitals by purchasing equity stakes the costs of care, improving quality, increasing
in them from corporations. Some corporations innovations, increasing consumer choice, and pro-
own a number of these facilities. Currently, there moting needed competition in healthcare. In sharp
are more than 100 specialty hospitals in the contrast, opponents, such as Arnold Relman, a
nation, and the number appears to be growing. Harvard Medical School professor and the former
The number of ambulatory surgery centers is editor-in-chief of the New England Journal of
over 3,000. Medicine, contend that the very concept of focused
factories is a delusion born of unfamiliarity with
the realities of medical care. Relman argues that
Examples
independent physician groups and facilities such
The example of a healthcare-focused factory that as centers for kidney dialysis, imaging centers, and
is most often cited is Shouldice Hospital in cardiovascular specialty hospitals already provide
Ontario, Canada. The hospital, an 89-bed, for- some specific medical treatments and procedures.
profit facility, is named after its founder, Edward He believes that it would be wrong for the nation’s
Shouldice, who developed an innovative surgical healthcare system to be entirely or even largely
technique for repairing hernias during World War based on thousands of independent, competing
II. Shouldice Hospital’s entire focus is on the sur- focused factories that specialize in treating only
gical repair of external abdominal wall hernias one ailment. He points out that patients often suf-
without complications. Surgeons at the hospital fer from multiple ailments, they develop addi-
each perform 15 to 20 hernia repairs a week, as tional ailments over time, and they may develop
compared with other surgeons in Ontario, who new ailments from being treated. And to treat all
perform on average only 1 per week. Because of these ailments, focused factories would need other
Shouldice Hospital’s narrow focus and high degree specialists and facilities, which would be wasteful
of specialization, it achieves excellent medical of resources. Last, Relman argues that focused
outcomes and a high degree of patient satisfac- factories would harm the continuity of patient
tion. The hospital has very low complication and care and lead to fragmented, chaotic, and lower-
infection rates and one of the lowest hernia recur- quality care.
rence rates in the world. Its patients have short Community hospitals, and the hospital associa-
length of stays, and nearly all of them report tions that represent them, have strongly criticized
being extremely satisfied with the care they specialty hospitals. Large community hospitals,
received. Furthermore, the overall cost of care at most of which are not-for-profit facilities, fear that
Shouldice Hospital is significantly lower than at the increasing growth of for-profit specialty hospi-
other Canadian hospitals. tals will siphon off the least complicated and best
Other examples of healthcare-focused factories insured patients, leaving the community hospitals
are Aravind Eye Hospitals in India, which special- to treat complex, high-cost, poor, and uninsured
ize in cataract surgery and eye diseases; Coxa patients. Community hospitals argue that such a
Hospital in Finland, which specializes in endoscopic shift would unfairly burden them and cut into their
410 Forces Changing Healthcare
already tight financial margins. And if community See also Certificate of Need (CON); Competition
hospitals cannot compete with specialty hospitals, in Healthcare; Consumer-Directed Health
they will be forced to cut back on money-losing Plans (CDHPs); Economies of Scale; Hospitals;
services such as emergency department care or to Public Policy; Regulation; Volume-Outcome
Relationship
negotiate higher prices from payers. They contend
that specialty hospitals may add unnecessary
capacity that could hurt the quality of medical care
in the community by reducing the volume of cases Further Readings
treated at each facility. They also assert that spe- Guterman, Stuart. “Specialty Hospitals: A Problem or a
cialty hospitals may put patients’ health at risk, Symptom?” Health Affairs 25(1): 95–105, 2006.
because very sick patients may not get the same Herzlinger, Regina. Who Killed Health Care?
attention they would at large community hospi- America’s $2 Trillion Medical Problem—and the
tals. Last, specialty hospitals, with their physician Consumer-Driven Cure. New York: McGraw-Hill,
ownership, may create incentives for excess 2007.
medical care. Iglehart, John K. “The Emergence of Physician-Owned
Specialty Hospitals,” New England Journal of
Medicine 352(1): 78–84, January 6, 2005.
Federal Moratorium Satiani, Bhagwan. “Specialty Hospitals: Who Do They
Because of the debate over the growth of spe- Help?” Surgery 143(5): 589–98, May 2008.
cialty hospitals, the U.S. Congress in 2003 Skinner, C. Wickham. “Focused Factory,” Harvard
enacted an 18-month specialty hospital morato- Business Review 52(3): 113–22, May–June 1974.
rium. Specifically, Congress prohibited the Relman, Arnold S. A Second Opinion: Rescuing
Centers for Medicare and Medicaid Services America’s Health Care. New York: Public Affairs,
(CMS) from issuing Medicare provider numbers 2007.
to new specialty hospitals, thus preventing them
from billing Medicare. The moratorium also
temporarily prohibited physician investors in Web Sites
these hospitals from referring Medicare patients American College of Surgeons (ACS): http://www.facs.org
to facilities in which they had a financial interest. American Hospital Association (AHA): http://www.aha.org
The moratorium expired in 2006, and the CMS American Medical Association (AMA):
once again is issuing Medicare provider numbers http://www.ama-assn.org
to new specialty hospitals, permitting them to National Surgical Hospitals (NSH): http://www.nshinc.com
expand, unless they are prohibited by specific Physician Hospitals of America (PHA):
state laws. http://www.physicianhospitals.org
Future Implications
There is very little empirical evidence concerning
the advantages or disadvantages of healthcare- Forces Changing Healthcare
focused factories. Given this lack of evidence, it
is not clear whether public policies should be Healthcare in the United States is undergoing
developed to encourage or discourage their fur- profound changes. These changes are driven by a
ther development. Resolving this and other number of demographic, economic, sociologic,
questions concerning focused factories is impor- and technologic forces, including population
tant because it is likely that more specialized, demographics; retiree healthcare benefits; payer
niche-type healthcare facilities rather than large, market consolidation; patient cost sharing; trans-
all-purpose community hospitals will increase in parency in costs, quality, and outcomes; value-
the future. based purchasing; globalization in healthcare;
consumerism; technology; and personalized medi-
Ross M. Mullner cine. Each of these 10 forces is discussed below.
Forces Changing Healthcare 411
Population Demographics acquisitions and become a national player. These

two health insurance giants are changing the
A very visible force that is reshaping the nation’s
face of the health insurance market as they
healthcare is the aging of the population and
assume a dominant position, and thereby offer
the workforce. The population in general is
less flexibility in reimbursement to many health-
aging; those who are already elderly are living
care providers.
longer; and the healthcare workforce, particu-
larly in nursing, the largest healthcare profes-
sion, is aging. This force suggests that there will Patient Cost Sharing
be increasing demand for care, which, in turn,
In recent years, consumer-directed healthcare
will increasingly tax the current diminishing
(CDHC) has emerged as one of the most potent
workforce.
ideas in healthcare reform. However, CDHC
means different things to various people. CDHC,
Retiree Healthcare Benefits which involves enrollment in consumer-directed
health plans (CDHPs), refers to insurance that
Many of the nation’s employers have ceased to provides financial incentives for consumers to
provide, or are in the process of discontinuing, become more involved in their healthcare-
healthcare benefits to their retirees. Employers purchasing decisions. Most of the literature uses
continuing retiree health benefits are shifting more the term consumer-directed health plans to refer
of the cost to retirees. The Agency for Healthcare to any high-deductible insurance plan. Typically,
Research and Quality (AHRQ) reports that only high-deductible denotes a plan with a deductible
13% of private-sector employers offered health of $1,000 or more. High-deductible plans are
benefits to their retirees in 2005, down from 22% sometimes coupled with personal health savings
in 1997. Even many large employers are not offer- accounts (HSAs). HSAs are tax-advantaged health
ing their retirees healthcare benefits. It appears savings accounts that may be used to pay for
that the implementation of the recent Medicare qualified medical expenses. HSAs must be paired
prescription drug benefit in 2006 further encour- with a health plan whose minimum deductible is
aged employers to have their retirees rely solely on $1,000 for individuals or $2,000 for families in
public-sector healthcare benefits, despite the fed- 2008 and the annual out-of-pocket expenses do
eral subsidy to employers maintaining their retiree not exceed $5,000 for individuals and $11,200
plans. for families. Health reimbursement accounts
(HRAs) are similar to HSAs but are owned by
employers and do not need to be coupled with a
Payer Market Consolidation
high-deductible plan.
The nation’s health insurance industry has under- In 2005, about 10% of privately insured
gone tremendous consolidation, and this can be nonelderly American adults were enrolled in a
expected to continue, albeit less rapidly, until plan with a high deductible; about 10% of them
such a time when mergers and acquisitions trig- had an HRA or HSA. One fifth of employers
ger a major reaction from government antitrust offering health insurance offered a high-deduct-
agencies. While consolidation has been under ible plan, and about 4% offered such a plan with
way for some time, a key turning point occurred an HRA and HSA option. However, demand for
in 2004 with the merger of Anthem and WellPoint these plans appears to be growing. A recent sur-
Health Networks—the largest ever managed-care vey of these plans found that enrollment had
merger, which encompassed a $16.4 billion deal more than tripled since early 2005, reaching 3.8
that has increased the plan’s membership to million in 2007. Predictions about the future
about 28.5 million enrollees. WellPoint, Inc., has growth of the HSA market are also impressive.
since acquired Empire Blue Cross, Blue Shield, One recent forecast is that the market will expand
moving into the eastern part of the country and to 15 to 30 million enrollees over the next 5 to 10
thereby becoming more of a national company. years. The important point is not the exact num-
The United Health Group has also made major ber of people enrolled in HSAs but rather that
412 Forces Changing Healthcare
these new insurance products are symptomatic of the recommended care. Furthermore, healthcare
a more widespread movement toward shifting spending varies greatly from region to region,
more of the cost—and the decision making and with no discernible improvement in quality of
the wellness accountability—from businesses to care or health outcomes associated with the
consumers. higher outlays.
Transparency in Costs,
Globalization in Healthcare
Quality, and Outcomes
There is a growing trend toward globalization
The nation is steadily moving toward a value-
in healthcare, which is called medical tourism—
based purchasing healthcare economy. This has
the basic practice of traveling to a distant loca-
mainly been driven by the major purchasers of
tion or even another country to obtain healthcare
care, such as the Centers for Medicare and
services. The increase in the popularity of
Medicaid Services (CMS), and large employers
medical tourism appears to be the result of the
who are seeking to quantify the value of the
uneven quality of care in local communities,
healthcare dollars they spend. Indeed, now
the high costs of healthcare, the long wait times
more than ever, there is a growing movement by
for procedures, the ease and affordability of
the purchasers of healthcare to demand docu-
international travel, and improvements in tech-
mentation on patient care quality, along with a
nology and standards of care in many countries
more transparent approach to pricing, particu-
of the world. Most medical tourists seek elec-
larly in the hospital sector. In addition, large
tive services such as aesthetic treatments (cos-
employers, labor organizations, and consumer
metic surgery) or orthopedic surgery. Countries
advocacy groups are working hard to make sure
such as India, Malaysia, Singapore, and
that any healthcare reform includes the require-
Thailand are positioning themselves as medical
ment that information on healthcare costs and
destinations. In general, physicians trained at
quality is collected and made available to the
the major medical centers in North America
public. Additionally, many hospitals and health
and Europe staff hospitals and clinics in those
systems are now beginning to share their cost
nations catering to medical tourism. Moreover,
and quality information with the public. A few
most of these physicians are board certified in
of them have gone so far as to commit to full
the United States. Furthermore, many American
disclosure of their performance (via pricing and
medical schools are forming partnerships with
quality indicators) to consumers on the Internet
Asian hospitals to penetrate this market. In the
and through direct mailing to consumers.
mid-1990s medical tourism did not exist; how-
ever, the number of medical tourists to India
Value-Based Purchasing alone has tripled in the past 4 years from
150,000 to 500,000.
It appears that the nation’s health insurance plans
will move much more aggressively in the next
several years to both measure the quality of physi-
Consumerism
cians and hospitals and reward those with better
performance records and improved outcomes. In Patients are increasingly demanding a greater role
part, this movement has been stimulated by the in the decisions that affect their healthcare. The
growing recognition of the large variance across development of the Internet and the availability of
providers in quality. Widespread quality-of-care online healthcare information have enabled
problems demonstrated that the nation is not get- patients to take a more active role in their health
ting the full value for its healthcare expenditures. management. Consumerism in healthcare is based
Indeed, there is growing national evidence of on the idea that individuals who are financially
inappropriate medical care and widespread and accountable for their wellness and who have better
dangerous medical errors. Research studies have access to information as well as more control over
shown that Americans only receive about half of their own healthcare will make better decisions
Forces Changing Healthcare 413
about treatment and provider options. If consum- quality indicators that are used to improve prac-
ers could better understand and more effectively tice and reward performance, thereby improving
use health services, community health status could the efficiency and efficacy of healthcare.
improve, the value of healthcare to the consumer Technological advances are also affecting care
could be enhanced, and the rate of increase in itself. Less invasive procedures, increased portabil-
healthcare costs could be reduced. ity of equipment and supplies, and advances in
To enhance consumerism, healthcare providers diagnosis and treatment have made it possible to
can take several actions. One is to provide clear change the locus and type of healthcare procedures.
communication, which means listening deeply Technology also affects consumer expectations for
and with an open mind, not only to the consum- healthcare. Unlike other industries, new technolo-
ers but also to the full spectrum of the stakehold- gies in healthcare are additive, often raising con-
ers. Another is to create consumer-focused sumer and provider expectations. Both consumer
systems, which involves improving internal sys- and provider expectations are shaped by experi-
tems and working with others to remove barriers ences with other, more technologically advanced
to engaging consumers rather than focusing on enterprises, such as the travel and banking indus-
the mechanics of the care. Providers should also tries. Healthcare is just now beginning to develop
simplify pricing, taking into account the patient’s the information systems that will improve transac-
medical condition, insurance coverage, discount tions among providers, consumers, and financiers
eligibility, and past medical history. Improving of healthcare. Technology has the potential to
patient safety, which involves developing safe and change healthcare delivery. As healthcare technol-
high-quality care-delivery systems such as an ogy advances, problems previously thought to be
electronic health record system and an underlying life threatening will begin to look more like chronic
clinical system to support it, is another avenue diseases. Nanotechnology, genetics, and biomedical
for improving consumerism. Also, serving the advances are changing both consumer and provider
underinsured to make consumers’ needs para- expectations for health, care, and treatment.
mount, regardless of their ability to pay, will also
enhance consumerism. Last, providers should
Personalized Medicine
provide accountability, which involves develop-
ing explicit action plans to address community Personalized medicine refers to the development
benefit and then reporting on how those plans and treatment of disease and disease propensity
were implemented. with interventions based specifically on a person’s
genetic profile. Advances in genomics, pharma-
cokinetics, and computer technology are quickly
Technology
making personalized medicine a reality. A criti-
Technology has far-reaching implications for cally important challenge will involve how health-
changing healthcare because it affects both the care payers can provide a reimbursement policy
processes of care and the way organizations work. that will encourage innovators to tailor drugs,
Among the broad-based effects of technology is biotech products, and perhaps even medical
the development of health information systems devices to the metabolism and other characteris-
and the genomics that are contributing to the biotics of different subgroups in the population,
technical advances in care. Health information based on factors such as age, gender, and ethnic-
systems are increasingly being used to decrease ity. Different groups respond in very different
healthcare costs by standardization and improved ways to these products. Yet if the market is sub-
data capture to support both billing practices and divided, will the payback of return on investment
care decisions. Information systems have the justify the cost of bringing “customized” prod-
potential to reduce the rate of increase in health- ucts to the market?
care costs, which are predicted to reach 19% of Personalized medicine also implies that treat-
the nation’s gross domestic product (GDP) by ment will be made personal, a trend already under
2014. Information systems enable managers and way. For example, patients are informed before
organizations to more effectively capture cost and their office visits about their care, and they evaluate
414 For-Profit Versus Not-for-Profit Healthcare
and compare the information they have obtained Congressional Budget Office (CBO):
with that provided by their physician or caregivers. http://www.cbo.gov
Customers expect to be a part of the planning pro- Institute for the Future (IFTF): http://www.iftf.org
cess for their health, discussing a plan of action for National Center for Policy Analysis (NCPA):
their own healthcare. As patients become more http://www.ncpa.org
knowledgeable about their healthcare, the time
pressure on providers can be expected to increase.
In 2004, the reported median time physicians spent
with patients on an office visit was 14.7 minutes. For-Profit Versus
The challenge for providers lies in applying exper-
tise to collaborations with consumers to evaluate Not-for-Profit Healthcare
information from the Internet and available up-
to-date scientific evidence. Just as technology is One distinctive feature of the U.S. healthcare system
increasingly an enabler assisting caregivers in is its mix of nonprofit, for-profit, and public owner-
diagnosis and treatment, it is also an enabler for ship of hospitals, nursing homes, and health insur-
patients, who assume more ownership of their own ers. Nonprofits dominate the hospital sector. About
health. Personalized medicine, which will likely 53% of the nation’s hospitals are nonprofit, 19%
become personalized healthcare over time, is one of for profit, and 28% government owned, including
the most exciting aspects of changing healthcare. local, state, and federal hospitals. For-profit owner-
ship is the norm in the nation’s nursing home indus-
Christopher G. Lis try, with 62% for profit, 31% nonprofit, and 7%
government owned. There are more than 1,300
health insurers and health plans in the nation, the
See also AARP; Center for Studying Health System
overwhelming majority being for-profits, but non-
Change; Congressional Budget Office (CBO);
profit insurers and health plans are among the larg-
Consumer-Directed Health Plans (CDHPs); Cost of
Healthcare; Health Insurance; Leapfrog Group; est and cover approximately one quarter of the
Medical Travel privately insured population.
Within both for-profit and nonprofit sectors,
ownership structures vary. For-profit ownership
can include individual proprietorships and part-
Further Readings
nerships or publicly traded or privately held cor-
Bernstein, A. B., E. Hing, A. J. Moss, et al. Health Care porate ownership, with corporate ownership
in America: Trends in Utilization. Hyattsville, MD: dominating the for-profit hospital, nursing home,
National Center for Health Statistics, 2003. and insurance sectors. Nonprofit organizations
Kongstvedt, Peter, and Joel Diamond. Healthcare Trends are restricted by law from distributing profits or
and Forecasts in 2008: Performance Expectations for net revenues to those outside the firm (the
the Industry. Manasquan, NJ: Healthcare Intelligence “noninurement” requirement). They may be tax-
Network, 2007.
exempt at the federal, state, or local level.
Society for Healthcare Strategy and Market Development
Nonprofit hospitals and nursing homes are gener-
of the American Hospital Association. Futurescan
ally owned by local corporations, with self-perpet-
2008: Healthcare Trends and Implications, 2008–2013.
uating, locally drawn boards, although a significant
number are owned by or affiliated with religious
orders or denominations or are part of local or
regional systems.
Web Sites Several issues arise in the analysis of ownership
American Hospital Association (AHA): http://www.aha.org in health services research. One is why nonprofits
American Sociological Association (ASA): play such a large role in providing health services
http://www.asanet.org and insurance. This issue can be approached from
Center for Studying Health System Change (HSC): both a theoretical and a historical perspective. A
http://www.hschange.com second issue is whether, because of the differences
For-Profit Versus Not-for-Profit Healthcare 415
in organization, management, or incentives, the historically it has been the case that even when
performance of nonprofits and for-profits differs opportunities for commercially viable for-profits
in ways that should matter to patients, payers, or are established, nonprofits do not cede the field but
regulators. Extensive research has been conducted often remain active competitors in the market.
on these issues, involving both direct comparisons Both of these theoretical explanations for the
of nonprofit and for-profit entities and examina- rise of nonprofits lead to predictions regarding
tion of cases in which nonprofits convert to for- observable differences in the behavior of for-profit
profit status. and nonprofit firms. For-profit firms are assumed
to be profit maximizers (and thus cost minimizers),
while nonprofits are assumed to have other goals,
Theories of Nonprofit Creation
such as prestige, size, quality, charity, staff satisfac-
and Support in Healthcare
tion, and donor satisfaction, which are to be
Three broad sets of theoretical explanations have implemented within a break-even constraint or
been put forward to explain the creation and balanced with a profit maximization thrust. There
ongoing support of nonprofit organizations in is no agreement in the literature concerning which
healthcare. The first builds on concepts of asym- of the other goals predominate, perhaps reflecting
metrical information, principal-agent problems, the fact that objectives may vary across nonprofits,
and the difficulties of monitoring performance even those within the same industry. Nonetheless,
and ensuring quality and fair dealing. Kenneth J. it is generally predicted that nonprofits in health-
Arrow was among the first to present this view in care will be less efficient and have higher costs,
his classic 1963 article, “Uncertainty and the offer lower prices, be less profitable, have higher
Welfare Economics of Medical Care,” in which he quality (particularly when quality is hard to moni-
notes that the very word profit is a signal that tor), be more likely to provide unprofitable ser-
denies a trust relationship. He goes on to say that vices and slower to adopt profitable services,
physicians try to avoid being seen as profit maxi- provide more community benefits generally, and
mizers in their trust relationships with patients. be less likely to close.
And from these special relationships come various The third set of theoretical analyses seeks to
forms of ethical behavior, which leads to the rela- explain the continued presence of both nonprofits
tive unimportance of profit making in hospitals. and for-profits in markets, belying models that
Henry Hansmann, in his 1996 book, The predict that one form would dominate and drive
Ownership of Enterprise, expands on this theme, the other out. Four sets of explanations have been
noting that because of the high costs incurred by offered. One is that it is simply a matter of timing—
customers of some firms, nonprofit firms such as that the firms coexist as markets shift from a state
hospitals are set up whose managers hold them in that advantages one form to a state in which the
trust for them. Other reports in the literature other form is advantaged. Another explanation put
expand on these models of nonprofits as a forward is that the continued presence of different
response to agency and trust problems. firms is supported by consumer heterogeneity; that
A second explanation put forward for the cre- is, some consumers cannot detect agency failure
ation of nonprofits is that they address consumer or and rely more on nonprofit status as a signal, while
charitable needs by creating organizations to deliver others who believe they can detect such failures are
goods and services that are not commercially via- more willing to buy from for-profit firms. A third
ble. This has been identified as the original impetus explanation is that different forms have asymmet-
for the creation of nonprofit hospitals, insurers, ric advantages, such as access to different sources
and health plans. Nonprofits are often classified as of capital, that allow nonprofits and for-profits to
donative, depending on contributions for support occupy different market niches or exploit different
of their activities, or commercial, depending on advantages when competing in the same niche. In
revenues from the sale of goods or services. Many this model, institutions, once established, operate
blend these two components, and over time, the to exploit the environment and strengthen their
mix of donations and commercial revenues can advantages through law and regulation. A fourth
shift, as it has in the hospital industry. Furthermore, explanation, which complements the third, is that
regulatory pressures, adoption of successful mod- homes, encouraging expansion of their numbers as
els from the other ownership form, and consumer well as the growth of for-profit corporations own-
or community norms and expectations encourage ing chains of nursing homes and differentiation of
nonprofits and for-profits in the same markets to facilities by levels of service.
mirror one another, which reduces the likelihood In the first part of the 20th century, few insur-
of one or the other being pushed out of a market. ers offered health insurance, fearing adverse selec-
This last explanation has important consequences tion. Modern health insurance in the United States
for comparing nonprofits and for-profits, since it was introduced during the Depression as hospi-
suggests that differences between nonprofits and tals, facing substantial numbers of patients unable
for-profits may not be observed in within-market to pay, sponsored prepayment programs for hos-
comparisons but only in cross-market comparisons pital care. These plans were largely created under
structured to differentiate between nonprofit- state legislation that established separate regula-
dominated and for-profit-dominated markets. tions and financial standards for nonprofit orga-
History suggests that consumer preferences for nizations. Similar physician plans were soon
nonprofit over for-profit hospitals, nursing homes, created as well. The earliest health maintenance
or health plans has not been a major element sus- organizations (HMO) were likewise created as
taining nonprofits. Rather, the evidence supports nonprofits. Only once the commercial feasibility
the model of donative or charitable creation and of health insurance and prepaid health plans was
the roles of asymmetric advantage and mimicry in established did for-profit insurers enter the market
sustaining both nonprofits and for-profits in the in substantial numbers. The comparative advan-
same markets. The first U.S. hospitals were non- tage of nonprofit or for-profit insurers and health
profit institutions created for the care of the poor, plans over time appears to be influenced by the
supported by donations. After the invention of regulatory advantages offered to nonprofits, the
anesthesia and antisepsis, hospitals could offer cost-based payment systems nonprofit insurers
services that could not be easily provided at home, negotiate with hospitals, and greater access to
and for-profits entered the hospital market. By capital available to for-profit firms. The 1980s
1910, for-profit hospitals were more common saw a series of nonprofit to for-profit conversions
than nonprofits. Differential access to capital has of a significant number of health plans, a trend
influenced the relative growth and decline of for- that continues with the conversion of several of
profits in the U.S. hospital system over time. Many the largest of the nation’s Blue Cross and Blue
for-profits closed during the Depression, while Shield plans.
nonprofits were sustained by community contribu- Public opinion surveys reinforce the judgment
tions and the creation of hospital insurance pro- that donative and commercial factors, not trust
grams that differentially favored nonprofit and agency issues, better explain the development
hospitals. The federal Hill-Burton program cre- of nonprofit and for-profit providers of hospitals,
ated additional subsidies for the expansion of nursing homes, and insurance services. Surveys
nonprofit hospitals after World War II. The estab- from the 1980s and 1990s found those surveyed to
lishment of Medicare in 1965, with payment rules be unsure about the ownership of the institutions
offering benefits to for-profit hospitals, encour- they used and belief to be mixed about the relative
aged their expansion and the purchase of individ- quality and efficiency of for-profit and nonprofit
ual-proprietorship and partnership-owned hospitals, HMOs, and health insurers.
hospitals by corporations.
Nursing homes were developed as homes for
Comparisons of Cost, Quality,
the aged or infirm, many as individual proprietor-
and Community Orientation
ships or partnerships, some, sponsored by religious
or community groups, as nonprofits. The Social Regardless of whether public support for the cre-
Security Act of 1935 required states to develop ation of nonprofits is based on concerns that
licensure programs for nursing homes. The estab- patients will be exploited, a significant public
lishment of Medicare and Medicaid in 1965 cre- policy debate emerged in the 1980s and continues
ated substantial revenue streams for nursing to the present about the desirability of for-profit
providers supplanting nonprofits, through either charity care, and decisions by for-profits to locate
for-profit expansion in the marketplace or conver- in areas with better-insured populations have all
sion of nonprofits to for-profit status. This has been suggested as explanations, and there is some
resulted in an extensive literature looking sepa- research to support each of these claims.
rately at hospitals, nursing homes, and insurers,
comparing for-profit and nonprofit cost and effi- Quality of Care
ciency, quality, and provision of community ben- Study of the quality of hospitals has been ham-
efits. The community benefits examined are broad pered by limited data. Many studies have focused
and not always clearly defined but include lower on mortality differences, with varying levels of
prices (i.e., failure to fully exploit local market control for patient-specific risk adjustment. More
power), charity care (or improved access for low- recently, data on other measures of quality have
income populations), and maintenance of unprof- become available, and studies have incorporated
itable but needed community services. Conversions these measures. The most complete systematic
from nonprofit to for-profit status have been a analysis of this literature examined 25 studies
focal point of this debate and, as a result, have led looking at mortality and 13 looking at other mea-
to a significant body of research. sures of quality, including surgical complications
Below is a summary of this literature for hospi- and medication errors. It found that a majority of
tals, nursing homes, and health plans. these studies found no statistically significant dif-
ference between for-profit and nonprofit hospitals,
Hospitals but it also found that those studies that were rep-
resentative of the United States as a whole tended
Costs and Efficiency to find lower quality of care among for-profit than
The relative costs and efficiency of nonprofit among nonprofit hospitals. Another study com-
hospitals in comparison with for-profit hospitals paring hospitals using the current Centers for
has been extensively studied. This research has Medicare and Medicaid Services (CMS) Hospital
used a wide range of data sets, including Medicare Compare measures of processes of care reinforces
cost reports and state hospital financial reports; this conclusion that for-profits have consistently
alternative modeling strategies (e.g., economic cost underperformed nonprofit hospitals.
functions, data envelopment analysis, and stochas-
tic frontier regression); different covariates; and Community Benefits
functional form; it has also examined different The two most widely considered community
time frames. The research has been subjected to benefits for which comparisons have been made
meta-analysis. The majority of studies either find between nonprofit and for-profit hospitals are
no difference in costs or efficiency between non- charity care and provision of unprofitable services.
profits and for-profits or find that nonprofits have While studies have found substantial variation
lower costs and greater efficiency than for-profits. across states in the relative provision of charity
The prediction from theory that nonprofits would care by ownership, on average, for-profit hospitals
be less efficient is not supported. have been found to provide less charity care than
nonprofits. At least some of this difference appears
Prices and Net Revenues to be a function of location decisions by for-
Prices and net revenues (or profits) of for-profit profits. For-profits have also been found less likely
and nonprofit hospitals have been less widely stud- to offer unprofitable services than nonprofit hospi-
ied than the relative costs and efficiency of these tals, and they are more sensitive to changes in
forms. These studies have found either no statisti- profitability over time.
cally significant difference in prices or profits or
Hospital Conversions From
higher prices or profits in for-profit hospitals. The
Nonprofit to For-Profit Status
studies do not allow the source of differences
in profits or net revenues to be clearly identified, There have been several waves of conver-
although differences in pricing, discretionary sions of nonprofit hospitals to for-profits. These
conversions or purchases have raised issues of Community Benefits

fair valuation of the assets of the nonprofit and Nursing homes have not been expected to offer
concerns about maintenance of charity care and as wide a range of community benefits as hospi-
services within the community. State-specific tals. One community goal has been to ensure
studies of conversions of nonprofits have found access to nursing homes for Medicaid patients.
that, on average, they are similar to for-profits For-profit nursing homes have been found by
in their states in the levels of charity care they researchers to be more likely to admit Medicaid
provide, although a national study concluded patients, thus disproportionately offering benefits
that charity care declined postconversion. to the community in this area.
Studies also suggest that after conversion there It was suggested above that differences between
is no evidence of reductions in charity or ser- nonprofits and for-profits may not be observed
vices by the converted hospital. One 1997 study in within-market comparisons but only in cross-
of conversion trends from 1980 to 1993 found market comparisons structured to differentiate
that while nonprofit to for-profit conversions between nonprofit-dominated and for-profit-
were the focus of public concern, there were dominated markets. There has been some research
also a substantial number of for-profit to non- using this framework examining the nursing home
profit conversions. industry. One study attempted this comparison,
using expansion of nursing home use as a measure
Nursing Homes of increasing consumer value from nursing home
services. It found higher use in communities with
Costs and Efficiency
more nonprofit nursing homes, concluding that
Studies consistently find that for-profit nurs- more quality of care per dollar could be achieved
ing homes have lower costs than nonprofit by encouraging a greater share of nonprofit nurs-
nursing homes. Examination of the sources of ing homes in most market areas in the nation.
cost differences has found wages and registered
nurse staffing to be higher in nonprofit homes.
No studies have adequately controlled for dif- Health Insurers and Health Plans
ferences in quality across the two ownership Studies of the relative performance of nonprofit
types, a significant omission given that (as and for-profit health insurers and health plans
described below) quality has been found to be have been limited. Conversions of nonprofits to
higher in nonprofit facilities. Thus, while cost for-profits have contributed significantly to the
differences are observed, there have been no interest in this topic, although the research specifi-
sufficient studies of efficiency differences across cally studying conversions has been limited.
the forms.
Costs, Efficiency, Pricing, and Profitability
Prices
Comparing the costs, efficiency, pricing, and
Limited studies exist of the prices charged pri- profitability of health plans is complicated because
vate-pay nursing home patients, and they are of the multiple measures that might be examined.
mixed as to whether nonprofits or for-profits have Premium levels, percentage of collected premiums
lower charges. paid as benefits, and administrative costs have
been examined, but the interpretation of differ-
Quality of Care
ences can be challenging. For example, higher
A large number of studies have compared the administrative costs have been interpreted as a sign
quality of care at for-profit and nonprofit nursing of inefficiency and alternatively as a measure of
homes. Across a wide variety of measures—mor- aggressive cost and utilization management.
tality, complications such as infections or bedsores, The evidence for greater efficiency, lower admin-
measures of processes of care, and regulatory defi- istrative costs, lower payment to providers through
ciencies, for-profit nursing homes have been found more aggressive negotiations or rate setting, or
to have lower quality. higher profits of one form over the other is mixed.
There is limited evidence that suggests but does defined by commitment to their communities, to
not conclusively demonstrate that both payments mutual company models, where their primary
to providers and the proportion of premiums paid commitment is to their customers. Assessing how
to providers are lower for for-profit plans and much impact conversion has on a company’s rela-
for Blue Cross plans following conversion, this tionship with its customers, its continuation of
difference being associated with higher profits. activities with community benefits, or its day-to-
Furthermore, better-controlled studies with more day business practices requires further research.
data are required to resolve the questions asked in
this research.
Future Implications
Quality This entry began by considering two questions:
Why is there substantial nonprofit presence in the
The relative quality of health plans has been
hospital, nursing home, and health insurance
assessed in a variety of ways. Given the concern
industries; and how do nonprofit and for-profit
among consumers that insurers might skimp on
entities compare in costs and efficiency, pricing
needed care, issues of trustworthiness are also fre-
and profitability, quality, and community benefit?
quently addressed in comparing quality across plans.
With respect to the first question, theory has
Studies have been conducted comparing objective
emphasized issues of asymmetric information
measures, such as the Healthcare Effectiveness Data
encouraging consumers to prefer nonprofits.
and Information Set (HEDIS) measures of the
Historical analysis suggests, however, that lack of
National Committee for Quality Assurance (NCQA),
functioning markets or the need for a donative
disenrollments and appeals, and patient and physi-
business model dominated the early creation of
cian surveys. These different approaches generally
nonprofits and that differential access to alterna-
find quality and patient and physician satisfaction
tive sources of capital and effective competition,
lower in for-profit health plans. Ownership may not
through mimicry or asymmetric market advan-
be the only factor influencing these scores, since
tages, provide better explanations of the contin-
there are substantial regional differences in the ages
ued presence in the market of both forms.
of plans and lengths of enrollment in the plans.
Notwithstanding the limited role asymmetric
Studies of conversions have found few or no differ-
information and consumer fear of exploitation
ences before and after conversion.
have played in creating nonprofit and for-profit
hospitals, there have been active and ongoing
Community Benefits
debates regarding the desirability of for-profit
One of the major issues in nonprofit to for-profit provision of health services and health insurance,
conversion of health plans has been the potential the risk of nonprofit to for-profit conversion, and,
loss of community benefits. Nonprofit plans have on the other side, the justification for continued
historically provided a wide range of benefits— tax exemption and public benefits for nonprofit
periodic open enrollment without preexisting con- providers.
dition restrictions, community rating of premiums, Research continues to fuel this debate. It has
innovation in products to provide access to insur- shown that while for-profit nursing homes are less
ance for low-income or vulnerable populations expensive and more likely to accept Medicaid
such as children, health services research, and pub- patients, their quality is lower than that of non-
lic health education, among others. Some of these, profits. Contrary to theoretical expectations, for-
most notably community rating, have come under profit hospitals appear to be no more efficient or
pressure even without conversion due to competi- less costly than nonprofits. Quality in for-profit
tion in the market place due to risk- and age-related hospitals appears to be comparable with or
premiums and active medical underwriting by for- slightly lower than in nonprofits, and for-profits
profit insurers. In the face of growing competition provide fewer community benefits. Comparisons
from for-profit insurers and health plans, Blue of nonprofit and for-profit health insurers find no
Cross and other nonprofit plans have been shifting difference in costs, some evidence of lower quality
from social service models, with their mission or consumer satisfaction in for-profits, and an
420 Fraud and Abuse
erosion of community benefits as for-profit pres- National Association of Community Health Centers
ence in insurance markets grows. (NACHC): http://www.nachc.com
In the future, research on these issues will likely National Committee for Quality Assurance (NCQA):
continue. One area that has only begun to be http://www.ncqa.org
explored is examining the role of norm setting in
markets by comparing the behavior of both for-
profits and nonprofits as the mix of the two forms
varies across markets. Fraud and Abuse
Jack Needleman Fraud and abuse in healthcare involve threats to
See also Arrow, Kenneth J.; Blue Cross and Blue Shield;
the integrity of reimbursement programs. The
Healthcare Effectiveness Data and Information Set most far-reaching laws concerning these practices
(HEDIS); Health Insurance; Hospitals; Nursing prohibit illegitimate means of obtaining payment
Homes; Public Policy; Skilled-Nursing Facilities from public programs, most notably Medicare
and Medicaid. Similar laws in most states apply in
the context of private insurance.
Further Readings Prosecution of fraud and abuse is the most
aggressive area of criminal enforcement in health-
Arrow, Kenneth J. “Uncertainty and the Welfare
care. More than 2,000 cases are brought each year,
Economics of Medical Care,” American Economic
netting an estimated $1 billion in recoveries from
Review 53(5): 941–73, December 1963.
violators, although the full extent of improper
Hall, Mark A., and Christopher J. Conover. “For-Profit
payments that could be recovered is projected at
Conversion of Blue Cross Plans: Public Benefit or
Public Harm?” Annual Review of Public Health 27:
several times this amount. However, the most sig-
443–63, 2006. nificant impact of fraud and abuse enforcement
Hansmann, Henry. The Ownership of Enterprise. may not be reflected in the sums regained from
Cambridge, MA: Harvard University Press, 1996. defendants but rather in the deterrent effect of
Needleman, Jack. “The Role of Nonprofits in Health these prosecutions for the much larger number of
Care,” Journal of Health Politics, Policy, and Law potential violators.
26(5): 1113–30, October 2001. Health services researchers study fraud and
Santerre, Rexford E., and John A. Vernon. “Ownership abuse to better understand the functioning of
Form and Consumer Welfare: Evidence From the healthcare reimbursement systems. The availabil-
Nursing Home Industry,” Inquiry 44(4): 381–99, ity of funding from a third party to cover the
Winter 2007. costs of healthcare goods and services creates a
Schlesinger, Mark, and Bradford H. Gray. “How temptation for some to use illicit means to obtain
Nonprofits Matter in American Medicine, and What it. Without efficient safeguards to deter such
to Do About It,” Health Affairs 25(4): W287–W303, behavior, reimbursement mechanisms cannot
July–August 2006. function. Nevertheless, schemes to game the sys-
Shen, Yu-Chu, Karen Eggleston, Jia Lau, et al. “Hospital tem short of actual fraud and abuse are common,
Ownership and Financial Performance: What and they shape many healthcare financial prac-
Explains the Different Findings in the Empirical tices. As a result, fraud and abuse laws and
Literature?” Inquiry 44(1): 41–68, Spring 2007. enforcement policies are key factors in guiding
much of the business structure of healthcare and
are essential components of the economics of the
Web Sites industry.
Alliance for Advancing Nonprofit Health Care:
http://www.nonprofithealthcare.org
Definition of Terms
American Association of Homes and Services for the
Aging (AAHSA): http://www.aahsa.org The term fraud and abuse refers to two kinds of
Catholic Health Association of the United States (CHA): illicit behavior. Fraud is the misrepresentation of
http://www.chausa.org material facts to obtain financial gain. For a
Fraud and Abuse 421
representation to constitute fraud, it must both Applicable Laws: The Basic Medicare
be false and known to be false by the party mak- Fraud and Abuse Prohibition
ing it. Common kinds of fraud in healthcare
involve claims for reimbursement submitted by The most important legal directive against fraud
providers that either fabricate services that were and abuse in healthcare is contained in the federal
never rendered or exaggerate the intensity of law governing the Medicare and Medicaid pro-
services that were rendered to obtain a higher grams. It was adopted in its present form in 1977
level of payment, a practice known as upcoding. and amended to permit limited exceptions in
Since all health insurance, both public and pri- 1987. The law contains an extremely broad set of
vate, requires that goods and services be neces- prohibitions that cover a wide range of financial
sary for medical treatment or diagnosis to be transactions. The section on fraud penalizes any-
eligible for reimbursement, submission of claims one who “knowingly and willfully makes or
for goods and services that are not necessary can causes to be made any false statement or represen-
also constitute fraud. tation of a material fact” in applying for benefits.
Abuse occurs when providers take advantage of The section on abuse applies to anyone who
their position of trust to promote inappropriate or knowingly and willfully either “solicits or receives”
unnecessary use of healthcare goods or services. or “offers or pays” any remuneration in return for
Most commonly, this involves the exchange of referring a patient for goods or services that are
payments in return for referring a patient for a eligible for coverage under Medicare, Medicaid,
product or service. Such payments can take the or similar state programs such as the State
form of kickbacks, as when a portion of the reim- Children’s Health Insurance Program (SCHIP).
bursement received is sent to the referring provider, The term remuneration is defined extremely
or less obvious schemes to bestow a reward indi- broadly to include kickbacks, bribes, and rebates
rectly. They are considered illegal and unethical, that are paid either directly or indirectly, overtly
because the opportunity for financial reward could or covertly, in cash or in kind.
cloud a referring provider’s judgment concerning The penalties for violations can be severe, as the
what is clinically best for the patient. violations are considered felonies. Criminal sanc-
While payments in return for referring busi- tions include imprisonment for up to 5 years and
ness are forbidden in healthcare, the opposite is fines of up to $25,000 for each transaction. Short
true in many other industries. In various con- of criminal prosecution, government enforcers can
texts, they are not only permitted but actually pursue violators in civil proceedings for fines and
constitute common practice. For example, real can seek that they be excluded from participation
estate agents receive commissions from the sell- in Medicare and Medicaid for up to 5 years. For
ers of homes in return for arranging sales, as do physicians who see a substantial number of geriat-
stock brokers for securities and car salesmen for ric patients, exclusion from Medicare can effec-
vehicles. The difference between these businesses tively destroy a medical practice.
and healthcare is that, unlike buyers of homes, Billing fraud under Medicare and Medicaid has
stocks, and cars, patients are buffered by insur- generated numerous well-publicized prosecutions.
ance from the financial consequences of their Large corporate hospital chains have paid settle-
purchasing decisions. This removes the incentive ments running into billions of dollars to resolve
to be economically prudent, a situation known charges involving practices such as falsifying cost
as moral hazard. The ability of unscrupulous reports, performing unnecessary heart procedures,
providers to steer patients to purchase unneeded multiple billing of procedures, and billing for ser-
goods and services is thereby enhanced consider- vices that never took place. Large pharmaceutical
ably, which creates a risk to payers of overuti- firms have paid similarly large sums for false bill-
lization that will escalate costs. Patients also ing and other deceptive practices. Prosecutions
must rely on the expertise of their physicians to have also netted settlements and convictions against
determine which goods and services they will academic medical centers, community hospitals,
obtain to a much greater extent than buyers in and individual physicians. Because of the compli-
other contexts. cated nature of Medicare and Medicaid billing
422 Fraud and Abuse
requirements and the ambiguity of many rules, fraud and services, and investment in smaller entities if
enforcement can involve highly complex litigation. stock ownership is not dominated by those who
The prohibition against abuse raises even more make referrals. Each safe harbor defines in detail
difficult issues in its application. After the U.S. the features that place a business relationship
Congress enacted the sweeping law in 1977, the above suspicion. Arrangements that contain some
willingness of the courts to apply it strictly remained but not all features of an applicable safe harbor
in doubt. Clarification came in 1985 from the fed- are not necessarily considered illegal; however,
eral Court of Appeals for the Third Circuit in the they lose the automatic presumption of legitimacy
case of United States v. Greber. In that case, a car- that strict compliance with the regulations
diologist accepted referrals of patients from pri- confers.
mary-care physicians for diagnostic tests, and he
paid the primary-care physicians fees for interpret-
Applicable Laws: The Stark Amendments
ing the results of the tests. However, the cardiolo-
gist acknowledged that one purpose of the fees was Relying on a perpetrator’s intent to find a viola-
to encourage referrals. The court ruled that if any tion leaves a significant enforcement gap. Some
intent behind a payment to a referring physician is kinds of payments to physicians influence refer-
illicit, then the entire payment is tainted, even if ring decisions even in the absence of a conscious
there is another legitimate purpose. This broad rul- intention to steer patients. These are general com-
ing established the precedent that the law against pensation schemes that can cement a physician’s
fraud and abuse is to be applied very stringently. loyalty even in the absence of a clear ulterior busi-
The breadth of the Greber decision gave teeth ness purpose. For example, physicians who invest
to the statute but left the status of many legitimate in clinical laboratories may be more likely to send
arrangements in doubt. There are some situations patients to those facilities even though the effect
in which the exchange of funds between referring of the referral on their investment’s value is
providers is not only innocuous but actually ben- remote. Along these lines, studies have shown
eficial to the healthcare system. For example, higher rates of referral to radiation therapy clinics
emergency room physicians are paid salaries by the by physicians who own stock in them.
same hospitals where they admit patients, and staff To close this perceived gap in the enforcement
physicians rent space in hospital-owned office armamentarium, the U.S. Congress passed two
buildings. Literal enforcement of the law to pre- companion amendments to the Medicare law in
vent these arrangements would produce absurd 1989 and 1993. Formally designated the Ethics in
results that could severely disadvantage patients. Patient Referrals Act, they are commonly known
To clarify the status of these and other beneficial as the Stark Amendments, after Congressman
business relationships, the U.S. Congress amended Fortney “Pete” Stark (D-CA), who sponsored
the law in 1987 to permit the U.S. Department of them. Rather than criminalizing specific transac-
Health and Human Services (HHS), which is tions, this set of laws broadly prohibits Medicare
responsible for administering the Medicare and or Medicaid reimbursement when the provider of
Medicaid programs, to designate selected practices a service has any kind of financial relationship
as immune from prosecution. with a physician who referred the patient or with
Regulations issued by HHS in 1991 in response a member of the physician’s immediate family,
to the amendment defined 11 safe harbors, types regardless of the underlying intent.
of arrangements that are considered safe from The relationships to which the Stark Amendments
enforcement. An additional 12 have since been apply include almost any that involve an exchange
added to the original list. Among the areas of of economic value, including employment, rentals
legitimate activity that fall within safe harbors are of space, investments, and loans. However, the law
employment of referring physicians, rental of carves out exceptions for arrangements that are
office space at fair market value, contracting for considered legitimate, including most of those cov-
professional services at fair market value, invest- ered by the safe harbor regulations, and HHS has
ment by referring physicians in large publicly issued regulations that further clarify the scope of
traded corporations that provide medical goods the exceptions. The applicability of the Stark
Fraud and Abuse 423
Amendments is further limited to certain “desig- Office of Inspector General (OIG) of HHS issues
nated” health services. The original 1989 amend- and enforces regulations regarding the integrity of
ment only concerned referrals to clinical laboratories. Medicare and Medicaid. It works in conjunction
The 1993 addition listed nine other kinds of ser- with another component of HHS, the Centers for
vices, including diagnostic radiology, radiation Medicare and Medicaid Services (CMS), which
therapy, physical therapy, occupational therapy, actually administers these programs. OIG audits
and the use of durable medical equipment. healthcare providers, initiates investigations when
fraud is suspected, and can impose exclusions
from eligibility for reimbursement. It issues regu-
Other Applicable Laws
lations to guide compliance, including the safe
Fraud in healthcare billing can also be prosecuted harbor rules for fraud and abuse and interpreta-
under a number of additional statutes that permit tions of exceptions to the Stark Amendments. It
prosecutors to request added penalties. The fed- also issues advisory opinions on proposed transac-
eral False Claims Act imposes civil monetary tions and “fraud alerts” that describe suspect
fines for knowingly making false claims to fed- practices for providers to avoid.
eral authorities. The mail fraud statute permits The activities of OIG are supplemented by the
prosecution for sending false claims through the U.S. Department of Justice (DOJ) when criminal
mail, and the wire fraud statute does the same for or serious civil penalties are sought. DOJ attor-
claims submitted electronically. Various criminal neys also handle appeals of OIG administrative
laws broadly forbid knowingly representing false actions in the courts. The agency may initiate
information to the federal government. Laws in investigations and prosecutions through its head-
many states have a similar effect with regard to quarters in Washington, D.C., or through U.S.
state health programs, most notably Medicaid. attorneys in the department’s regional offices
Since private insurance is primarily regulated by around the country.
the states, state-level laws address fraud in this Providers that operate on a nonprofit, tax-ex-
sphere. empt basis, as do many hospitals, also face fraud
For many healthcare providers, the greatest and abuse enforcement by the Internal Revenue
enforcement threat comes not from the govern- Service (IRS). To be eligible for recognition of
ment but from private individuals who act as charitable status, the IRS requires that healthcare
whistleblowers. Federal legislation enables them organizations refrain from letting their activities
to bring civil claims for fraud committed against “inure” to the benefit of private individuals.
the government in a type of suit known as a qui Payments to induce referrals are considered to rep-
tam action. Once such an action is filed, govern- resent such private inurement. Hospitals that are
ment prosecutors may choose to proceed, or they found to have engaged in this practice are subject
may leave it to the original whistleblower to do so, to fines and, in egregious cases, to loss of their tax-
generally through his or her own attorney. If a exempt status.
claim succeeds, the claimant is entitled to a por- Various authorities at the state level enforce the
tion of the recovery equal to 15% to 25% if the fraud and abuse prohibitions concerning private
government conducts the litigation and 25% to insurance, Medicaid, and SCHIP. These include
30% if it is pursued privately. In a large prosecu- the departments of health, welfare, and insurance.
tion, this can amount to a substantial sum. Qui State offices of attorneys general usually play the
tam actions represent an ever-present hazard for role of the DOJ when enforcement actions reach
providers, as they can be initiated not only by the courts.
members of the public but also by employees and
competitors.
Future Implications
The presence of fraud and abuse in healthcare
Enforcement Agencies
stems from the large amount of money that is avail-
Two federal agencies hold primary authority for able through public and private insurance to reim-
enforcing the laws against fraud and abuse. The burse services. This money creates a temptation for
424 Free Clinics
unscrupulous providers and patients to try to Field, Robert I. Health Care Regulation in America:
obtain more than a legitimate share. Because of the Complexity, Confrontation and Compromise. New
complicated nature of healthcare services and of York: Oxford University Press, 2007.
the procedures through which they are billed, the Furrow, Barry R., Thomas L. Greaney, Sandra H. Johnson,
legal directives that forbid fraud and abuse and the et al. Health Law. 5th ed. St. Paul, MN: West, 2004.
processes through which these directives are Jost, Timothy S., and Sharon L. Davies. “The Empire
enforced are marked by complexity and changing Strikes Back: A Critique of the Backlash Against
interpretations. Fraud and Abuse Enforcement,” Alabama Law
Review 51(1): 239–309, Fall 1999.
The incentive to overbill exists primarily within
Stanton, Thomas H. “Fraud-and-Abuse Enforcement in
insurance arrangements that reimburse providers
Medicare: Finding Middle Ground,” Health Affairs
on a fee-for-service basis—that is, with a discrete
20(4): 28–42, July–August 2001.
payment for each healthcare service rendered.
Thornton, D. McCarty. “Perspectives on Current
Some alternative mechanisms avoid this induce- Enforcement: ‘Sentinel Effect’ Shows Fraud Control
ment, most notably capitation under managed Works,” Journal of Health Law 32(4): 493–502,
care, in which a provider is paid the same amount Fall 1999.
for each patient regardless of the quantity of ser- Torras, Hoyt W. Health Care Fraud and Abuse: A
vices that are actually provided. Under such Physician’s Guide to Compliance. 2d ed. Chicago:
arrangements, overtreatment, inflation of bills, and American Medical Association Press, 2003.
payments for referrals no longer generate financial United States v. Greber, 760 F.2d 68, 71–72
returns. If this kind of reimbursement paradigm (3d Cir. 1985).
spreads further, fraud and abuse enforcement in its
traditional form may fade in importance. However,
it may be replaced with an opposite concern, that Web Sites
of undertreatment, and with it, new challenges for
policymakers and government agencies.
Fraud and abuse enforcement policy, therefore,
can be seen to reflect the underlying economic
http://www.kff.org
dynamics of the healthcare industry. As the indus- Public Citizen’s Health Research Group:
try’s structure evolves, legal doctrines will, as well. http://www.citizen.org/hrg
The resulting interplay presents health services U.S. Department of Health and Human Services (HHS),
researchers with opportunities to better under- Office of Inspector General (OIG):
stand the relationships between financial incen- http://www.oig.hhs.gov
tives, healthcare business practices, and policy U.S. Department of Justice (DOJ): http://www.usdoj.gov
responses. U.S. Government Accountability Office (GAO):
http://www.gao.gov
Robert I. Field
See also Antitrust Law; Centers for Medicare and

Medicaid Services (CMS); Medicaid; Medicare; Moral
Hazard; Regulation; State Children’s Health Insurance
Program (SCHIP)
Free Clinics
Free clinics are community-based entities that pro-
vide healthcare services mostly to uninsured peo-
Further Readings ple at little or no cost to their patients. Free clinics
Becker, David J., Daniel P. Kessler, and Mark B. are organized as private, nonprofit organizations
McClellan. “Detecting Medicare Abuse,” Journal of (or programmatic components of nonprofit orga-
Health Economics 24(1): 189–210, January 2005. nizations). They are run by volunteer, licensed
Crane, Thomas S., Patric Hooper, Robert L. Roth, et al. healthcare professionals who deliver basic medical
Health Care Fraud and Abuse: Practical Perspectives. services, but the clinics often have a small paid
Chicago: American Bar Association, 2002. staff to support their volunteer infrastructure. Free
Free Clinics 425
clinics tend to be located in permanent stand-alone Research

facilities or mobile units or housed in borrowed or
Despite their long history and broad geographic
rented spaces, such as church basements or home-
distribution, free clinics have received little atten-
less shelters. They may be independent entities or
tion from health services researchers, largely due
part of or affiliated with another nonprofit orga-
to a dearth of publicly available data and a lack of
nization (e.g., church, hospital, or social service
consensus about what constitutes a free clinic.
agency). Free clinics also are supported mostly by
Notably, the national Institute of Medicine’s
private sources of funding.
(IOM) seminal study on the nation’s safety net
America’s Health Care Safety Net: Endangered
History but Intact (2000) does not even mention free clin-
ics. Consequently, there is very little understand-
The American Medical Association (AMA)
ing about the roles that free clinics play in the
shunned the free-clinic movement of the 1960s,
nation’s ambulatory healthcare safety net.
the era when the number of free clinics grew rap-
idly. Since 1994, however, official AMA policy has
supported free clinics. Free clinics are now a pre- The Uninsured and the
ferred model that private physicians adopt to Ambulatory-Care Safety Net
provide care for the growing numbers of unin-
sured and underserved individuals. In the mid- It is estimated that 47 million persons in the United
1990s, the Robert Wood Johnson Foundation States have no health insurance coverage. It is
(RWJF) funded 40 projects through a $12 million widely reported that uninsured individuals delay
initiative to encourage private physicians to or forgo needed or preventive healthcare often
improve access to care for the uninsured and because the cost of obtaining care is prohibitive.
underinsured. Under this RWJF grant program, Free clinics are one choice among a range of other
physicians in nearly one of every three projects choices—including private physicians, federally
chose a free-clinic model as a method to improve qualified health centers (FQHCs), public clinics,
access to healthcare. Free clinics may have emerged hospital outpatient departments, academic medical
initially to treat “outsiders” (e.g., drug addicts centers, and hospital emergency rooms—that unin-
and runaway youth), as exemplified by the Haight sured patients have when seeking a source of pri-
Ashbury Free Clinics in San Francisco, a free mary care. Except for free clinics, most sources of
medical clinic situated at the epicenter of the care for uninsured patients require (often substan-
1960s hippie movement, founded to serve patient tial) cost sharing from patients. In most ambulato-
populations who identified with the countercul- ry-care settings, uninsured patients are charged a
ture. However, many free clinics now serve less flat fee or an amount according to a sliding fee
marginalized segments of the population, such as scale based on a family’s income. Ambulatory pro-
low-income individuals who cannot afford health viders also generally bill patients. In contrast, free
insurance, and underinsured patients. Many free clinics distinguish themselves from these other
clinics today target their services to the so-called primary-care providers by offering their care for
working poor. Thus, in the past 40-plus years, free free or for a nominal fee and by not billing patients.
clinics have redefined “needy” to include the Free clinics are, therefore, one of the few viable
medically indigent or underserved, a much broader options available to uninsured patients with lim-
spectrum of patients than in the past. ited funds.
Over the years, the number of free clinics in the
nation has grown exponentially, from 59 in the
Free Clinics Versus Federally
1960s to more than 1,000 in the 2000s. However,
Qualified Health Centers
their precise number is unknown. Free clinics are
found in every state except Alaska. The number of To appreciate the niche that free clinics fill in the
free clinics in the states varies widely, from 1 free ambulatory care safety net, it is illustrative to
clinic each in Delaware, Hawaii, and Rhode Island compare free clinics with FQHCs, because they
to more than 70 free clinics in North Carolina. are most analogous to (and often confused with)
426 Free Clinics
free clinics. Free clinics have essential features that Reportedly, free clinics do not bill patients for
distinguish them from these health centers. services. In contrast, as part of their mandate to
Specifically, free clinics annually raise $300 mil- maximize revenue from all sources, including
lion in private funds to serve an estimated 3.5 mil- patients who are uninsured/self-pay, health centers
lion uninsured and underinsured patients, according routinely bill patients for services.
to the National Association of Free Clinics. In Free clinics tend to rely mostly on private
2006, the $1.8 billion federal health center program sources of funding for their operating budget.
supported roughly 1,000 health center grantees, Most of the clinics receive no revenues (or very
which accounted for approximately 4,000 sites. little) from government sources. By comparison,
Collectively, these health centers served 15 million health centers receive the majority of their fund-
patients, of whom 6 million were uninsured. ing from government sources. Federal appropria-
Free clinics seek to serve the uninsured. Many tions to health centers account for approximately
only see patients who are uninsured. In contrast, one fifth of a health center’s revenues, and
approximately 40% of health center patients are Medicaid accounts for more than one third. Very
uninsured; the majority of patients are insured, few free clinics bill for third-party reimbursement
principally by Medicaid. from insurers.
Free clinics target the working poor. Many target Last, free clinics rely on volunteer, licensed health-
patients who are unlikely to qualify for public care professionals to deliver services. A small paid
health insurance programs. Often these patients staff often supports their volunteer infrastructure. In
have incomes between 100% and 200% of the fed- contrast, the core clinical staff members operating in
eral poverty level. In contrast, health centers serve health centers are paid, full-time employees.
mostly poor patients who qualify for Medicaid.
Reportedly, free clinics do not charge patients
Heterogeneity of Free Clinics
based on their ability to pay. By comparison, health
centers are required to use a sliding fee scale based A commonly repeated saying in the free-clinic
on a patient’s income and family size. The amount sector—“If you’ve seen one free clinic, you’ve
of the sliding fee scale is set by each clinic and var- seen one free clinic”—aptly describes the great
ies widely but ranges from $20 to about $100. variety of clinics that comprise the population of
Free clinics provide a limited range of health- free clinics. Free clinics span a continuum from
care services on-site. They deliver free services those that see a limited number of walk-in patients
on-site as well as make arrangements for patients one night per week to others that provide compre-
to receive free care from formal networks of hensive primary care services to thousands of
referral providers. Most free clinics provide ser- patients annually with the support of full-time,
vices such as physical examinations, urgent/ paid staff and a multimillion-dollar operating
acute care, chronic disease management, medica- budget. The considerable diversity in the free-
tions, and health education on-site. Often ser- clinic model makes it difficult to draw conclusions
vices are available through a referral arrangement. about the adequacy of individual free clinics to
By comparison, health centers are required to meet the needs of uninsured patients. The differ-
provide comprehensive primary-care services. ences seen across free clinics suggest that the mer-
The scope of services is specified by law and in its of these clinics must be evaluated on a
regulations. case-by-case basis.
Most free clinics are not open full-time.
Furthermore, their patients generally cannot con-
Current and Future Trends
tact a clinic provider after-hours, when the clinic is
closed. In contrast, health centers are generally Having existed for many decades but remaining
open full-time. Furthermore, they are expected to fairly invisible, free clinics today are garnering
ensure telephone access to another health center or more attention as they become more formalized.
community provider when the clinic is closed and The National Association of Free Clinics, a mem-
to have procedures in place for patients who need bership organization representing free clinics, was
care to be seen. established in 2001. State and regional free-clinic
Fuchs, Victor R. 427
associations predate the national association. The Geller, Stephanie, Buck M. Taylor, and H. Denman Scott.
24 state and regional free-clinic associations today “Free Clinics Helping to Patch the Safety Net,”
encompass 33 states. Twenty-two states operate Journal of Health Care for the Poor and Underserved
their own free-clinic associations. The first state 15(1): 42–51, February 2004.
association, the Virginia Association of Free Gusmano, Michael K., Gerry Fairbrother, and Heidi
Clinics, was founded in 1993. Signifying the prog- Park. “Exploring the Limits of the Safety Net:
ress toward standardization, the free-clinic asso- Community Health Centers and Care for the
ciation in Virginia has developed a process to Uninsured,” Health Affairs 21(6): 188–94,
November–December 2002.
certify free clinics. Virginia’s certification process
Isaacs, Stephen L., and Paul Jellinek. “Is There a
has been replicated, in part, by Ohio.
(Volunteer) Doctor in the House? Free Clinics and
Free clinics’ visibility also is enhanced by their
Volunteer Physician Referral Networks in the United
increasing participation in government programs.
States,” Health Affairs 26(3): 871–76, May–June
Historically, free clinics have eschewed govern- 2007.
ment involvement, and today most free clinics do Jacobson, Peter D., Vanessa K. Dalton, Julie Berson-
not receive any funding from government sources. Grand, et al. “Survival Strategies for Michigan’s
But in response to the Health Insurance Portability Health Care Safety Net Providers,” Health Services
and Accountability Act of 1996 (HIPAA), which Research 40(3): 923–40, June 2005.
extends federal medical malpractice coverage to National Academy of Sciences, Institute of Medicine.
volunteer healthcare professionals at free clinics, America’s Health Care Safety Net: Endangered but
more than 2,000 health professionals at 73 spon- Intact. Washington, DC: Institute of Medicine, 2000.
soring free clinics have been deemed eligible for Scott, H. Denman, Johanna Bell, Stephanie Geller, et al.
medical malpractice protection under the Federal “Physicians Helping the Underserved: The Reach Out
Tort Claims Act (FTCA) as of 2007. To be eligible Program,” Journal of the American Medical
for FTCA coverage, free clinics must maintain a Association 283(1): 99–104, January 5, 2000.
risk management system and providers must meet
privileging and certification requirements. These
requirements introduce bureaucratic red tape, Web Sites
which free clinics historically have shunned.
National Association of Free Clinics:
These recent developments suggest that the free
http://www.freeclinics.us
clinics of the future may be different in important
Rx Assist: http://www.rxassist.org
ways from those of the past. Continued monitor-
Tap-In: http://tap-in.org
ing of free clinics is needed to account for the Volunteers in Medicine:
changing healthcare environment and its impact http://www.volunteersinmedicine.org
on the free-clinic sector.
Julie S. Darnell
See also Access to Healthcare; American Medical

Association (AMA); Federally Qualified Health
Fuchs, Victor R.
Centers (FQHC); Health Insurance Portability and
Accountability Act of 1996 (HIPAA); Primary Care; Victor R. Fuchs is a leading health economist who
Robert Wood Johnson Foundation (RWJF); Safety is perhaps best known for his work Who Shall
Net; Uninsured Individuals Live? Health, Economics, and Social Choice,
which provides healthcare professionals and poli-
cymakers with the tools to understand the eco-
Further Readings nomic and policy problems in healthcare that have
Casey, Michelle, Lynn A. Blewett, and Kathleen T. Call. emerged in recent decades. Fuchs is the Henry J.
“Providing Health Care to Latino Immigrants: Kaiser, Jr., Professor Emeritus at Stanford University,
Community-Based Efforts in the Rural Midwest,” senior fellow in the Freeman Spogli Institute for
American Journal of Public Health 94(10): 1709–11, International Studies, and a core faculty member in
October 2004. the Center for Health Policy/Primary Care and
428 Fuchs, Victor R.
Outcomes Research at Stanford. Fuchs is also a University. He is also a past president and distin-
research associate of the National Bureau of guished fellow of the American Economic
Economic Research (NBER). Association and holds elected memberships or fel-
Fuchs received his bachelor of science degree in lowships in the American Philosophical Society,
business administration from New York University the American Academy of Arts and Sciences, and
and a master’s and a doctoral degree in economics the National Academy of Sciences, Institute of
from Columbia University. Fuchs began his profes- Medicine (IOM).
sional career as a faculty member at Columbia His current research examines the attitudes and
University and New York University. He later was beliefs in public support for national health insur-
a program associate for the Ford Foundation ance. He is developing a proposal for a universal
Program in Economic Development and Adminis healthcare voucher system in which all individuals
tration, scholar-in-residence at the Rockefeller would receive a government voucher that would
Foundation in Lake Como, Italy, and fellow at the guarantee coverage in a private health plan with
Center for Advanced Study in the Behavioral standardized benefits.
Sciences in Stanford, California. In 1968, Fuchs
joined the faculty at the Mount Sinai School of Renardis Banks
Medicine as professor of community medicine and See also Cost of Healthcare; Health Economics; National
the City University of New York Graduate Center Health Insurance; Pay-for-Performance; Payment
as professor of economics and served as vice presi- Mechanisms; Physicians; U.S. National Health
dent of the National Bureau of Economic Research Expenditures
(NBER). In 1974, he accepted a position at
Stanford University, where he continues to teach
and conduct research. Further Readings
Fuchs’s work involves applying economic Fuchs, Victor R. The Future of Health Policy.
analysis to solve social problems of national con- Cambridge, MA: Harvard University Press, 1993.
cern, with an emphasis on health and medical Fuchs, Victor R. “Economics, Values, and Health Care
care. He has been particularly interested in the Reform,” American Economic Review 86(1): 1–24,
influence of financial incentives on physician March 1996.
behavior and its relation to healthcare expendi- Fuchs, Victor R. Who Shall Live? Health, Economics, and
tures. He has published extensively on topics Social Choice. River Edge, NJ: World Scientific, 1998.
such as the cost of medical care and the determi- Fuchs, Victor R. “Health Care Expenditures
nants of health, with particular focus on the role Reexamined,” Annals of Internal Medicine 143(1):
of socioeconomic factors. His scholarly work has 76–78, July 5, 2005.
resulted in 15 books and more than 180 articles Fuchs, Victor R. “What Are the Prospects for Enduring
and papers. Comprehensive Health Care Reform?” Health Affairs
Fuchs’s contributions have been recognized 26(6): 1542–44, November–December 2007.
through many awards and honors, including the
John R. Commons Award from the Omicron Delta
Epsilon, the Emily Mumford Medal for Dis Web Sites
tinguished Contributions to Social Science in National Bureau of Economics Research (NBER)
Medicine from Columbia University, the Distin Working Papers: http://www.nber.org/cgi-bin/
guished Investigator Award from the Association author_papers.pl?author=victor_fuchs
for Health Services Research, the Baxter Foundation Stanford Center for Health Policy/Center for Primary
Health Services Research Prize, and the Madden Care and Outcomes Research:
Distinguished Alumni Award from New York http://healthpolicy.stanford.edu/people/victorrfuchs
G
programs for this new entity were global health,
Gates Foundation education, libraries, and the Pacific Northwest.
In 2006, the foundation reorganized, focusing its
The Bill and Melinda Gates Foundation is the giving on three areas: global development, global
largest private philanthropic foundation in the health, and the United States. The same year, the
world. With assets in excess of $38.9 billion in investor and philanthropist Warren Buffett
2007, the foundation focuses its grant-making made a lifetime pledge to the foundation of
and advocacy efforts on eliminating global inequi- Berkshire Hathaway stock, valued at $31 billion.
ties and increasing opportunities for those in need. At this time, the foundation also changed its
In 2007, it contributed more than $1.5 billion to structure, creating the Bill and Melinda Gates
programs that addressed global agricultural and Foundation Trust to manage and invest the
economic development, medical research and endowment assets. The foundation is based in
public health initiatives in developing countries, Seattle, Washington, with offices in Washington,
and the improvement of education and access to D.C., and Beijing, China.
information in the United States.
Program Areas
Background
Since 2006, the Bill and Melinda Gates Foundation
Bill Gates, Microsoft’s cofounder, and his wife, has focused on three main program areas: the
Melinda, established the William H. Gates Global Development program, the United States
Foundation in 1994, which focused its charitable program, and the Global Health program. These
giving on advancing global health and the com- programs all strive to accomplish the foundation’s
munity of the Pacific Northwest. Gates’s father, mission to increase equity and opportunity to
William, managed the activities of this entity. those populations that are most in need.
Three years later, the Gates Library Foundation
was created, which aimed at improving access to
Global Development
public libraries for low-income families in North
America. It was later renamed the Gates Learning The Global Development program, the newest
Foundation to reflect its expansion into broader of the foundation’s programs, strives to eliminate
education efforts. extreme poverty and hunger. In its 1st year,
The Bill and Melinda Gates Foundation was the program’s grant-making activities totaled
established in 2000 through the merger of the $170,304,000, and in 2007, the foundation paid
two Gates foundations. The original priority $308,041,000 in grants in this area.
429
430 Gates Foundation
Through strategic partnerships and grant- program’s established purview. These activities
making activities in its agricultural development help shape potentially new directions for the pro-
initiative, the program helps increase opportunities gram. The program also handles advocacy for the
for farmers in developing countries, as well as foundation’s efforts in this country.
researching the production of rice and flour
enriched with micronutrients. The Global
Development program also has an initiative aimed Global Health
at increasing financial services to the poor; it funds The Global Health program is the largest of the
projects that examine the effectiveness of loans, Bill and Melinda Gates Foundation programs. It is
insurance, financial planning, and financial educa- committed to addressing the high mortality and
tion in impoverished countries. morbidity rates from preventable diseases in devel-
In addition to these two key initiatives, the oping countries; it focuses on funding to projects
Global Development program is committed to that would increase access to existing vaccines and
global libraries, supporting public libraries and treatments for common diseases and researching
organizations that work to increase access to infor- new, affordable, and practical health solutions. In
mation technology. Finally, the program’s Global 2007, the program paid $1,220,008,000 in grants
Special Initiatives awards grants to organizations in this area.
that research issues of concern to the developing Projects funded by the Global Health program
world, including water, sanitation, and hygiene. address prevention and treatment of diseases that
meet three criteria: (1) they cause widespread ill-
ness and death in developing countries, (2) they
United States Program
represent the greatest inequities in health between
The United States program is dedicated to developed and developing countries, and (3) they
reducing inequities that exist in this country for receive inadequate attention and funding. The
low-income, minority, and vulnerable populations. foundation’s priority diseases and conditions are
The program also aims to increase opportunities acute diarrheal disease, acute lower-respiratory
for these populations. In 2007, the program paid a infections, child health, HIV/AIDS, malaria, poor
total of $483,626,000 in grants. nutrition, reproductive and maternal health, tuber-
The United States program houses the founda- culosis, vaccine-preventable diseases, and other
tion’s education initiative, which focuses on keep- infectious diseases.
ing young students from dropping out of school Also through the Global Health program, the
and better preparing high school graduates for breakthrough science initiative funds projects that
college. This program also oversees the activities advance health research and technologies in the
of the public libraries initiative, which strives to developing world. This initiative supports the
provide access to computers and the Internet at development of affordable and accurate medical
local public libraries; this initiative also aims to tools. The foundation’s Grand Challenges in Global
keep technology systems up-to-date for libraries Health is part of this initiative.
and provide adequate training and support for In addition to the disease-specific and special
this technology. Showing a continued commit- initiatives, the program also handles the founda-
ment to the foundation’s immediate community, tion’s global health advocacy efforts and global
the Pacific Northwest initiative addresses the health interventions at the local community level
issues of inequity and opportunity for families and provides immediate support for natural disas-
and children living in Washington and Oregon. ter and emergency relief.
This initiative’s activities include supporting proj-
ects that work with at-risk youth and helping to
Future Implications
reduce homelessness among families in the
region. As the world’s largest private foundation, the
Beyond these three initiatives, the United States Bill and Melinda Gates Foundation is poised to
program also includes activities for special initia- make a major impact in the areas of global policy,
tives that identify needs that fall outside the global health, education, and access to information
General Health Questionnaire 431
technology. Since 2006, when the Bill and Melinda considered to be a significant advancement in
Gates Foundation Trust was established, the psychiatric epidemiology since general practitio-
pledge from Warren Buffett was received, and the ners did not diagnose their patients with signifi-
announcement was made that the charity has a set cant psychiatric illness in the 1970s. Recognizing
lifespan of 50 years after the deaths of its found- the need for physicians to test and assess their
ers, the foundation has developed a strategic outpatients and make a tentative diagnosis of men-
look to maximize its charitable giving. Because of tal illness, David Goldberg at the Institute of
criticism of its investment practices—namely, that Psychiatry, London, developed and published
several corporations in the foundation’s portfolio the GHQ.
are not environmentally and socially conscious
and may contribute to global development and
Overview
health problems, the foundation is currently reas-
sessing its investment practices. The GHQ was designed as a self-administered
In July 2008, Bill Gates stepped down from his screening instrument with the ability to differenti-
position at Microsoft to devote his efforts full-time ate psychiatric patients from healthy individuals
to the Bill and Melinda Gates Foundation. With within a community. However, the GHQ is not
this change, the foundation may identify addi- concerned with making a specific psychiatric diag-
tional priority areas or increase its activities. nosis. The GHQ was originally developed as a
60-item instrument. Currently, there are four short
Kathryn Langley ened versions available. In addition, the GHQ has
See also Computers; Ethnic and Racial Barriers to
been translated into 38 languages, and it has been
Healthcare; Health Disparities; Infectious Diseases; extensively used in both research and clinical
Preventive Care; Public Health; Vulnerable Populations practice. Furthermore, this survey instrument has
been validated cross-culturally in many adult
populations across the world.
Further Readings
Bill and Melinda Gates Foundation. Annual Report Rating Scale
2007. Seattle, WA: Bill and Melinda Gates Each item on the GHQ is rated on a 4-point scale:
Foundation, 2008.
less than usual, no more than usual, rather more
Fleishman, Joel L. The Foundation: A Great American
than usual, or much more than usual. For example,
Secret: How Private Wealth Is Changing the World.
the GHQ-12 gives a total score of 36 or 12 based on
New York: Public Affairs, 2007.
the selected scoring methods. One of the most com-
mon scoring methods used is the bimodal method,
where the responses are assigned the numeric values
Web Sites
of 0-0-1-1. Another method is the Likert scoring
Berkshire Hathaway, Inc.: http://www. style, which assigns the values as 0-1-2-3.
berkshirehathaway.com/donate/webdonat.html The areas of mental health that are assessed by
Bill and Melinda Gates Foundation: the original version of the GHQ include depres-
http://www.gatesfoundation.org sion and anxiety, social functioning, psychophys-
iologic symptoms, general health, and vague
aches and pains. The internal consistency of the
GHQ is reported to be in the range of 80% to
General Health Questionnaire 90%, which indicates the high reliability of the
instrument. Additionally, the coefficients of cor-
The General Health Questionnaire (GHQ) was relation with global clinical assessments of psy-
developed to assess the extent of psychiatric ill- chopathology are in the range of .55 to .83,
ness in general practice. Contrary to what the indicating high validity. The overall sensitivity
name suggests, this questionnaire does not assess has been reported to be about 68% with a speci-
general health but mental health. The GHQ is ficity of about 81%.
432 General Health Questionnaire
Factors Assessed The GHQ has also been adapted for different
populations and cultures. There are three main
The GHQ assessment focuses on breaks in nor-
reasons that account for the interest in adapting
mal functioning rather than lifelong traits. The
this instrument to different samples and lan-
GHQ is based on two major classes of phenome-
guages. First, the GHQ-28 has the advantage of
non that occur in patients with psychiatric illness.
being shorter, with approximately 3 to 5 minutes
First, it assumes that patients with psychiatric ill-
required for the full questionnaire to be filled
ness are not able to carry out normal healthy
out. Additionally, it can be applied to primary-
functions. Furthermore, it assumes that such
care settings, where the majority of minor psy-
patients have episodes of distress. The items in the
chiatric disorders arise. Furthermore, apart from
GHQ concentrate on the specific spectrum
providing an overall assessment, the GHQ-28
between psychiatric disturbance and normal func-
contains four scales that furnish additional
tioning, rather than ranging over the whole array
information.
of mental health from normality to severe distur-
bance. Respondents are not asked how long they
have experienced symptoms. As a result, disor- Use
ders with less than 2 weeks’ duration are included.
In contrast, the Diagnostic and Statistical Manual The GHQ has been used in different settings for
of Mental Disorders (DSM-IV), another diagnos- various purposes, including within clinical-prac-
tic instrument for assessing the severity of depres- tice settings for research studies and clinical trials
sion requires that symptoms be present in a and in population-based epidemiological studies.
respondent for at least 2 weeks to be included as The use of GHQ and its versions is protected by
a positive symptom of depression. Certain demo- copyrights held by David Goldberg and the
graphic variables also affect the GHQ scores, Institute of Psychiatry, London. The GL Assessment
while some do not. For example, females who are acts on behalf of the original copyright holders,
divorced or separated, unemployed, or living in and it allows researchers to use the GHQ after
urban areas generally have higher scores than paying user fees and signing various legal agree-
women who are not in the same situation. Age ments. Based on the study design and the context
and social class, however, do not have a strong of use, there is also a provision to use GHQ free
effect on the GHQ score. of cost.
Future Implications
Versions
The GHQ has been used to assess the mental
Several versions of the GHQ are available. These health status of individuals and populations for
include the GHQ-60, the fully detailed 60-item more than three decades. The GHQ has also been
questionnaire; the GHQ-30, a short form without translated and validated across many languages
items relating to physical illness; the GHQ-28, a and cultures. A general note of caution should be
28-item scaled version that assesses somatic symp- exercised in using the GHQ or in interpreting the
toms, anxiety, insomnia, social dysfunction, and results from this survey in the clinic setting,
severe depression; and the GHQ-12, a quick, reli- because it does not differentiate between different
able, and sensitive short form, which is ideal for types of mental illness. Among all the different
research studies. versions of the GHQ, the 12-item short form
In terms of validity, reliability, and prediction, remains a quick, reliable, and sensitive question-
the 60-item version has been shown to outperform naire, making it ideal for research studies. In addi-
the shorter counterparts. The 12-item and the tion, it has been shown that the use of GHQ by
30-item versions have been more widely used in general practitioners can increase their ability to
community samples because they are brief and recognize hidden psychiatric morbidity and a new
take less time to complete. Over the past 10 years, episode of illness.
the GHQ-28 has become a widely used question-
naire in epidemiological studies. Vikrant Vats
General Practice 433
See also Diagnostic and Statistical Manual of Mental a long-term relationship with patients; providing
Disorders (DSM); Health Surveys; Measurement in patient-centered, comprehensive and cost-effective
Health Services Research; Mental Health; Mental care; and identifying and addressing the family
Health Epidemiology; Short-Form Health Surveys and psychosocial factors that affects the health
(SF-36, -12, -8)
and wellness of patients. A general practitioner
(GP) is a physician who practices family medicine
and provides primary care to patients to treat
Further Readings
acute and chronic illnesses, as well as providing
Hankins, Matthew. “The Reliability of the Twelve-Item routine preventive care and health education.
General Health Questionnaire Under Realistic
Assumptions,” BMC Public Health 8(1): 355–61,
October 14, 2008.
Overview
Hu, Yongjian, Sarah Stewart-Brown, Liz Twigg, et al. With a mission to preserve and promote the sci-
“Can the 12-Item General Health Questionnaire Be ence and art of family medicine and to ensure
Used to Measure Positive Mental Health?” high-quality, cost-effective healthcare for patients
Psychological Medicine 37(7): 1005–13, July 2007. of all ages, the American Academy of Family
Ouimette, Paige, Michael Wade, Annabel Prins, et al. Practice (AAFP) was founded in 1947. Family
“Identifying PTSD in Primary Care: Comparison of practice was officially recognized in February
the Primary Care-PTSD Screen and the General 1969 as the 20th primary medical specialty. With
Health Questionnaire-12,” Journal of Anxiety
this new designation came added responsibility.
Disorders 22(2): 337–43, March 2008.
Training and preparation for family practitioners
Picardi, Angelo, Damiano Abeni, Eva Mazzotti, et al.
was standardized to include a wide variety of
“Screening for Psychiatric Disorders in Patients With
medical disciplines, including general internal
Skin Diseases: A Performance Study of the 12-item
General Health Questionnaire,” Journal of
medicine, women’s health and obstetrics, infec-
Psychosomatic Research 57(3): 219–33, September
tious disease, pediatrics, newborn care, emer-
2004. gency medicine, surgery and its subspecialties,
Willmott, Sasi A., Jed A. P. Boardman, Carol A. ophthalmology, dermatology, otolaryngology,
Henshaw, et al. “The Predictive Power and and more. Office-based training of the fledgling
Psychometric Properties of the General Health family practice physician became a high priority
Questionnaire (GHQ-28),” Journal of Mental Health to maintain wellness and decrease rising hospi-
17(4): 435–42, August 2008. talization rates. Recently, family practice train-
ing programs have collaborated within their
respective communities and academic institu-
Web Sites tions to offer more hospital-based care to their
patient populations, ensuring greater continuity
American Psychiatric Association (APA):
of care for the patients. This programmatic phi-
http://www.psych.org
losophy for more hands-on experience with
GL Assessment: http://www.gl-assessment.co.uk
inpatient care instead of training in outpatient
National Institute of Mental Health (NIMH):
http://www.nimh.nih.gov
care has been necessary because of the increasing
fragmentation of the healthcare system in the
United States and the rising costs associated with
healthcare.
Family and general practitioners are often the
General Practice first point of contact for people seeking healthcare,
and these providers generally act as the traditional
General practice, also known as family practice or family physician. In general practice, a wide range
family medicine, and more recently termed pri- of medical services is typically available, including
mary care, is the field of medicine dedicated to newborn and well-child care, age-appropriate vac-
caring for people of all ages. The principles and cinations, and care of the sick child as needed.
philosophy of general practice include establishing Adolescent and young-adult care, along with
434 General Practice
appropriate counseling tailored to this formative such as Canada, which has a higher percentage of
period in life, completes the care of children as medical students who enter training programs in
they progress into adulthood. Most physicians in primary care, the United States spends much more
general practice also offer care to women of child- on healthcare. By investing in the training and
bearing age, which includes services during pre- retention of general practitioners and the promo-
conception and pregnancy as well as care of the tion of this field, the United States may be able to
newborn. Additionally, one quarter of general improve health outcomes and decrease health
practitioners have incorporated obstetrical care expenditures.
into their practices, which involves the delivery of With the rise in medical specialties and subspe-
the newborn and immediate care of the mother cialties and financial incentives that encourage
following the birth. Mainstream adult care of medical specialization, the number of general-
people 25 years of age and above, along with care practice physicians in the United States has been
of the elderly, is the main purview of physicians in declining in recent years. The Bureau of Labor
general practice. Comprehensive physical exams, Statistics (BLS) estimates that about 40% of physi-
screening tests, treatment of common and acute cians are primary-care providers; however, family
conditions, management of chronic disease, coor- and general practitioners represent just over 12%
dination of allied healthcare, and even home care of this group.
are all a part of the routine health maintenance
functions that form a common thread in general
Future Implications
practice.
The strength of general practice lies in the General practitioners play a pivotal role in the
relationships forged between the patient and the healthcare system as the primary deliverers of
physician. This bond allows the patient to feel care. The need for general practitioners of family
comfortable revealing confidential, discreet medicine will continue to grow as the population
problems of both physical and psychological ages and there is a greater emphasis on preven-
origin. This type of relationship most often helps tive healthcare. Public policies that encourage
identify medical and health concerns in their increasing the number of providers of general
early stages, which reliably leads to a satisfac- practice are needed to address the current short-
tory resolution of the issue or a timely referral to age and to ensure adequate access to healthcare
specialty services if necessary. Communication for everyone.
between the patient and the physician and
between the physician and other healthcare pro- Samuel N. Grief
viders is the key to successful general practice of See also Access to Healthcare; Acute and Chronic
medicine. Diseases; American Academy of Family Physicians
The advantages of family practice and general (AAFP); Cost of Healthcare; Physicians; Primary Care;
practitioners lie in their ability to help decrease the Primary-Care Case Management (PCCM); Primary-
financial burden faced by every U.S. resident. Care Physicians
Nations that have an adequate supply of family
practice physicians and general practitioners expe-
rience significant financial rewards and lower costs Further Readings
of healthcare. General practice is traditional medi- De Maeseneer, Jan M., Lutgarde De Prins, Christiane
cal care that is not only the most cost-effective in Gosset, et al. “Provider Continuity in Family
comparison with other medical fields but also Medicine: Does It Make a Difference for Total Health
associated with better health outcomes. Twenty- Care Costs?” Annals of Family Medicine 1(3):
eight nations, including Cuba, New Zealand, and 144–48, September–October 2003.
most of the European countries, had lower infant Fairburst, Karen E., and Carl May. “What General
mortality rates than the United States. The United Practitioners Find Satisfying in Their Work:
States also ranks fairly low in terms of overall life Implications for Health Care System Reform,” Annals
expectancy and has a relatively high incidence of of Family Medicine 4(6): 500–505, November–
chronic disease. Compared with other nations December 2006.
Genetics 435
Green, Larry A., Susan M. Dovey, and George E. Fryer this has translated into better prediction, diagnosis,
Jr. “It Takes a Balanced Health Care System to Get It and drug development and hence better treatment
Right,” Journal of Family Practice 50(12): 1038–39, of many diseases, especially monogenic disorders
December 2001. such as hemophilia, cystic fibrosis, fragile X syn-
Martin, James C., Robert F. Avant, Marjorie A. drome, and Huntington’s disease. Unfortunately,
Bowman, et al. “The Future of Family Medicine: A similar medical advances remain to be seen in rela-
Collaborative Project of the Family Medicine tion to the genetic etiology of most common human
Community,” Annals of Family Medicine 2(Suppl. 1): diseases, such as hypertension, diabetes, cancer, and
S3–S32, March–April 2004.
age-related macular degeneration. As populations
Starfield, Barbara, Leiyu Shi, and James Macinko.
age, the relative burden of these conditions has gen-
“Contribution of Primary Care to Health Systems and
erally been on the rise.
Health,” Milbank Quarterly 83(3): 457–502,
Several reasons can be given to explain this situ-
September 2005.
ation in which current technology-driven advances
in molecular genetics have not proven to be con-
ceptual breakthroughs. In particular, population
Web Sites
and clinical scientists have not done enough to
American Academy of Family Physicians (AAFP): assess the utility of the new advances in molecular
http://www.aafp.org/online/en/home.html technology. The key challenge in genetics at this
American Board of Family Medicine (ABFM): time is to translate the information from genotyp-
http://www.theabfm.org ing and sequencing studies into clinically relevant
tools.
Genetics Developing an Evaluation Framework

To accurately evaluate the impact of molecular
Genetics is the study of the life blueprint (com- genetics on common diseases, appropriate crite-
monly referred to as DNA) that makes up the ria to assess the contribution to treatment and
genes (the fundamental units of heredity), which prevention must first be available. Key elements
are found in the human chromosomes. In total, of such an evaluation framework must provide
there are 23 pairs of chromosomes that make up answers to questions such as the following:
the human genome (the total package of heredity How do the answers provided by this new
information). Human molecular genetics focuses, research fit with what researchers already know?
among other things, on discovering and under- Can molecular tests provide new information
standing the inventory of human genes; their func- about prediction or risk stratification? Will it
tions; the effects of variation in their distributions help to tailor therapy? And will it yield insights
among different individuals; their roles in the eti- into pathogenesis and/or pathways? Answers to
ology of human diseases; and how such knowl- these and related evaluation questions will have
edge can be used to improve the prevention, to be provided by data from the different but
diagnosis, and treatment of human diseases. dependent stages of molecular genetic research,
Substantial progress has been made in the field of from discovery to application, as illustrated in
molecular genetics in the past several decades, and Figure 1.
Localize
Technology Define
susceptible Clinical
to sequence molecular
variants in application
a genotype mechanisms
the genome
Figure 1 Schematic of Stages in Molecular Genetic Research

436 Genetics
A pertinent question therefore becomes, What These proposed valuable outcomes from genetic
will the payoff be from finding disease susceptibil- research must be evaluated in light of the current
ity variants or loci? The first most likely outcome experience. In fact, up to this point, knowing the
is improved prediction and/or risk stratification. genotype has generally not been a useful guide to
Experience so far suggests that prediction is an therapy, even for monogenic disorders including
unlikely use of the knowledge of susceptibility loci. long QT syndrome, Marfan syndrome, Factor V
To be useful for diagnosis or risk stratification, Leiden—venous thrombosis, and hereditary hemo-
such a genetic test must substantially increase the chromatosis. The challenge remains to narrow the
posttest probability and also provide supplemental gap between the vision of personalized medicine
and independent information beyond currently and reality. This will involve making realistic esti-
available tests. Based on the assumption that indi- mates of the precision of individual prediction,
viduals known to be at high risk of developing a revisiting the trade-offs of the high-risk versus
disease will benefit from earlier, more intensive population strategy in the context of how genetic
intervention, either through lifestyle changes or screening will be used for common diseases,
drugs, risk stratification could also be an impor- describing and experimentally verifying the pro-
tant use of the knowledge of disease susceptibility cedures to move from anonymous genetic mark-
loci. However, in a situation where both exposure ers to causal variants, and describing how
and susceptibility are widespread, population-wide knowledge of pathways and mechanisms will
measures are often the most effective public health open new preventive and therapeutic options. All
strategy (e.g., smoking, high cholesterol). Likewise, these research efforts will entail potential costs.
measurement of the phenotype (e.g., high blood These costs could include diversion of resources
pressure) is likely to provide more information within the scientific research community away
than the genotype. from preventive interventions that already work,
fostering the impression that technology will
solve social problems, and a rekindling of the
Personalized Medicine
debate over biological determinism and racial/
Another area where identification of susceptibility ethnic health disparities. However, the seduction
variants will potentially be of benefit to public of even larger genetic studies appears poised to
health is tailored therapy. There are many neutral cause the diversion of already declining resources
variants in the human genome that have survived in the foreseeable future.
evolutionary selection and are now known to alter
drug metabolism or response. These variants
Future Implications
could therefore be responsible for the large indi-
vidual variation in toxicity as well as any thera- Based on these considerations, molecular medi-
peutic effect. This background variation constitutes cine’s role is likely to remain marginal in the con-
the potential basis for tailored therapy (sometimes trol of common diseases in the foreseeable future.
referred to as personalized medicine). At the same time, it is likely that a whole new
In addition, it is argued that in many instances dimension of biology will be learned, and this will
susceptibility genes will mimic pathogenesis. Under in some instances illuminate causal processes. In
this assumption, a description of the genetic basis some cases, prediction will be sufficiently precise.
for chronic illness will lead to a better understand- Some drug discovery will be possible, and this
ing of disease processes, including new physiologic should have a positive impact on the ability to
pathways that will create new opportunities for deliver more effective healthcare. However, there
interventions through prevention or drugs. These is a need for balanced and unbiased expectations
payoffs are, however, contingent on a thorough of the future contribution of genetics to medicine
understanding of the biology since genetic markers and public health, knowing that molecular medi-
cannot unravel pathways. It is important to note cine relies heavily on unproven assumptions of the
that knowledge of pathways or mechanisms is only potential for technology to solve health problems.
useful to public health if it leads to modifiable Some researchers argue that genomics may hold
exposures or drugs. the potential to advance the claims of a science
Geographic Barriers to Healthcare 437
belief system, over the pragmatic needs of the have a linear relationship relative to structural,
long-term movement, toward prevention through financial, personal, and geographic barriers. Major
the creation of a healthier environment as the geographic barriers to healthcare access include
most effective means to control common diseases. the following: shortage of healthcare service pro-
viders, clinics, and/or hospitals in the vicinity of a
Richard S. Cooper and Bamidele O. Tayo community; increased travel time to the nearest
See also Disease; Epidemiology; Evidence-Based Medicine
facility or provider; lack of transportation—slow,
(EBM); Forces Changing Healthcare; Public Health; erratic or nonexistent public transportation sys-
Risk; Technology Assessment tems; residing in public housing or mountainous,
rural, snowbound, or disaster areas; physical in-
ability to access facilities due to disability; sea-
Further Readings sonal barriers, such as excessive rainfall or snow;
and poor or nonexistent road systems.
Carlson, Rick J. “Preemptive Public Policy for The main tenet of preventive care is that regular
Genomics,” Journal of Health Politics, Policy and access to primary medical care reduces the need for
Law 33(1): 39–51, February 2008.
acute care. Geographic barriers to care have
Cooper, Richard S., and Bruce M. Psaty. “Genomics and
adverse implications both before and after an indi-
Medicine: Distraction, Incremental Progress, or the
vidual enters the realm of healthcare delivery,
Dawn of a New Age?” Annals of Internal Medicine
which can lead to considerable health disparities.
138(7): 576–80, April 1, 2003.
Offit, Kenneth. “Genomic Profiles for Disease Risk:
Geographic access is typically characterized as a
Predictive or Premature?” Journal of the American
measure of distance to care, with 30 minutes gener-
Medical Association 299(11): 1353–55, March 19, ally being viewed as the accepted maximum time to
2008. access healthcare. Access is influenced by the area
Skirton, Heather, Christine Patch, and Janet Williams. of an individual’s activity space; the spatial distri-
Applied Genetics in Healthcare: A Handbook for bution of healthcare facilities; and the spatial struc-
Specialist Practitioners. New York: Taylor and tures, such as mountains, lakes, and rivers, that act
Francis, 2005. as barriers. Distance can be measured from two
different perspectives. It can be considered from the
perspective of the suppliers, who look at the dis-
Web Sites tance to healthcare facilities. It also can be viewed
by the individuals, who determine how to obtain
American College of Medical Genetics (ACMG):
the services and how far to travel to receive health-
http://www.acmg.net//AM/Template.cfm?Section=Home3
care. A number of methods are used to calculate
National Human Genome Research Institute (NHGRI):
distance, such as the linear distance across a map,
http://www.genome.gov
National Library of Medicine (NLM), Genetics Home
road distance, travel time, perceived distance, per-
Reference: http://www.ghr.nlm.nih.gov
ceived travel time, and the distance to the nearest
National Office of Public Health Genomics: provider. Calculating distance alone, however, does
http://www.cdc.gov/genomics not take into account the variation in individual
mobility, preferences, and spatial habits; differ-
ences in road and travel conditions; and subjective
perceptions of distance—for example, younger
Geographic Barriers people may be more comfortable traveling longer
distances than the elderly, sick, or handicapped.
to Healthcare Healthcare utilization is frequently related to
travel time and distance. Research has shown that
Access to care can be defined as the timely use of long travel time due to poor transportation to or
personal health services to achieve the best possi- due to long distance from facilities decreases utili-
ble health outcomes. Equitable access to health- zation. People tend to forgo preventive, acute, and
care is directly linked to the quality of life of chronic care when travel is cumbersome and costly
populations. Healthcare access and outcomes and when facilities are far away, which is common
438 Geographic Barriers to Healthcare
in rural areas worldwide. This distance decay and inner-city areas and a surplus in urban and
effect has been well established, as increasingly suburban areas. Despite an increase in the overall
smaller proportions of populations are using ser- physician-to-population ratio, this disproportion-
vices at greater distances from them. The extent of ate distribution continues. The smallest and most
distance decay depends on the type and severity of geographically remote communities experience
illness. the greatest shortages, though almost all rural
communities have comparatively fewer physi-
cians of all disciplines, particularly specialists,
Healthcare Geography
than metropolitan areas. Not surprisingly, this
A community’s geographic location has impor- scarcity carries over into the fields of nursing,
tant implications for personal healthcare and therapy, psychology, and ancillary services. In the
healthcare service delivery. Human geography United States, the greatest shortages are found in
focuses on the patterns and processes that shape remote rural communities with fewer than 10,000
human interaction with various environments people, where the physician supply has remained
and how they adapt to it. Medical geography relatively unchanged since the 1940s. In urban
studies the correlation between disease and dis- areas, the physician-to-population ratio has more
ease diffusion, without explicitly considering the than doubled since 1960, while increasing by only
other aspects of human interaction. Together, 15% in rural areas. These trends are evident glob-
human and medical geography span the structure ally, in poor and rich nations, mostly due to the
of health services and explain how people use difficult working conditions in geographically
health services in ways that reflect and create remote areas. Factors that make the recruitment
disparities. In the context of healthcare, eco- of healthcare providers difficult in rural areas
nomic geography focuses on the location of include safety issues, inadequate infrastructure
healthcare facilities and on transportation and and supplies for effective treatment, low pay,
trade. Remote and rural areas still suffer from poor housing and education for children, lack of
inadequate healthcare infrastructure and person- social options, poor bonding with the local com-
nel; they are also lacking in public transportation munity, and significant distance from metropoli-
systems. Using geographic mapping to set bound- tan areas.
aries with relation to healthcare delivery and The closure and mergers of many community
outcomes and to compare different regions is and public hospitals over the past several decades
increasingly being accepted in health policy for- has aggravated the shortage of healthcare person-
mulation and resource allotment. Geospatial nel in many areas. When hospitals close, already
mapping is now a common approach for govern- underserved populations have to travel greater
ments to assess the availability of healthcare pro- distances to access services. People who must
viders and infrastructure in relation to adjacent travel farther often incur greater transportation
communities, to identify geographic barriers to costs, by taking off from work or due to loss of
care, and to institute remedial measures. However, income. These factors may lead to delays in seek-
a universally acceptable, fundamental unit of ing treatment and adverse health outcomes, which
geography for measuring health and healthcare may prove to be more costly in the long run.
has yet to be defined. Pregnant women, children, the elderly, and the
physically or mentally challenged are more prone
to suffer from poor health outcomes due to poor
Geographic Maldistribution
access as they often need someone to accompany
of Healthcare Providers
them to remote centers, and they may also lack
The phenomenon of physicians and associated transport facilities and funds.
healthcare professionals choosing to practice in
affluent, urban communities is a recognized global
Travel Burden
trend. It is referred to as the maldistribution of
healthcare providers. This ongoing trend creates a Transportation and healthcare access are directly
shortage of healthcare providers in remote, rural, linked to health outcomes. Travel burden is one
Geographic Barriers to Healthcare 439
of the key components of conceptualizing geo- physicians or hospital beds. The denominator is the
graphic access to healthcare. Determinants of population size within the area, usually computed
travel burden include arranging transportation from census files. Areas are analyzed for the relation
and childcare, travel time, driving distance, between provider-to-population ratio values and
transportation expenses, and the costs of missing some indicator of healthcare utilization or health
work. Rural residents have the dual burden of status. These ratios are only useful for providing
lack of public transportation and living far from comparisons of large geopolitical areas; analysts
healthcare facilities. In rural America, only 1% rely on these ratios to identify medically under-
of healthcare visits are made using public trans- served areas and minimal standards of supply.
portation. Those individuals without cars or The travel impedance, or travel cost to the near-
who cannot drive must depend on family mem- est provider, another tool used to measure spatial
bers or community resources to take them to accessibility, is considered to be a reliable measure
clinics, which limits their control over appoint- for rural areas as people are most likely to visit the
ment times and the choice of providers. nearest health facility for care. Urban populations,
Transportation barriers are also linked to a on the other hand, often have a large number of
reduction in patient compliance with treatment provider options, so travel cost to the nearest pro-
plans, as well as limited use of preventive and vider is a poor indicator of availability.
public health services. Spatial accessibility can be better assessed by the
combined measures of travel impedance and sup-
ply. Average travel impedance to providers is a
Measuring Geographic
combined measure of accessibility and availability,
Barriers to Healthcare
with similar points of measurement to travel
Various measures of spatial accessibility and activ- impedance.
ity space are now commonly used to measure the Also used as a measure of spatial accessibility,
distance between supply and demand. The health- gravity models are an indicator of both accessibil-
care sector also is adopting innovative geographic ity and availability. They provide the most valid
information systems (GIS) and technology to con- measures of spatial accessibility because they are
ceptualize and measure geographic access using applicable to both urban and rural settings.
spatial measurements. The term spatial refers to Some drawbacks of using GIS are potential
space on the earth’s surface; spatial phenomena inaccuracies or incompleteness in data sources,
are concepts that can be shown on maps. Powerful which could lead to unjustifiable causal inferences
computer hardware and software mapping tools from ecological associations. It is a reasonable
are now available to project the distance between assumption that improved spatial accessibility of
supply and demand. These tools can be used to healthcare should lead to better population health
identify geographic locations of future hospitals over a period of time. However, the relationship
and clinics in order to provide equitable access to between changes in spatial accessibility of primary
residents in that area. care and the time taken for an impact to occur is
Spatial accessibility combines the concepts of still being defined.
distance and the provision of healthcare, and it is Activity space, defined as the local areas within
used by health researchers in needs assessment. which people move or travel in the course of their
Spatial accessibility to healthcare can be classified daily activities, measures individual spatial behav-
into four categories: provider-to-population ratios, ior within local environmental differences. It aims
distance to the nearest provider, average distance to provide a comprehensive picture of individual
to a set of providers, and gravitational models of geographic accessibility to healthcare within an
provider influence. individual’s sphere of movement. The number of
Provider-to-population ratios, easily measured healthcare facilities mapped inside this space indi-
supply ratios, are computed within defined areas, cates the degree of individual accessibility, while
such as counties, metropolitan areas, or health ser- the number of facilities outside the given boundary
vice areas. The numerator may be any indicator represents the extra effort and expense required to
of health service capacity, such as the number of gain access to care.
440 Geographic Barriers to Healthcare
Telehealth who live in less affluent countries bear the brunt

of adverse health outcomes due to these barriers.
Telehealth is a resource that relies on technology
The scarcity of primary-care provision persists in
to provide services, education, and medical con-
spite of valiant attempts by governments to
sultations. Using telehealth to deliver services in
address the issue, primarily because of the lack of
remote areas has gained acceptance as a quick,
healthcare providers. Advances in GIS and tech-
easy method of offering timely healthcare, par-
nology have helped calculate the healthcare needs
ticularly for preventive, public health, and
of populations. However, GIS is an expensive
chronic care. However, the use of these services
tool and may be unaffordable by many countries,
depends on Internet availability, access to com-
and it cannot ensure an adequate supply of
puters, adequate literacy, and the ability to
healthcare providers. Though transportation sys-
navigate the system. For struggling, low-income,
tems continue to improve in remote areas, geo-
or minority communities, these resources may
graphic barriers to care are still responsible for
be difficult to obtain. Also, the number of physi-
persistent health disparities. Addressing these
cians willing to deliver online care is limited, as
barriers is an ongoing challenge for health ser-
is the number of reimbursable online consulta-
vices researchers.
tions. The ability to filter accurate online infor-
mation from misleading Web content, which Karen E. Peters and Sunanda Gupta
requires considerable health literacy skills, is an
ongoing problem. Telehealth technology holds See also Access to Healthcare; Critical Access Hospitals
great promise as a tool for healthcare delivery (CAHs); Geographic Information Systems (GIS);
and access in geographically remote areas, Geographic Variations in Healthcare; Rural Health;
though, as the world is increasingly connected Telemedicine; Timeliness of Healthcare; Transportation
to the Web.
Further Readings
Efforts to Increase Access
Chan, Leighton, L. Gary Hart, and David C. Goodman.
In the United States, the federal government has “Geographic Access to Health Care for Rural
designated Medically Underserved Areas (MUAs) Medicare Beneficiaries,” Journal of Rural Health
and Medically Underserved Populations (MUPs) 22(2): 140–46, Spring 2006.
as those that face shortages of primary medical Kurland, Kristen Seamens, and Wilpen L. Gorr. GIS
care, dental and mental health providers, and Tutorial for Health. 2d ed. Redlands, CA: ESRI Press,
hospitals due to various reasons, including geo- 2007.
graphic barriers. MUAs and MUPs are funded to Meade, Melinda S., and Robert J. Earickson. Medical
open community health centers and receive higher Geography. 2d ed. New York: Guilford Press, 2005.
rates of Medicare and Medicaid reimbursable Onega, Tracy, Eric J. Duell, and Xun Shi. “Geographic
services in an attempt to address the growing Access to Cancer Care in the U.S.,” Cancer 112(4):
health disparities due to closure of healthcare 909–18, February 2008.
facilities. Closures particularly affect public World Health Organization. Putting People and Health
health clinics and hospitals that provide free ser- Needs on the Map. Geneva, Switzerland: World
vices to underserved populations in rural and Health Organization, 2007.
impoverished inner-city neighborhoods, forcing
these populations to travel longer distances for
healthcare. Web Sites
Association of American Geographers (AAG):
http://www.aag.org
Future Implications
National Conference of State Legislatures (NCSL):
Geographic barriers to care exist worldwide and http://www.ncsl.org
adversely affect health outcomes in even the most National Rural Health Association (NRHA):
developed countries. The vast majority of people http://www.ruralhealthweb.org
Geographic Information Systems (GIS) 441
from one of many other coordinate systems used

Geographic Information for mapping. Lines are created by connecting the
Systems (GIS) points; these lines can be routes for home-delivered
healthcare services and similar factors. Health-
planning districts might be represented as areas,
Geographic information systems (GIS) are com-
objects formed by closed, connected lines. These
puter-based systems for managing, integrating, and
types of spatial data are referred to as object, or
analyzing geographic data. Geographic data are
entity, data. Vector databases are collections of dis-
observations or measurements of objects or events
crete objects modeled as points, lines, or areas
referenced explicitly to their locations on the earth.
whose locations and other attributes are described.
Location is the basis for integrating data in a GIS.
Vector databases that describe property parcels are
GIS tools have been available for more than two
sometimes referred to as cadastral databases. These
decades and are widely used to integrate and ana-
databases are often used for local public health ser-
lyze many different types of spatial data, including
vice applications such as drinking water regulation
data on health needs, healthcare providers and
and emergency response.
facilities, health services delivery and utilization,
GIS software functions enable users to import
healthcare accessibility, and health outcomes.
tabular data and to create and edit points, lines,
GIS implementation involves organizing people
and areas representing objects of interest. Tables of
to use computer hardware, software, and spatial
data containing X, Y coordinates, such as longi-
databases to answer questions or solve problems.
tude and latitude values, captured using global
The institutional context of this implementation
positioning system (GPS) technology can be added
plays a significant role in governing system design,
to a GIS and converted to point databases. The
application development, and database design. In
United States and other nations use address-
the case of health services, the range of institu-
matching geocoding tools in GIS software to map
tional settings for GIS implementation is especially
locations of cases of disease, healthcare facilities,
wide and includes both public agencies and private
and other points of interest. The Healthy People
entities operating at local, state, national, and
2010 initiative of the U.S. Department of Health
international levels. These settings have implica-
and Human Services (HHS) revised its objective
tions for GIS data acquisition, integration, analy-
for the use of geocoding in health data systems to
sis, and distribution.
achieve 100% nationwide use of GIS by 2010 by
increasing the proportion of major national health
data systems that use geocoding.
Spatial Database Management,
Other types of information that can be man-
Mapping, and Analysis
aged and integrated using GIS include network
GIS tools support spatial database management, data, raster data, and imagery. Network databases
visualization and mapping, and analysis. Many describe space in terms of paths and nodes in a
public and private health agencies manage data- network. The network, however, constitutes the
bases, usually stored and viewed as tables, describ- entire space where objects can be located or events
ing the health status and health service utilization of can occur. These databases are used for modeling
individuals. GIS software functions can be used to service areas of facilities, finding the shortest net-
make these data mappable at a high level of geo- work path between an origin and a destination, or
graphic disaggregation. The objects—for example, finding the facility closest to a point.
patients with specific health problems and the Raster data provide measurements of continu-
health facilities where they receive treatment— ous phenomena, such as air quality or land cover,
whose attributes are described in a health database taken at discrete locations in space. Digital remote-
can also be assigned spatial dimensions and attri- sensing databases classified to model surface veg-
butes. Objects represented as points, such as the etation, water, and the built environment are
place where a clinic or patient resides, have position examples of spatial data using a raster data struc-
in space, and these positions are recorded using ture. Most GIS enable users to convert data from
longitude and latitude coordinates or coordinates raster to vector and vice versa. Raster data have
442 Geographic Information Systems (GIS)
been more widely used in epidemiological applica- with technological advances such as wireless com-
tions of GIS, especially those involving infectious munications, has led to the growth of commercial
disease, than in health services applications of GIS. systems capable of intruding on individual privacy
Imagery includes scanned maps and digital images through the capture and integration of a wide
or photographs of the earth’s surface. Imagery is range of information, including health data.
increasingly important in all types of GIS applica- Although there is widespread recognition of the
tions, but image files must be accompanied by files value of assigning geographic identifiers to health
containing information to register the locations of data, there is little agreement on their form, assign-
the pixels in the image to the earth’s surface. ment, reporting, or use. Legislation such as the
Data integrated in a health services application federal Health Insurance Portability and Accoun
of GIS are commonly drawn from many sources. tability Act (HIPAA) of 1996 restricts the disclo-
Health services providers have direct access to uti- sure of health data, and many health surveillance
lization data and to information on the locations databases, such as the National Health and
of the facilities where they deliver services, but Nutrition Examination Survey (NHANES) and the
these are likely to be only a small part of the data Health Survey of England (HSE), distribute data
needed to geocode addresses, analyze health infor- primarily at the national, state, or regional level.
mation, and map data and results. Data on the Even when data are aggregated spatially and
need, or demand, for health services in vulnerable mapped by area, cartographic representations of
populations may be drawn from national or local health data must be carefully designed to com-
census databases or health surveillance databases. municate patterns of health and disease or medi-
Because health services needs are often age and cal-care accessibility effectively. GIS can produce
gender specific, detailed demographic information multiple views of data, which is a major advan-
is most useful. Data on the facilities of other ser- tage in using the tool. Tables, summary statistics,
vice providers may be more difficult for a health and multiple cartographic representations can be
agency to acquire. Most GIS applications rely on created using these systems, providing a com-
foundation data layers of street networks, political plete description of a health issue. In addition,
and administrative boundaries, and imagery that the spatial analysis functions of GIS can provide
are acquired from government agencies or geo- insight into how partitioning data by areas
graphic database vendors. Database management affects analyses of health services utilization and
is one of the most expensive and time-consuming other processes.
tasks in GIS implementation. The spatial data analysis functions of GIS soft-
Once data have been georeferenced, they can be ware often receive less attention than the mapping
displayed using the mapping and visualization and visualization functions, but they are equally
function of the GIS. Confidentiality remains an important. Spatial modeling functions include tech-
important issue in health services applications of niques such as buffering and overlay. Buffering can
GIS that involve mapping. Research has demon- be used to identify all areas within a certain distance
strated that maps used to display individuals as of a feature such as an emergency warning alarm.
points, even when published at low resolution with Overlay operations can be used to identify the por-
few geographic reference features, may reveal tion of an area that lies within another area, so that
patient location information in a way that breaches people living within the service area of more than
confidentiality. The process of reverse geocoding one medical provider can be identified. Mathematical
converts points on maps to addresses, and these modeling techniques used in GIS applications
conversions can be accomplished with a fairly high account for the influence of distances between
level of accuracy. objects and the geographical positioning of objects
Critics of GIS as a surveillance technology on patterns of interaction between objects. Models
acknowledge that the development of information of healthcare accessibility consider factors such as
systems such as the centralized universal-number the distance between residential communities and
emergency response systems benefits those receiv- healthcare facilities. Spatial statistical techniques
ing emergency medical care. Additional critique model dependencies in data and enable analysts to
also demonstrates that this infrastructure, coupled investigate health outcomes in context. All these
spatial, analytic operations result in new geographic These entities have access to large databases on pat-
databases that can be mapped to provide insights terns of health service utilization that could be
into a range of health services issues. analyzed spatially. There is evidence that health
insurance companies and other corporate entities
use GIS as part of their operations, but few exam-
Health Applications
ples of these applications appear in the health ser-
Few applications of GIS in public health, epidemi- vices literature.
ology, or health planning appeared before the
1990s. During that decade, interest in GIS and
Geographic Dimensions of
their use in health applications increased rapidly.
Health Services Analysis
The term GI Science was coined at this time to
distinguish geographic information as a research Geographic analysis of health services has five
field from the technology of GIS. As in other main dimensions: (1) analyzing the geographic
areas, GIS applications in health services have distribution of vulnerable populations and their
built on the theories and methods of spatial analy- need for services, (2) modeling the location and
sis, relevant long before the innovations that made distribution of health services providers and
GIS possible. The health services literature of the their capacities, (3) describing patterns of health
1960s and 1970s, and even earlier, addresses and services delivery and utilization, (4) analyzing
provides methods for analyzing the location and accessibility to health services, and (5) investi-
distribution of healthcare providers, patient origin gating disparities in health outcomes. Populations
patterns, facility service areas, medically under- are not evenly distributed across regions, and
served areas, and health services. Some of these local populations differ in age, gender, culture,
methods, such as the use of spatial interaction and other characteristics that affect health
models to study health services accessibility, have status and the need for health services. For exam-
been implemented, fully or partially, using GIS ple, mapping the number of Black women
functions, especially those system functions that 50 years of age and above gives an indication of
are used to measure the distance to health service the need for annual routine mammography screens.
sites. The availability of GIS has led to a rediscov- Figure 1 provides an example of such a map for
ery of many spatial analytic methods applicable to Connecticut.
health services research. And the use of this tech- When people are placed in their community set-
nology is likely to encourage the development of tings, the challenge for health services delivery
other new methods. becomes clear. In addition to health services plan-
The shift toward greater privatization of health ning, the design of randomized control trials
services that began in the United States in the (RCTs) and public health interventions needs to
1980s, leading to less federal and state involvement take into account the underlying spatial distribu-
in health services planning and regulation, coin- tion of the target population. GIS tools are well
cided with the development of GIS. One conse- suited for mapping and exploring geographical
quence is that data on patient origins, provider variation in the need for health services.
networks, and healthcare insurance coverage The supply of health services can also be inves-
became a form of proprietary business information, tigated using GIS by mapping the locations and
unlikely to be published by large healthcare organi- capacities of healthcare providers. For example,
zations. Additionally, this information was unlikely many hospitals have radiology units capable of
to be accessible to public health researchers, either providing mammography screens. GIS can be used
as public domain or through regulatory disclosure. to display the locations of these facilities in rela-
For this reason, it is difficult to document the use of tion to the geographic distribution of need. It
GIS in many areas of health services delivery or would also be desirable to map the locations of
planning. The growth of managed care resulted in other providers of mammography services, includ-
the creation of new health-related businesses—for ing freestanding radiology centers, women’s health
example, companies that manage prescription drug centers, and other facilities. The number of appoint-
benefits for major health insurance companies. ment slots, days and times when appointments can
444 Geographic Information Systems (GIS)
and serve the most number of residents of

particular communities. Patient origin areas
may differ widely depending on the partic-
ular service offered, even for the same
healthcare facility.
In addition to measuring the attractive-
ness of the services and the level of compet-
ing demand for the services from patients in
other communities, models of geographical
accessibility to health services usually involve
some measure of distance between potential
patients and service sites. The network
analysis functions of GIS can be used to esti-
mate the area within a specified travel dis-
Figure 1 A Dot Density Map of the Distribution of Black
tance or travel time from a facility. Measuring
Women 50 Years of Age or Older in a Town in
Connecticut
travel time along a network often yields a
much more accurate measure of distance than
Source: Summary File 1, U.S. Census 2000 and the Connecticut creating a simple distance buffer. Figure 3
Department of Environmental Protection. reflects the measurement of travel time.
Modeling geographical coverage of exist-
ing healthcare facilities provides insight into
areas that are not covered or are under-
served by the existing supply of healthcare
providers. This information can be used to
plan for the redistribution of capacity across
service sites, the location of new services, or
the location of alternative services. It can
also be used to evaluate the characteristics
of populations that have different levels of
access to healthcare services.
GIS tools make it possible to understand
patterns of health and disease in the con-
text of healthcare services accessibility. The
geographical organization of health ser-
vices, the geographical differences in acces-
Figure 2 The Location of Community Hospitals in Connecticut
sibility to healthcare, and the geographical
reach of surveillance and screening systems
Source: Office of Health Care Access, Connecticut Department of may act to filter the underlying distribution
Environmental Protection. of health problems and influence the appar-
ent geographical distribution of health
be made, and other attributes of the services pro- problems mapped by health analysts.
vided that might affect who can access care should Increasingly, information on health condi
also be recorded. Figure 2 provides an example of tions and health services is delivered
such a map, showing the geographic distribution through the Internet.
of community hospitals in Connecticut.
Healthcare providers can also geocode and map
the residential locations of the patients they serve.
GIS and the Internet
This information can be used to identify the com- Changes in computing technology were recog-
munities that send most of their residents to par- nized as major drivers in the development and
ticular providers, as well as the providers that treat rapid diffusion of GIS to new application areas.
Web site distributes cartographic boundary

files of census units that can be used in GIS.
Similarly, government agencies such as
the Health Resources and Services Admi
nistration (HRSA) participate in the gov-
ernment’s Geospatial One Stop portal.
Alternatively, organizations such as the
National Cancer Institute (NCI) can use GIS
to share information by publishing static
maps or maintaining interactive Web-based
GIS that allow users to map data. Another
type of distributed system involves serving
GIS analysis tools. This type of application
is most commonly used within an agency to
allow staff members to manage spatial data-
Figure 3 Network Analysis Identifying the Service Area
Neighborhood Within 30 Minutes of Travel Time bases. Location-based services enable users
Based on 40-mph Travel Speed and a 20-Mile Buffer to access information about a location and
nearby areas. A person seeking healthcare
Source: Office of Health Care Access and the Connecticut can use location-based services to find the
Department of Environmental Protection. nearest provider and determine the best
route to a particular destination.
In the early years of GIS adoption, the use of

workstations and desktop computers with larger
Future Implications
memories and improved graphics capabilities, Although GIS technology developed outside the
the availability of inexpensive and reliable sphere of public health, the systematic application
printers, and the emergence of networks were of computer science and information technology in
among the most important developments affect- public health and healthcare is not new. The same
ing GIS. During the first decade of this century, forces affecting GIS today are also fostering a
both the Internet and wireless networks and population-focused, experience-based, and
devices are having a significant effect on geo- research-oriented approach to public health infor-
spatial information technology. The develop- mation systems in the emerging field of health
ment of GIS on the Internet has the potential for informatics. GIS tools play an important role in
broadening access to geographic data because these systems by supporting the geocoding, map-
data users do not need to have GIS software or ping, and spatial analysis of health and health ser-
databases on their own computers or wireless vices data.
devices. GIS software companies offer Internet
map server products supporting online systems. Ellen K. Cromley
The launch of Google Earth in 2005, however,
provided organizations with a different frame- See also Access to Healthcare; Epidemiology; Geographic
Barriers to Healthcare; Geographic Variations in
work for delivering cartographic displays of
Healthcare; Healthcare Markets; Health Informatics;
geographic data, one that does not rely on GIS
Health Planning; Public Health
software packages.
Distributed GIS supports four main activities:
(1) data sharing, (2) information sharing, (3) data
processing, and (4) location-based services. Data in Further Readings
original format and metadata describing the geo- Cromley, Ellen K., and Sara McLafferty. GIS and Public
graphical database may be published for down- Health. New York: Guilford Press, 2002.
loading on an organization’s Web site or through a Davis, David E. GIS for Everyone. 3d ed. Redlands, CA:
data clearinghouse portal. The U.S. Census Bureau’s ESRI Press, 2006.
446 Geographic Variations in Healthcare
Harvey, Francis. A Primer of GIS: Fundamental no clear benefits in patient outcomes or health-
Geographic and Cartographic Concepts. New York: care quality. Geographic differences have been
Guilford Press, 2008. reported across the healthcare system, from the
Koch, Tom. Cartographies of Disease: Maps, Mapping, intensity of hospital use and end-of-life care to
and Medicine. Redlands, CA: ESRI Press, 2005. the patterns of elective surgeries. The geographic
Lai, Poh C, Fun-Mun So, and Ka-Wing Chan. differences reported in healthcare delivery have
Spatial Epidemiological Approaches in Disease raised many important questions for health ser-
Mapping and Analysis. Boca Raton, FL: CRC Press, vices researchers on what and how much care is
2009.
appropriate and what is the relative value of the
Maheswaran, Ravi, and Massimo Craglia, eds. GIS in
differential spending and treatment across
Public Health Practice. Boca Raton, FL: CRC Press,
regions.
2004.
Neteler, Markus, and Helena Mitasova. Open Source
GIS: A GRASS GIS Approach. 3d ed. New York: Overview
Springer, 2008.
Sommer, Shelly, and Tasha Wade, eds. A to Z GIS: An The use of healthcare services and the associated
Illustrated Dictionary of Geographic Information spending patterns vary greatly across the nation.
Systems. Redlands, CA: ESRI Press, 2006. Geographic variations in healthcare are generally
measured over large areas, such as at the state
level, while measurement of smaller geographic
areas can focus on counties, metropolitan statisti-
Web Sites cal areas, and hospital referral areas. Medicare
Centers for Disease Control and Prevention (CDC): patient data have been extensively used to study
http://www.gis.cdc.gov geographic variations in the United States, because
Health Resources and Services Administration (HRSA): of the large number of patients and the readily
http://datawarehouse.hrsa.gov/DWOnlineMap/ accessible data.
MainInterface.aspx In 1967, Wennberg analyzed Medicare data to
National Cancer Institute (NCI): http://www.gis.cancer.gov examine how this program was serving communi-
U.S. Census Bureau: http://www.census.gov ties. Through his research, Wennberg found unwar-
U.S. Geospatial One Stop: http://gos2.geodata.gov/wps/ ranted differences in patient care that could not be
portal/gos explained by the severity of patients’ illnesses,
World Health Organization (WHO): http://www.who.int medical need, or evidence-based medicine. Over
the years, Wennberg and others have found many
geographic variations in healthcare. Recently,
Wennberg’s Dartmouth Atlas of Healthcare Project
Geographic Variations reported finding differences in hemoglobin A1C
testing for Medicare patients with diabetes, rang-
in Healthcare ing from 91% in Vermont to 71% in Alaska. It
also reported differences in Medicare beneficiaries
Geographic variations in healthcare are the dif- who have a primary-care physician as the pre-
ferences in healthcare services delivery to patients dominant provider, ranging from 86% in Nebraska
based on the location where they receive them. to 65% in New Jersey.
John E. Wennberg, a New England physician, The unwarranted differences in healthcare
first described the phenomenon of geographic across regions can be attributed to effective care,
variation in healthcare in the late 1960s after meaning clinically proven treatments, and patient
finding small area variations based on Medicare safety; preference-sensitive care, or patient’s choices
spending. Although some variation in the delivery in their treatment; and supply-sensitive care, or
of healthcare is justified and acceptable, unwar- care that is associated with the healthcare system’s
ranted variations in the delivery of healthcare resource capacity and supply. The majority of the
services leads to differential medical spending geographic differences in healthcare, however, can
and treatment across regions of the nation with largely be attributed to supplier-sensitive care. The
Geographic Variations in Healthcare 447
underlying theory is that because there is a lack of Overall, differences in geographic spending on
firm evidence to treat many medical conditions, healthcare have been increasing over the years;
the general assumption is that more care leads to however, the variation in Medicare spending
better patient outcomes. Therefore, in areas with has decreased recently because of changes in its
more healthcare resources, the tendency of health- reimbursement policies. The Veterans Health
care providers is toward greater intensity of Administration (VHA) has also experienced geo-
healthcare services. graphic differences in healthcare spending despite
The notion of supply-sensitive care overlaps a national resource allocation formula.
with the concept of supplier-induced demand.
Supplier-induced demand was first identified in the
Small-Area Variation Analysis
early 1960s by the public health professor Milton
I. Roemer (1916–2001). Roemer found that when Small-area variation analysis, developed by
health insurance was widespread in a community, Wennberg and Gittelsohn, is a tool that is used by
increased utilization of services resulted in an health services researchers to understand the geo-
increase in the supply of hospital beds. Roemer graphic differences in the rates of healthcare utili-
coined the saying “A bed built is a bed filled.” This zation and also how this varies over defined
finding became known as the Roemer effect, or areas. Because of the substantial variation in
Roemer’s law. healthcare utilization and spending across regions
Geographic differences in care can also arise of the country, small-area variation analysis uses
from the uneven distribution of morbidity. For established epidemiological methods to better
example, the higher rates of cardiovascular pro- grasp the causes of these variations across similar
cedures in the southeastern United States may be communities, which can help guide healthcare
due to the higher prevalence of tobacco use in decision making and resource planning. Because
this area. Also, certain regions may be more apt healthcare is provided at the local level by physi-
to adopt low-cost and effective healthcare prac- cians and other providers, the differences in
tices, while other regions may maintain high-cost medical treatment at this level appear to be due to
practices, leading to further differences across the different prevailing practices. Small-area vari-
areas. ation analysis has become an important technique
Geographic differences in healthcare also result that researchers use to disentangle the disparities
in differences in spending across regions. For examin healthcare utilization and treatment as well as
ple, in 2004, the per capita spending in Utah was provide further insight into whether or not more
$2,400 compared with $6,700 in Massachusetts. care leads to better health outcomes. Some areas
These differences persist even at smaller geographic of concern regarding the proper use of small-area
levels and even among providers. Research con- variation analysis are accurate defining of geo-
ducted by the Dartmouth Atlas of Health Care graphic boundaries, the population at risk, case-
found that among Medicare beneficiaries with mix adjustments, and the stability of rates across
similar health status, those living in high-spending time. The further development of small-area
areas received 60% more healthcare services than variation analysis will entail the development of
those who live in low-spending areas. Some more refined measures, case-mix adjustment, and
researchers predict that Medicare spending would appropriate small areas to be examined.
decrease by 29% if spending in high- and medium-
spending areas was equivalent to that in low-
Future Implications
spending areas.
The geographic differences in patient care and It is likely that geographic variations in health-
spending that have been highlighted indicate that care will continue to persist in the future given
the healthcare system is not as efficient as it could the uneven distribution of disease and of health-
be. There is a growing body of literature suggest- care providers across the nation. Although there
ing that the overuse or misuse of and increased will always be some random geographic and
spending on healthcare services do not produce regional differences in the care that patients
better care or improved patient outcomes. receive, it is the clinical and statistical significance
448 Ginsburg, Paul B.
of the disparities in care that are of concern. The

wide variation in agreement regarding the risks Ginsburg, Paul B.
and benefits of certain treatment options for spe-
cific diseases due to patient and provider prefer- Paul B. Ginsburg is president of the Center for
ences will further yield differences in care. Health Studying Health System Change (HSC). Founded
services research will play an integral role in pro- in 1995, the HSC conducts research to inform
viding a deeper understanding of the underlying policymakers and other audiences about changes in
reasons for the unwarranted differences in care, the organization, financing, and delivery of care
as well as in helping ascertain the appropriate and the effects on people. Data are gathered
amount of care needed to yield maximum clinical through the Community Tracking Study, which
effectiveness. includes surveys of households and physicians and
site visits to interview health system leaders in 12
Jared Lane K. Maeda communities that are representative of the nation.
The HSC is widely known for the objectivity and
See also Flat-of-the-Curve Medicine; Geographic Barriers
technical quality of its research and its success in
to Healthcare; Geographic Information Systems (GIS);
Health Disparities; Medicare; Roemer, Milton I.;
communicating results to policymakers and the
Supplier-Induced Demand; Wennberg, John E. media, as well as to the research community. A
sister organization to Mathematica Policy Research,
the HSC is funded principally by the Robert Wood
Johnson Foundation but also receives funding from
Further Readings other foundations and from government agencies.
Auerbach, David, and Chapin White. Geographic Before founding the HSC, Ginsburg served as the
Variation in Health Care Spending. Pub. No. 2978. founding executive director of the Physician Payment
Washington, DC: Congressional Budget Office, Review Commission (PPRC), now the Medicare
February 2008. Payment Advisory Commission (MedPAC). Widely
Fisher, Elliott S., and John E. Wennberg. “Health Care regarded as highly influential, the commission
Quality, Geographic Variations, and the Challenge of developed the Medicare physician payment reform
Supply-Sensitive Care,” Perspectives in Biology and proposal enacted by the U.S. Congress in 1989.
Medicine 46(1): 69–79, Winter 2003. Ginsburg was also a senior economist at the RAND
Kane, Robert L., Wen-Chieh Lin, and Lynn A. Blewett. Corporation and served as deputy assistant director
“Geographic Variations in the Use of Post-Acute at the U.S. Congressional Budget Office (CBO).
Care,” Health Services Research 37(3): 667–82, June Before that, he served on the faculties of Duke and
2002. Michigan State Universities. He earned his doctor-
Sporer, Scott M., James N. Weinstein, and Kenneth J. ate in economics from Harvard University.
Koval. “The Geographic Incidence and Treatment Ginsburg is a noted speaker and consultant on
Variation of Common Fractures of Elderly Patients,”
the changes taking place in the nation’s healthcare
Journal of the American Academy of Orthopaedic
system and its future outlook. He frequently testifies
Surgeons 14(4): 246–55, April 2006.
before the U.S. Congress. In addition to presenta-
Wennberg, John E., and Alan Gittelsohn. “Small
tions on the overall direction of change in the
Area Variation in Health Care Delivery: A
Population-Based Health Information System
healthcare system, recent topics have included cost
Can Guide Planning and Regulatory Decision-
trends and drivers, consumer-driven healthcare,
Making,” Science 182(4117): 1102–8, provider payment, and the future of employer-based
December 14, 1973. health insurance and competition in healthcare. In
2007, for the fifth time, Ginsburg was named by
Modern Healthcare as one of the 100 most power-
ful people in healthcare. He recently received the
Web Sites first annual Health Services Research Impact Award
Congressional Budget Office (CPO): http://www.cbo.gov from AcademyHealth, the professional association
Dartmouth Atlas of Health Care: for health policy researchers and analysts. He is a
http://www.dartmouthatlas.org founding member of the National Academy of
Ginzberg, Eli 449
Social Insurance and a public trustee of the American and one of the first health economists in the
Academy of Ophthalmology; he served two elected United States.
terms on the Board of AcademyHealth. Ginzberg was born in and lived most of his life
in New York City. He had a very long and well-
Alwyn Cassil respected tenure at Columbia University, where he
See also AcademyHealth; Center for Studying Health
earned his bachelor’s (1931), master’s (1933), and
System Change; Congressional Budget Office (CBO); doctoral (1935) degrees. In 1935, he began his
Forces Changing Healthcare; Mathematica Policy teaching career at Columbia University’s faculty in
Research (MPR); Medicare Payment Advisory the Graduate School of Business. He would go on
Commission (MedPAC); RAND Corporation; Robert to teach at Columbia for more than 60 years.
Wood Johnson Foundation (RWJF) Ginzberg’s early years at the university exposed
him to experiences that helped prepare him for his
interests in public policy and healthcare. During
Further Readings World War II, he helped plan healthcare services
Ginsburg, Paul B. “Controlling Health Care Costs,”
for wounded soldiers and discharges for military
physicians. In 1943, Ginzberg helped prepare for
October 14, 2004. the 1944 European invasion by U.S. forces by serv-
Ginsburg, Paul B. “Don’t Break Out the Champagne: ing as chief logistical advisor to the Surgeon
Continued Slowing of Health Care Spending Growth General of the Army. In 1946, he returned to
Unlikely to Last,” Health Affairs 27(1): 30–32, Columbia University and eventually retired from
January–February 2008. the faculty in 1979, although he continued teach-
Lesser, Cara S., Paul B. Ginsburg, and Kelley J. Devers. ing classes at the university.
“The End of an Era: What Became of the Managed Ginzberg served as director of the Eisenhower
Care Revolution in 2001?” Health Services Research Center for the Conservation of Human Resources
38(1 pt. 2): 337–55, February 2003. at Columbia University and director for the Revson
Nichols, Len M., Paul B. Ginsburg, Robert A. Berenson, Fellows Program on the Future of the City of New
J., et al. “Are Market Forces Strong Enough to Deliver York. From 1962 through 1981, he served as chair
Efficient Health Care Systems? Confidence Is Waning,” for the National Manpower Advisory Committee.
Health Affairs 23(2): 8–21, November 2004. In 1982, Columbia University awarded him an
Strunk, Bradley C., Paul B. Ginsburg, and John P. honorary doctorate of letters.
Cookson. “Tracking Health Care Costs: Declining Ginzberg’s interests centered on people and the
Growth Trend Pauses in 2004,” Health Affairs Web conditions in which they lived and worked. For
Exclusive W286–W295, 2005. example, in the 1960s, it was thought that there
Strunk, Bradley C., Paul B. Ginsburg, and Jon R. Gabel. was a national physician shortage, and efforts and
“Tracking Health Care Costs: Growth Accelerates funds were directed toward building new medical
Again in 2001,” Health Affairs Web Exclusive
schools, upgrading older programs, increasing stu-
W299–W310, 2002.
dent enrollments, and providing financial aid
opportunities. Ginzberg countered the claim by
Web Site
declaring that the physician shortage was only in
low-income and high-poverty areas, and even if
Center for Studying Health System Change the number of physicians in the graduating classes
(HSC) Staff Profile: http://www.hschange.com/ was increased, these socioeconomic areas would
index.cgi?file=staff#ginsburg continue to be underserved. His solution was to
train more paraprofessionals, nurse practitioners,
and physician assistants as well as to restructure
the manner in which the medical services were
Ginzberg, Eli delivered to this portion of the population.
Several times throughout his career, he addressed
Eli Ginzberg (1909–2002) was a writer, scholar, the education and utilization of nurses. Because he
teacher, government consultant, policy analyst, thought that hospital training exploited nursing
450 Grossman, Michael
students, he advocated for nursing education to

become the responsibility of higher education. To Grossman, Michael
improve the nursing profession’s status, Ginzberg
recommended that graduate programs include Michael Grossman is a well-known health econo-
management courses in the curriculum. Addressing mist, who has spent much of his long, distin-
the various levels of education found in the nursing guished career in two organizations: the National
profession and the need to improve working con- Bureau of Economic Research (NBER) and the
ditions and job satisfaction, Ginzberg recom- City University of New York (CUNY). Grossman
mended tying levels of responsibilities to the was one of the first economists to use the concept
nurses’ education, with the more educated nurses of human capital in healthcare research. He has
having higher levels of responsibilities. greatly influenced the field of health economics
Acknowledging the U.S. culture of individual- through his research and the many students he has
ism and its socioeconomic structure, he stressed mentored and trained.
the need for national health insurance to provide Born in 1942 in Brooklyn, New York, Grossman
essential medical care as well as policies addressing received his bachelor’s degree from Trinity College
the health sector’s shortcomings in the areas of in 1962. He attended graduate school at Columbia
access, costs, and quality of care. University, where he earned a doctoral degree in
Ginzberg, a prolific writer, was interested in the economics in 1970.
human experience and human resources. He was In 1966, Grossman began his long affiliation
one of the first health economists, and his work with NBER. At NBER, Victor Fuchs, a well-known
continues to influence health policymakers. health economist, hired him as a research assistant.
Grossman held a number of positions at the orga-
Anne L. Buchanan nization, and in 1972, he became a research associ-
ate and Program Director of Health Economics
See also Health Economics; Health Professional Shortage
Areas (HPSAs); Health Workforce; Nurse Practitioners
Research, a position he presently holds.
(NPs); Nurses; Physicians; Public Policy In 1972, Grossman began his long affiliation with
the CUNY. He started at the university as a visiting
assistant professor and successfully rose through the
academic ranks. In 1978, Grossman was appointed
Further Readings
professor, and in 1988, he became Distinguished
Ginzberg, Eli. Health Services Research: Key to Professor of Economics, a position he presently holds.
Health Policy. Cambridge, MA: Harvard University In addition to teaching, he also served as the execu-
Press, 1993. tive officer (chairperson) of that university’s doctoral
Ginzberg, Eli. “U.S. Health Care: A Look Ahead to program in economics from 1983 to 1995. And he
2025,” Annual Review of Public Health, 20: 55–66, has supervised nearly 100 doctoral dissertations.
1999. Grossman has conducted research and written
Ginzberg, Eli. “A Life in Health Policy: Nearing Ninety, extensively on a wide variety of health economic
an Economist Looks Back on Six Decades in Health topics including the following: economic models
Workforce,” Health Affairs, 19(6): 239–44, 2000. of the determinants of infant, child, and adult
Ginzberg, Eli, and Miriam Ostow. Men, Money, and
health; the cost of capital for tax-exempt hospital
Medicine. New York: Columbia University Press,
bonds; the introduction of national health insur-
1969.
ance in Taiwan; the impact of taxes on cigarette
Ginzberg, Eli, and Miriam Ostow. The Road to Reform:
smoking and alcohol use; and the economic fac-
The Future of Health Care in America. New York:
Free Press, 1994.
tors associated with adult obesity. He has authored
or coauthored four books, more than 40 academic
journal articles, and numerous book chapters.
His first book, The Demand for Health: A Theoretical
Web Site and Empirical Investigation, is considered a seminal
Columbia University, Mailman School of Public Health: work. The supply and demand model of healthcare he
http://www.mailman.hs.columbia.edu/news/ginzberg.html presented in the book has greatly influenced the field of
Grossman, Michael 451
health economics and is widely cited in the literature. Further Readings

His most recent book, edited with Chee-Ruey Hsieh, is Grossman, Michael. The Demand for Health: A
The Economic Analysis of Substance Use and Abuse: Theoretical and Empirical Investigation. New York:
The Experience of Developed Countries and Lessons Columbia University Press, 1972.
for Developing Countries. Grossman, Michael. “The Demand for Health, 30 Years
Grossman is a coeditor of the Review of Later: A Very Personal Retrospective and Prospective
Economics of the Household, a series coeditor of Reflection,” Journal of Health Economics 23(4):
Advances in Health Economics and Health Services 629–36, July 2004.
Research, and an associate editor of the Journal of Grossman, Michael. “Individual Behaviors and
Health Economics. He also reviews manuscripts Substance Use: The Role of Price,” Advances in
for many other healthcare journals. Health Economics and Health Services Research 16:
Grossman has received numerous academic and 15–39, 2005.
professional honors for his work. Grossman has Grossman, Michael, Frank J. Chaloupka, and
been a consultant to the National Institute on Kyumin Shim. “Illegal Drug Use and Public
Alcohol Abuse and Alcoholism, the National Policy,” Health Affairs 21(2): 134–45,
Academy of Sciences, the National Science March–April 2002.
Foundation, and the RAND Corporation. He is Grossman, Michael, and Chee-Ruey Hsieh, eds. The
included in Who’s Who in America and Who’s Who Economic Analysis of Substance Use and Abuse: The
in Economics, and he is an elected member of the Experience of Developed Countries and Lessons for
National Academy of Sciences, Institute of Medicine Developing Countries. Cheltenham, UK: Edward
Elgar, 2001.
(IOM). In 2008, Grossman won the Victor Fuchs
Lifetime Contribution Award from the American
Society of Health Economists (ASHE).
Web Sites
Ross M. Mullner
City University of New York (CUNY): http://web.gc.
See also American Society of Health Economists (ASHE); cuny.edu/economics
Fuchs, Victor R.; Health Economics; Obesity; Public National Bureau of Economic Research (NBER):
Health Policy Advocacy; Public Policy; Tobacco Use http://www.nber.org
H
parties accountable. If a society conceives that
Health good or ill health is a consequence of an individu-
al’s discretionary behaviors (e.g., washing hands
The World Health Organization (WHO) defines before handling food to avoid food poisoning),
health as “a state of complete physical, mental, and then individuals would be responsible for their
social well-being and not merely the absence of own health. Conversely, if a society regards health
disease or infirmity.” This definition is perhaps the as a reflection of social and political systems (e.g.,
most well known and also the most criticized, increased infant mortality after community health
mainly because it is difficult to operationalize for center funding is cut), then policymakers would be
achieving (and measuring) health. Despite its lack of held accountable. Societies and individuals have
specificity, however, the definition introduces the different and complex matrices of causality and
social dimension of health. For the WHO definition accountability for various health outcomes. Some
to be useful in health research and practice, physical, health conditions are attributed to individuals,
mental, and social well-being must be interpreted in while others to social policy or even to uncontrol-
specific social, political, and cultural contexts. lable forces (e.g., fate, nature). Health services
Different conceptualizations of health indi- researchers and policymakers must recognize the
cate different determinants of health. These strengths and limitations of the various conceptu-
determinants of health, in turn, prompt specific alizations of health that they use in studying
public policies and individual behaviors for health-related issues, shaping public policy, and
achieving health. For example, suppose health is providing services.
considered as the normal physiological function- In the following sections, the philosophical
ing of the bodily organs. If contaminated water underpinnings for the definition of health will be
is believed to disturb the normal functioning of discussed, and the ways in which different views of
the organs, then social policies would regulate health are reflected in various measures of health
water quality, while individuals might choose will be examined. Next, various determinants of
not to drink tap water. In another example, if a health from a social-ecological perspective will be
society considers health as active social partici- reviewed. Finally, the question of who is responsi-
pation, then social policies would be in place to ble for health is addressed.
remove barriers to social participation, and indi-
viduals would seek out opportunities for social
activities.
Naturalist and Normativist
The various ways of conceptualizing health are
Definition of Health
reflected in social policies and individual behav- The definition of health has long been a subject of
iors. These conceptualizations also hold different debate among philosophers. Two major, contrasting
453
454 Health
perspectives have been proposed. Derived in the changes in society force us to consider how health
1970s from the traditional biomedical standpoint, and well-being may coexist with disease and func-
the naturalist view defines health as the freedom tional limitations. While the naturalist definition
from disease, which, in turn, is defined as the inabil- of health is important in advancing medical
ity of one’s body to perform all the typical physio- research on managing disease, the normative defi-
logical functions with at least typical efficiency. This nition of health—with its focus on wellness rather
view places health and disease (or death) at the two than illness—better informs health research and
poles of a continuum, and individuals find them- practice.
selves somewhere between the two poles. According
to this definition, for example, a person with diabe-
Measures of Health
tes cannot be “healthy,” even if his or her condition
is well managed with insulin, because his or her The different perspectives on health have implica-
body is not able to perform all the typical physio- tions for health measurement. The naturalist
logical functions. definition sees a person as a physiological being;
A contrasting definition of health was proposed therefore, measures of health based on this defini-
in the 1990s. The normativist view defines health tion are in fact measures of physiological func-
as a person’s ability to achieve his or her vital goals tioning. The long history of medicine has provided
given standard circumstances. Advocates of the a wide array of measures for assessing individuals’
normativist perspective suggest the possibility of physiological functioning, from blood cell count-
people being healthy (i.e., able to achieve impor- ing to magnetic resonance imaging (MRI). These
tant life goals) despite functional limitations. measures are objective in the sense that others can
Consider, for example, the athletes who compete judge a person’s health status, often medical pro-
in the Paralympics. While the normativist defini- fessionals. This is a valuable approach as some
tion considers them healthy, perhaps healthier than serious medical conditions can develop without
many others without functional limitations, these outward signs (e.g., hypertension or high blood
athletes cannot be healthy according to the natu- pressure). Especially for preventive purposes, not
ralist definition because of their physical or mental waiting for overt symptoms to appear is an impor-
disabilities. In other words, the normativist defini- tant practice.
tion allows every individual, regardless of his or These objective measures are useful in detecting
her physical and mental abilities, the possibility to a medical condition that has a clear physiological
be healthy and become healthier. definition (e.g., blood pressure as a measure of
The debate continues between the proponents cardiovascular health). However, if health is more
of these two perspectives, which are not mutually than just the absence of disease, these functional
exclusive; that is, individuals would have a better indicators may not fully capture one’s health sta-
chance for achieving their vital goals if they were tus. If health is the ability to achieve one’s vital
free from impairments in physical and mental goals, a person’s assessment of his or her own
capacities. However, having physical or mental health can be a valid measure. A well-known
malfunctions does not necessarily prevent people example of such a measure is a simple question
from achieving their life goals, especially with the asking people to rate their general health status as
ever-advancing medical technologies. As medical excellent, good, fair, or poor. This measure has
management of many diseases (i.e., physiological been found to be predictive of mortality: Studies
malfunctions) progresses, an increasing number of have found that people who rate their general
individuals survive and live well with their dis- health status as poor had a nearly twofold higher
eases. For example, about 1 in 10 adults in the mortality risk, a relationship that did not change
United States currently has diabetes, and the when it was adjusted for functional status, depres-
5-year survival rate for breast cancer increased sion, and chronic diseases. These findings imply
from 60% to 86% between 1950 and 2000. More that if functional status, depression level, and
generally, life expectancy has been increasing in chronic-disease status are the same, those who rate
developed countries, indicating that more and their health as excellent were more likely to survive
more people are attaining advanced age. These for a certain time period than those who rate their
Health 455
health as poor. What is captured in this simple self- Biological Determinants

rated health question may be the normativist view The most proximal determinants of health are
of health. Despite this utility, however, the measure often biological. Centuries of medical research
has a major limitation: It does not inform health have identified numerous biological, causal factors
services researchers or policymakers regarding of disease and developed treatments for many of
which strategies would improve the person’s self- them. Although various infectious diseases have
rated health status. Self-rated health is, therefore, been effectively controlled, new diseases continue
most useful as an outcome indicator for social to emerge, some with drug resistance. Today, infec-
policies and programs. tious diseases such as influenza and AIDS are listed
The objective (i.e., physiological) and subjective among the leading causes of death.
(i.e., evaluative) measures of health have advan- Genetics is also a major biological determinant
tages and limitations that complement each other. of health. Recent advances in genetic technology
Therefore, using them together will provide a bet- have identified genes responsible for diseases such
ter description of health. Because refined observa- as breast cancer and Huntington’s disease. It is now
tional-biomedical measures of health, which the possible to know whether a person has a specific
naturalist definition of health calls for, contribute gene mutation that will manifest itself as a disease.
to successful interventions, such measures will help Genetic testing is potentially beneficial because the
detect medical conditions in their early stages and individual can take the necessary precautions to
monitor the progress of treatment. Better manage- reduce the damage caused by the disease. However,
ment of medical conditions is a way of enabling the emotional, social, and financial consequences
individuals to be healthy in the normativist view of knowing one’s genetic predisposition must be
also (i.e., being able to achieve vital goals). It is pos- considered. For example, growing attention has
sible, however, that sometimes the management of been paid to “genetic discrimination” by health
disease fails to enhance health in a normative sense insurance companies and employers against indi-
(e.g., invasive treatment for cancer that results in viduals with known genetic mutations that may
isolation from the family and home environment). require expensive medical intervention once the
Evaluative measures of health capture this poten- disease manifests. Because genetic predisposition is
tial disjunction between well-being and a lack of not modifiable, the social and psychological conse-
disease. quences of knowing it could be devastating.
Determinants of Health Behavioral Determinants

Various factors affect health at different levels, It has been estimated that tobacco use, poor diet
from micro (e.g., bacteria) to macro (e.g., socio- and physical inactivity, and alcohol consumption
economic position). They do not exist in isola- account for nearly 40% of all deaths in the United
tion: These factors are embedded in the next States. The deaths caused by these behavioral risk
larger factors. For example, diabetes (a physio- factors are, in theory, preventable by reducing
logically defined state) may be caused by a poor these unhealthy behaviors. Other behaviors that
diet and a lack of exercise (behavioral risk fac- have an impact on health include illicit drug use,
tors), which may, in turn, reflect a lack of access immunization, and various safety practices (e.g.,
to nutritious fresh food and a safe place for exer- using a child seat in the car). The Center for
cising (social factors). The social-ecological per- Disease Control and Prevention (CDC) conducts
spective promoted in public health provides a the Behavioral Risk Factors Surveillance System
framework to integrate these different levels of (BRFSS) to monitor the trends in health behaviors
health determinants. in the United States.
In this section, four determinants of health with
various levels of proximity to the person will be
Social Determinants
discussed. Topics discussed under each determinant
are not exhaustive but, rather, are suggestive of The significant impact of social interaction on
important issues in current research and practice. health has been well documented. Social support is
456 Health
associated with lower mortality from all causes, industrial wastes and commercial products. Most
and the health-enhancing effect of social support is of these chemicals are not tested for the potential
observed in relation to many health conditions health effects of long-term exposure. Therefore,
(e.g., depression, cardiovascular disease, cancer, constant monitoring of environmental hazards is
and infectious diseases). needed for identifying and controlling adverse
One of the most robust social determinants of health effects.
health is the individual’s socioeconomic position in Although the impact of environmental hazards
society. The Whitehall studies—longitudinal stud- is a serious public health problem, in general, spe-
ies of more than 10,000 British civil servants— cial attention should be given to the unequal expo-
documented a social gradient of health: the higher sure to environmental hazards experienced by
a person’s socioeconomic position, the better his or people of different races and classes (i.e., environ
her health status. This gradient was found even mental injustice). For example, hazardous waste
between those at the top and those second to the sites are more likely to be found in racial-minority
top in the occupational hierarchy. Similar or some- and low-income communities. This differential
times steeper gradients by education, income, and exposure may be responsible for health disparities.
occupational prestige are found in the United Since 1994, the U.S. Environmental Protection
States. Many studies have found that the social Agency (EPA) has launched the environmental jus-
gradient of health is partly explained by material tice strategy to reduce the unequal distribution of
deprivation, inadequate access to healthcare, and environmental burden.
unhealthy lifestyle. However, the social gradient of
health does not disappear after these factors are
Who Is Responsible for Health?
taken into consideration. The causal link between
socioeconomic position and health is not yet well Each level of the determinants of health holds
understood, but the stress associated with socio- different entities potentially responsible. Iden
economic disadvantage is suspected as an explana- tifying the determinants of health, therefore, has
tory factor. implications for health accountability. For bio-
The WHO has established the Commission on logical determinants, an individual may feel pow-
Social Determinants of Health (CSDH) to address erless and turn to medical professionals to take
societal causes for health inequalities, including charge of restoring his or her health. For behav-
poverty, social exclusion, work conditions, unem- ioral determinants, individuals themselves may
ployment, and poor housing. The committee be held accountable for their health through
asserts that the social gradient of health reflects maintaining healthy lifestyles. For social determi-
the gradients of two fundamental human needs: nants, social institutions (e.g., schools, work
autonomy and social participation. That is, the organizations, health service providers, medical-
lower a person’s socioeconomic position, the less insurance companies, and governments) need to
autonomy and social participation the person has, be involved in reducing health-compromising
and this relative deprivation is detrimental to factors. For preserving healthy ecosystems for all
health. communities, all who are affected by the ecosys-
tem should have an equal voice in environmental
regulations and policies. Who is responsible for
Ecosystems
reducing health-compromising factors and
The quality of the air, water, and soil can affect increasing health-promoting factors? Who should
the health of current and future generations. Many bear the cost? Consequently, how should resources
elements in the environment (e.g., lead, radon, be allocated to enhance health? These questions
nitrogen dioxide, and persistent organic pollutants) are matters of serious debate. The answers may
have been identified as potentially causing various be different for each health condition and afflicted
health conditions ranging from skin or respiratory group.
irritation to cancer and infertility. These identi- Identifying health determinants and health
fied hazards are only a fraction of the numerous accountability ultimately influences public health
chemicals released into the environment through policy and intervention. The resources available
Healthcare Cost and Utilization Project (HCUP) 457
for public health intervention are limited. To Marmot, Michael G. “Status Syndrome: A Challenge to
achieve the maximum impact with the limited Medicine,” Journal of the American Medical
resources, policymakers must identify the most Association 295(11): 1304–7, March 15, 2006.
effective targets for change (i.e., high-impact National Center for Health Statistics. Disability and
leverage points), which may vary by different Health in the United States, 2001–2005. HHS Pub.
health outcomes. The social-ecological model sug- No. (PHS) 2008–1035. Hyattsville, MD: National
gests that because diverse human and environ- Center for Health Statistics, 2008.
mental determinants of health are interrelated, Taboada, Paulina, Kateryna Fedoryka Cuddeback, and
Patricia Donohue-White, eds. Person, Society, and
changes in one factor potentially affect other fac-
Value: Towards a Personalist Concept of Health.
tors and create synergetic effects. For example, a
Boston: Kluwer Academic, 2002.
smoking ban in public space, originally intended
Wainwright, David, ed. A Sociology of Health.
to reduce environmental tobacco smoke, may
Thousand Oaks, CA: Sage, 2008.
encourage some people to quit smoking. Finding
the high-impact leverage points to enhance the
health of society will require a broad definition of
Web Sites
health and a thorough understanding of its under-
lying causal factors. Center for Disease Control and Prevention (CDC),
Health is such a fundamental concept of Behavioral Risk Factors Surveillance System (BRFSS):
human existence that many people intuitively http://www.cdc.gov/brfss
believe that they know what health is. However, National Genome Research Institute (NHGRI): Genetic
health services researchers and policymakers Discrimination: http://www.genome.gov/PolicyEthics
must recognize the different definitions of health U.S. Environmental Protection Agency (EPA):
as well as the consequences of adopting a certain Environmental Justice: http://www.epa.gov/
compliance/environmentaljustice/index.html
definition over others. The conceptualization of
World Health Organization (WHO): Commission
health dictates whether or not certain factors are
on Social Determinants of Health (CSDH):
considered as determinants of health, which, in
http://www.who.int/social_determinants/en
turn, determines policy and intervention. Social
forces such as the political climate, the global
and national economies, culture, and history
influence this process of defining health, identi-
fying the determinants of health, and establish-
Healthcare Cost and
ing social policy. Recognizing the complexity of Utilization Project (HCUP)
health as a concept is imperative for research
and practice. The Healthcare Cost and Utilization Project
(HCUP) is a family of healthcare databases and
Kaori Fujishiro and Erin Hayes Kelly software tools developed to facilitate research on a
broad range of health policy issues. HCUP repre-
See also Community Health; Disability; Disease;
Morbidity; Mortality; Public Health; Public Policy; sents the ongoing, collaborative efforts of federal,
World Health Organization (WHO) state, and private agencies and institutions to build
a national information resource of patient-level
healthcare data and to make these products avail-
Further Readings able for use in health services research and health
Albertson, Leana J., ed. Genetic Discrimination. New policy analyses. These efforts have culminated in
York: Nova Science, 2008. the largest collection of longitudinal, discharge-
Kawachi, Ichiro, S. V. Subramanian, and Daniel Kim, level data on hospital care in the United States.
eds. Social Capital and Health. New York: Springer, Based on information from HCUP, quality indica-
2008. tors (QIs) that measure the clinical performance of
Kronenfeld, Jennie J., ed. Inequalities and Disparities in hospitals have been developed to aide in quality
Health Care and Health: Concerns of Patients, assessment and continuous quality improvement
Providers, and Insurers. Boston: Elsevier JAI, 2008. efforts.
458 Healthcare Cost and Utilization Project (HCUP)
Development at the state and national levels on inpatient and

ambulatory/outpatient care provided to adults
In response to increasing concerns about health-
and children in the United States from as early
care quality and the growing interest in tools for
as 1988. The State Inpatient Databases
quality assessment, the Agency for Healthcare
(SID), Nationwide Inpatient Sample (NIS), State
Research and Quality (AHRQ) initiated the
Ambulatory Surgery Database (SASD), Kids’
HCUP in 1989. HCUP was charged with creating
Inpatient Database (KID), and State Emergency
a national, comprehensive, and uniform data set
Department Databases (SEDD) are all included in
of hospital inpatient records and developing a set
HCUP.
of healthcare QIs that could be used with hospital
administrative data for health policy analysis.
Many organizations lack the resources necessary HCUP Quality Indicators
for extensive data collection and a quality mea-
Building on data from the project, HCUP QIs were
surement system for continual and comprehen-
constructed as a low-cost, ongoing, quality mea-
sive monitoring of quality. Furthermore, the
surement resource to aide continuous quality
definitions and formats of administrative data
improvement efforts. Rather than addressing dimen
vary widely from state to state, making interstate
sions of quality such as patient satisfaction or effi-
comparisons difficult. HCUP was developed to
ciency, the HCUP QIs were developed, in 1994, to
address the infrastructural barriers that were hin-
measure clinical performance. HCUP QIs comprise
dering quality improvement by minimizing the
a set of 33 measures of clinical performance to be
burden on the healthcare industry and states in
used as a screening tool to identify quality concerns
collecting, standardizing, and distributing national
for further research and analysis. Development of
hospital data.
these measures was performed in several phases: a
Since its inception, HCUP has grown in size and
review and evaluation of existing measures, the
scope. The first release of HCUP data consisted of
selection and specification of measures, distribu-
a statistical sampling of data on inpatient stays in
tion and empirical testing, and further refinement.
community hospitals from 11 participating states.
The indicators spanned the following three dimen-
Currently, agencies and hospitals from a total of 38
sions of hospital care quality: (1) outcomes follow-
states provide census hospital administrative data,
ing surgery, including mortality and complication
representing 90% of all hospital discharges in the
rates, by procedure; (2) utilization, such as the rate
United States. HCUP data originally featured
of cesarean section or coronary artery bypass graft;
aspects of hospital inpatient care but now also
and (3) access to primary care, looking at factors
includes outpatient care provided at U.S. commu-
such as low birth weight and vaccination rates
nity hospitals. The first products of the project
among older patients.
were the Nationwide Inpatient Sample (NIS) data
Despite the methods and expertise employed in
set, a statistical sampling of hospital discharge
their development, careful reviews of the empirical
data, and a set of clinical performance measures
literature and the methods employed in HCUP
constructed from the NIS and known as the HCUP
QI measurement revealed several limitations. The
Quality Indicators (HCUP QIs). Today, HCUP is a
majority of HCUP QIs measured surgical-care per-
suite of databases, software, tools, and reporting
formance and, thereby, inadequately represented
and support systems that enable research on health
the care of chronic medical conditions. Some mea-
outcomes and policy at the local, state, and
sures were not useful in screening for real quality
national levels.
concerns. Moreover, some indicators were inap-
propriately based on hospital-level, rather than
area-level populations. Last, the measures lacked
Databases adjustments for risk and severity. To address these
The HCUP maintains several databases, each of limitations, the AHRQ sponsored new efforts to
which contains encounter-level records for both further refine the QIs. Between 1998 and 2002,
insured and uninsured patients and are compiled select HCUP QIs were removed, and revised meth-
in a uniform format. HCUP data report information ods were invoked for the creation of new and
Healthcare Effectiveness Data and Information Set (HEDIS) 459
improved measures. Under its new name, the AHRQ Data Organizations (NAHDO); National Healthcare
Quality Indicators (AHRQ QIs) are a refinement Quality Report (NHQR); Quality Indicators; Quality
of the HCUP QIs. Management; Quality of Healthcare
AHRQ Quality Indicators Further Readings

Similar to HCUP QIs, the AHRQ QIs are mea- Davies, Sheryl M., Jeffery Geppert, Mark McClellan,
sures of healthcare quality based on hospital, et al. “Refinement of the HCUP Quality Indicators,”
inpatient, administrative data available in the NIS. Technical Review (No. 4). Pub. No. 01–0035.
New methods, addressing the above-mentioned Rockville, MD: Agency for Healthcare Research and
weaknesses of the HCUP QIs, were used to Quality, 2001.
develop the AHRQ QIs. The new measures have Elixhauser, Ann, Mamatha Pancholi, and Carolyn M.
also been reorganized into four foci of quality: Clancy. “Using the AHRQ Quality Indicators to
(1) preventive care (Prevention Quality Indicators Improve Health Care Quality,” Joint Commission
[PQIs]), (2) inpatient care (Inpatient Quality Journal on Quality and Patient Safety 31(9): 533–38,
Indicators [IQIs]), (3) pediatric care (Pediatric September 2005.
Quality Indicators [PDIs]), and (4) patient safety Romano, Patrick S., Jeffrey J. Geppert, Sheryl Davies,
(Patient Safety Indicators [PSIs]). et al. “A National Profile of Patient Safety in U.S.
Although the AHRQ QIs represent conceptual Hospitals Based on Administrative Data,” Health
and methodological improvements over the previ- Affairs 22(2): 154–66, March–April 2003.
ous HCUP QIs, limitations remain. Development Steiner Claudia, Ann Elixhauser, and Jenny Schnaier.
of the AHRQ QIs is based on administrative data, “The Healthcare Cost and Utilization Project: An
and the documentation of patients’ medical con- Overview,” Effective Clinical Practice 5(3): 143–51,
ditions and care received differ across hospitals. May–June 2002.
Zhan, C., and M. R. Miller. “Administrative Data-Based
Administrative data are also limited in its ability
Patient Safety Research: A Critical Review,” Quality
to monitor adverse events, elucidate temporal
and Safety in Health Care 12(Suppl. 2): ii58–ii63,
aspects of care, and distinguish preexisting comor-
December 2003.
bidities from complications resulting from care.
Finally, the indicators do not account for differ-
ences in the environmental conditions that exist Web Site
outside the healthcare system, such as sociodemo-
graphics or patient preferences. Nonetheless, the Agency for Healthcare Research and Quality (AHRQ):
unique features of the AHRQ QIs are a useful http://www.ahrq.gov/data/hcup
resource for identifying quality concerns in health-
care at the hospital, community, state, and
national levels.
Operated and maintained by AHRQ’s Center Healthcare Effectiveness Data
for Organization and Delivery Studies and the and Information Set (HEDIS)
AHRQ QI development team at the University of
California at San Francisco’s Evidence-Based The Healthcare Effectiveness Data and Information
Practice Center, downloadable AHRQ QIs are Set, more commonly called HEDIS, consists of
accompanied by available software, reporting compiled reports from managed-care organiza-
tools, and technical assistance for research in qual- tions concerning their health plan performance on
ity tracking, improvement, comparative analyses, a broad range of clinical and nonclinical mea-
and public reporting. sures. The National Committee for Quality
Assurance (NCQA) developed and released the
Virginia Wang and William R. Carpenter
initial version of the measures in 1993. Although
See also Agency for Healthcare Research and Quality most participation in HEDIS is voluntary, more
(AHRQ); Data Sources in Conducting Health Services than 90% of U.S. health plans submit HEDIS
Research; Hospitals; National Association of Health data, in part to increase their competitiveness but
460 Healthcare Effectiveness Data and Information Set (HEDIS)
also, often, as part of accreditation or certification under a continuous improvement process, which
activities. Health services researchers also use may result in their alteration or removal from the
HEDIS measures to conduct studies of the access, HEDIS set.
cost, quality, and outcome of care.
HEDIS measures are divided into eight catego-
ries: (1) effectiveness of care, (2) access to and New Measurement Controversies
availability of care, (3) satisfaction with the experi- Although NCQA earns broad respect for its
ence of care, (4) use of services, (5) cost of care, measurements, its processes sometimes draw criti-
(6) health plan descriptive information, (7) health cism. For example, the 2006 addition to HEDIS
plan stability, and (8) informed-care choices. Of (after 5 years of debate) of specific blood pressure
these, effectiveness of care is the largest category and glycemic-control outcome benchmarks for
and includes measures dealing with highly specific patients with diabetes mellitus met with resistance
standards of care such as appropriate medication from some areas of the medical establishment.
for asthma patients and the use of medical-imaging Most clinical HEDIS measures focus on process
studies for lower-back pain. Measures in other rather than clinical benchmarks: Some felt that
categories evaluate other aspects of patients’ expe- adding such specific measurements failed to ade-
riences (e.g., the number of customer service calls quately account for comorbidities and other indi-
abandoned) and the business aspects of the health vidual patient variations.
plans (e.g., financial stability). Over time, HEDIS
has evolved to meet changing standards of health-
care and in response to regulatory changes, and Uses of NCQA’s Published HEDIS Reports
NCQA now publishes changes to HEDIS measures NCQA makes HEDIS information available in a
on an annual basis. variety of forms to meet the needs and goals of its
constituencies, chiefly accreditation and certifica-
tion activities, delivering information to organiza-
Development and tional purchasers of health plans, and delivering
Evaluation of HEDIS Measures information to healthcare consumers.
NCQA uses an ongoing process to develop new
HEDIS measures, evaluate existing ones, and
retire those that have outlived their usefulness. Accreditation and Certification
Proposals for new measures first are examined NCQA uses HEDIS reports in many of its
through expert Measurement Advisory Panels national accreditation and certification programs,
(MAPs) tasked with evaluating them using three notably for managed-care organizations, managed-
criteria: (1) relevance (e.g., health importance, behavioral-healthcare organizations, and preferred
cost-effectiveness, and potential for improvement); provider organizations (PPOs).
(2) feasibility (e.g., cost and ability to be audited); Nationally, the federal Centers for Medicare and
and (3) scientific soundness (e.g., basis in evidence Medicaid Services (CMS) require HEDIS reporting
and reproducibility). Once approved by an MAP, from all health plans seeking certification as pro-
the proposed measures move through a process of viders for Medicare parts C (Medicare Advantage)
technical development and field testing before and D (prescription drug coverage). Similarly,
being released for public comment. Measures sub- many states require HEDIS reporting from health
sequently reviewed and accepted by NCQA’s plans seeking certification as Medicaid health
Committee on Performance Measurement (CPM) maintenance organizations (HMOs). A few HEDIS
are added as first-year measures in the new HEDIS measures only apply to plans serving Medicare or
set. NCQA does not provide public reporting on Medicaid patients (e.g., glaucoma screening in
new measures during their first-year status, allow- older adults is collected from Medicare plans only).
ing time for reporting organizations to evaluate Conversely, Medicare and Medicaid plans do not
the initial results and address any technical issues. submit data on some measures (e.g., those evaluat-
In subsequent years, MAPs evaluate the measures ing clinical services not covered by Medicare).
Healthcare Effectiveness Data and Information Set (HEDIS) 461
Organizational Purchasers of Health Plans Incentive Programs

NCQA publishes Quality Compass as a data- Increasingly, managed-care organizations are
base-driven tool for organizational purchasers of implementing physician performance incentive
health plans to use when evaluating competitive programs as one of their initiatives to increase the
products, including cost and member satisfaction quality of healthcare. Although different strate-
information. Quality Compass includes data from gies for measuring performance exist, applying
both commercial plans and Medicaid plans. HEDIS measures has emerged as one of the more
NCQA also offers a Web-based Quality Dividend popular and effective means for incentivizing phy-
Calculator, enabling commercial health plan pur- sician performance. For example, a study of phy-
chasers to explore how the quality of differing sicians in Massachusetts found that using HEDIS
health plans interacts with factors such as work- measures produced performance improvements
force demographics, type of industry, and number and that physicians were more likely to respond
of provided sick days to predict the total impact of positively to evaluation systems based on HEDIS
health plan selection on costs. measures.
Consumer Information Future Implications

On its own, NCQA uses HEDIS data to con- From its origins as a tool for competitive analysis
struct health plan report cards for use by consum- and accreditation, HEDIS has evolved to become
ers in making individual choices about insurance. the gold standard of health plan quality evalua-
However, NCQA’s published HEDIS reports also tion. Given the current configuration of the U.S.
form the basis for many tools and publications healthcare system, NCQA will likely continue
offered by employers; local, state, and federal gov- expanding its reach with new products and publi-
ernment agencies; and the annual health plan rank- cations using HEDIS data to inform health plan
ings presented in U.S. News and World Reports. selection. At the same time, with the current
emphasis on healthcare quality improvement,
HEDIS will likely provide the basis for an expand-
Other Uses of HEDIS Measures ing array of performance initiatives.
However, in the event of substantive changes
Although NCQA’s data collection and reporting to the U.S. healthcare system, HEDIS may play an
remain the primary uses for HEDIS measures, an even more important role. First, in any national,
indication of their general acceptance lies in their healthcare reform movement that mandates indi-
application for non-NCQA purposes, primarily in vidual health insurance, NCQA is well positioned
healthcare research and incentive programs. to make HEDIS the foundation of a national,
selection mechanism, and most managed-care
organizations will likely participate because of
Research increased competition. Second, former senator
The advent and standardization of HEDIS mea- Tom Daschle and others have recently proposed
sures has had two substantial impacts on health- the establishment of a nonpartisan, federal,
care research in addition to the quality assessments healthcare board, combining aspects of the Federal
performed by NCQA. First, the HEDIS measures Reserve Board and the defunct Office of
provide universally understood and widely accepted Technology Assessment to create national stan-
standards that researchers can use as benchmarks dards for healthcare and health coverage. If
when studying the effectiveness of new or modified HEDIS measures are used for some of its initial
clinical interventions. Second, researchers can use standards, NCQA might play a critical role in
these agreed-on benchmarks as the basis for evalu- evaluating compliance with the new body’s rec-
ating nonclinical changes to healthcare delivery, ommendations and rules.
such as those affecting patterns of use, reimburse-
ment rates, or covered services. Jason Rothstein
462 Healthcare Financial Management
See also Competition in Healthcare; Health Report organizations, such as the Joint Commission,
Cards; Managed Care; National Committee for rarely provide requirements for healthcare finan-
Quality Assurance (NCQA); Outcomes Movement; cial managers but, instead, hold the organization’s
Pay-for-Performance; Quality Indicators; Quality of chief executive officer (CEO) responsible for its
Healthcare
financial management. Formal, educational pro-
grams for healthcare financial management are not
common and usually exist as postgraduate certifi-
Further Readings
cate programs. The chief financial officers (CFOs)
Bardenheler, Barbara H., Hooly Groom, Fangjan Zhou, of most large healthcare organizations possess a
et al. “Managed Care Organizations’ Performance in master’s degree in business administration, a bach-
Delivery of Adolescent Immunizations: HEDIS, elor’s degree in accounting, a certificate in public
1999–2002,” Journal of Adolescent Health 42(2): accounting, and have healthcare experience. For
137–45, February 2008. formal, continuing education and certification in
Daschle, Tom, Jeanne Lambrew, and Scott Greenberger. healthcare financial management, managers can
Critical: What We Can Do About the Health Care obtain membership and certification in healthcare
Crisis. New York: St. Martin’s Press, 2008. professional associations such as the Healthcare
Dean Beaulieu, Nancy Epstein, and Arnold M. Epstein. Financial Management Association (HFMA).
“National Committee for Quality Assurance Health-
Plan Accreditation: Predictors, Correlates of
Performance, and Market Impact,” Medical Care General Functions
40(4): 325–37, April 2002.
Healthcare financial management applies account-
Eddy, David M., L. Gregory Pawlson, David Schaaf,
ing and finance functions to healthcare organiza-
et al. “The Potential Effects of HEDIS Performance
tions. It is a broad-based field, drawing from several
Measures on the Quality of Care,” Health Affairs
27(5): 1429–41, September–October 2008.
disciplines and adapting to incorporate current
Lim, Kaiser G., Ashok M. Patel, James M. Naessens,
trends.
et al. “Flunking Asthma? When HEDIS Takes the
ACT,” American Journal of Managed Care 14(8): Accounting
487–94, August 2008.
Accounting is generally divided into two major
areas: financial accounting and managerial account-
Web Sites ing. The purpose of financial accounting is to pro-
vide accounting information, generally historic in
Centers for Medicare and Medicaid Services (CMS): nature, to external users, including owners, lenders,
suppliers, the government, and other insurers.
National Association for Healthcare Quality (NAHQ):
Accounting information prepared for external use
http://www.nahq.org
must follow the formats established by the American
National Committee for Quality Assurance (NCQA):
Institute of Certified Public Accountants (AICPA)
http://www.ncqa.org
and other similar organizations and must also fol-
low the generally accepted accounting principles
used for standardization. The 1996 AICPA Audit
and Accounting Guide for Health Care Organiza
Healthcare Financial tions established four basic financial statements
Management that hospitals should prepare for external use: (1) a
consolidated balance sheet, (2) a statement of
The purpose of healthcare financial management operations, (3) a statement of changes in equity,
is to provide both accounting and finance infor- and (4) a statement of cash flows. A new audit
mation that will assist healthcare managers in guide by AICPA was published in 2008. The new
accomplishing the organization’s purposes. There audit guide includes revenue recognition criteria,
are no licensure requirements to be a practicing including the (a) accounting and disclosures for
healthcare financial manager. Facility-accrediting charity care and other uncompensated care,
Healthcare Financial Management 463
(b) illustrative financial statement disclosures of Major Objectives

activity for settlements due to or paid from third
parties, (c) physician loans and guarantees, (d) The purpose of healthcare financial management
affiliated receivables when collection is doubtful, is to provide accounting and finance information
(e) joint-operating agreements between not-for- that can assist healthcare management in accom-
profit healthcare organizations, (f) transfers of lia- plishing all the organization’s varied objectives.
bilities or net assets between unrelated not-for-profit Yet all organizations have at least one objective in
organizations, (g) a separate guide for continuing- common: to survive and grow. Organizations in
care retirement communities, (h) malpractice and other industries might refer to this as “maximizing
insurance liabilities, (i) contributions and pledges, the owners’ wealth”; healthcare organizations
and (j) auditor association with cost reports. typically refer to this as “maintaining community
The purpose of managerial accounting is to pro- services.” In either case, the organization will be
vide accounting information—generally, current or of little use if it cannot afford to continue to oper-
prospective in nature—to internal users, including ate. Therefore, the most important objective of
managers. Such accounting information supports healthcare financial management is to generate a
the planning and control management functions. reasonable net income (i.e., the difference between
In this way, managerial accounting is the link collected revenue and expenses) by investing in
between financial accounting and the manager, assets and putting the assets to work.
and it, therefore, relies on the information pro- In addition to generating income, another major
vided by financial accounting. Managerial account- objective of financial management in healthcare is
ing, or accounting information prepared for to respond to the regulations of the federal, state,
internal use, requires no prescribed format and, and local governments. Because healthcare organi-
therefore, varies greatly among organizations. zations are in a position to take unfair advantage
Managerial accounting topics, such as budgeting of the sick and the elderly, regulation of the indus-
and inventory control, require a knowledge of eco- try serves to protect individuals who cannot pro-
nomics, statistics, and operations research. tect themselves. Government funding pays more
Many managerial accountants believe that cost than 45% of all healthcare bills and therefore has
accounting, which is the study of costs, including a vested interest in ensuring that the money is well
methods for classifying, allocating, and identifying spent. Healthcare organizations must also meet
costs, is either synonymous with or a subset of quasi-regulations in the form of accreditation or
managerial accounting. Some argue, however, that certification standards to qualify for reimburse-
cost accounting includes all managerial accounting ment from many third-party payers and to qualify
and also requires some financial accounting. Cost for loans from certain lenders. Therefore, the sec-
accounting and managerial accounting include ond objective of healthcare financial management
topics that could be considered part of finance as is to respond to the myriad regulations in a timely
well. and cost-effective manner.
The third objective of healthcare financial man-
agement is to facilitate the organization’s relation-
Finance
ship with third-party payers, who are agents of the
Historically, the purpose of finance has been to patient who have agreed to pay all or a portion of
borrow and invest the funds necessary for the the patient’s bill. Third-party payers account for
organization to accomplish its purpose. Today, the more than 81% of a healthcare organization’s oper-
purpose of finance is to analyze the information ating revenues. Financial management must be
provided by managerial accounting to evaluate responsive to third-party payers and, in many ways,
past decisions and make sound decisions regarding must treat them as customers—in the economic
the future of the organization. It uses techniques sense of the word—because the third party pays
such as ratio analysis and capital analysis and the patient’s bill. At the same time, financial man-
requires knowledge of financial and managerial agement must be attentive to the patient as the
accounting, economics, statistics, and operations customer—in the service sense of the word—
research. because the patient has influence over the third-party
464 Healthcare Financial Management
payer and in some cases may be partially responsi- protecting their tax-exempt status from the
ble for his or her bill. attempts of state and local governments to find
The fourth objective of healthcare financial new revenue sources. The more difficult objective
management is to influence the method and rests with the not-for-profit organizations because
amount of payment chosen by third-party payers. most healthcare organizations are not for profit
Third-party payers are becoming increasingly and corporate, tax-exempt status has come under
aggressive in asking healthcare organizations for increasing judicial and public scrutiny.
discounts if they represent large numbers of
patients. In certain cases, healthcare organizations Value of Healthcare Financial Management
are discounting prices below cost to maintain their
market share. Some third-party payers, such as Healthcare financial management provides
Medicare, are asking healthcare organizations to accounting information and financial techniques
assume part of the financial risk for the patient by that allow managers to perform management
agreeing to a prospective payment, that is, agree- functions and management connective processes;
ing in advance to a price for providing care to the it, therefore, helps accomplish the organizational
patient. Healthcare organizations lose money if objectives. In addition to this important indirect
they provide care that costs more than the prospec- value, healthcare financial management has a
tive payment. Some third-party payers are asking direct value in the performance of the management
healthcare organizations to assume substantial risk functions and management connective processes.
by agreeing to a capitated price, that is, a price per
subscriber, before the subscriber actually needs
Management Functions
care. Capitated prices put healthcare organizations
at risk for the cost of care, if needed, and the Healthcare financial management assists an
extent of the use of care by the subscriber. organization in accomplishing its mission and
Healthcare financial management also strives to goals through planning, organizing, appropriately
monitor physicians and their potential financial staffing, motivating, and controlling the budget.
liability to the organization in terms of their order- After the governing body completes the strate-
ing patterns and their possible negligence. In 2005, gic plan and senior management completes the
physicians and other professionals accounted for operating plan, financial management is often
31% of all healthcare spending in the nation, responsible for completing the operating budget
hospitals were responsible for 31%, and nursing and capital budget. The operating budget often
homes accounted for 6%. Physicians, however, provides the incentives to plan properly.
influence much of the healthcare spending attribut- Financial management provides a chart of
able to hospitals and nursing homes. For example, accounts, based on the organizational chart, that
physicians order the patient’s admission, diagnostic identifies revenue centers and cost centers. Together
testing and treatment, and discharge. Healthcare with the organizational chart, this provides the
financial management must ensure—through the basis for responsibility accounting, that is, holding
utilization review process—that physician-ordering department managers responsible for their reve-
patterns are consistent with what the patient needs. nues and expenses.
Regarding the possibility of physician negligence, Financial management often staffs a variety of
healthcare financial management must ensure— departments and processes important to the health-
through the credentialing process and the risk care organization. Departments such as medical
management process—that the healthcare organi- records and information systems are currently
zation has minimized its exposure to legal liability being placed under the supervision of financial
for the physician’s possible, negligent actions. management, in addition to departments such as
The sixth major objective of healthcare finan- accounting, admitting, and materials management,
cial management is to protect the organization’s which have been traditionally under financial
tax status. For-profit healthcare organizations management. The increasing importance of non-
seek ways of reducing their tax liability, and not- traditional departments in the billing process
for-profit healthcare organizations seek ways of appears to justify this trend.
Healthcare Financial Management 465
Also known as motivating and influencing, depression was characterized by rapidly falling
directing provides financial management with the prices; restrictions on credit, including down-
opportunity to use both rewards and penalties to graded credit ratings; reduced production; numer-
accomplish the organization’s purposes. ous bankruptcies, mergers, and acquisitions; and
The responsibility that is, perhaps, closest to the high unemployment. Although this conclusion is
overall function of financial management—the not comforting, it points out that healthcare is one
control of the budget, financial reports, financial of several industries that society has allowed to
policies and procedures, and financial audits— grow beyond the industry’s ability to produce effi-
allows financial management to monitor perfor- ciently. The same type of growth followed by
mance and take the appropriate corrective action depression occurred in agriculture during the
when performance is unsatisfactory. 1970s and in oil and financial services during the
These management functions mean little with- 1980s; it is predicted that depression in govern-
out the management connective processes to inte- ment and education will follow the depression in
grate them. the healthcare industry.
Regarding bankruptcies, the most notorious
bankruptcy in not-for-profit healthcare history was
Management Connective Processes the Allegheny Health Education and Research
The connective processes of communicating and Foundation (AHERF), which occurred in 1998. The
coordinating are important to financial manage- AHERF was a 14-hospital system in Pennsylvania.
ment for both reporting and advising. Also impor- The AHERF bankruptcy had a chilling effect on
tant is coordinating the relationships between, for bond ratings for most not-for-profit healthcare
example, revenue and expenses, capital budgets organizations.
and operating budgets, and volumes and prices There is significant evidence that the peak of
and collected revenues. the economic depression was in the late 1990s and
Decision making is important to financial that the healthcare industry is on the upside of
management as a direct measure of quality. economic recovery. The percent increase in hospi-
Governing boards, CEOs, and outside sources tal prices has risen steadily since its low in 1997;
(e.g., independent auditors) often judge the qual- hospital outpatient prices have risen an average of
ity of financial management based on the deci- 6.75% through 2004, and hospital inpatient
sions and recommendations made by financial prices have risen an average of 5.56% through
management. The advantage of this view of qual- 2004. Another indication of economic recovery is
ity is that it assumes rational decision making. hospital merger activity, which generally contin-
Decisions made in healthcare financial manage- ues to decline with 142 reported in 1999 com-
ment are often based on politics or other criteria pared with only 50 mergers in 2005. Most of the
that are unknown to the evaluator of the deci- mergers were driven by a desire to consolidate
sion. Therefore, a decision may be evaluated as operations, thus improving efficiency rather than
bad based on the known facts, but it may be financial distress.
evaluated as good based on other criteria unknown
to the evaluator.
Future Implications
Healthcare financial management will continue
Effects of Financial Management
to evolve in the future along with the ongoing
on Changing Healthcare
changes in government healthcare policies. The
One widespread view holds that financial manage- government and private insurers will increasingly
ment is the most important predictor of whether demand greater accountability from healthcare
healthcare organizations will survive in the current organizations. Well-managed healthcare organiza-
competitive climate and beyond. According to one tions will survive, and financial management will
author, the healthcare industry entered an eco- be instrumental to their survival.
nomic depression in the early 1990s that lasted
through 2005. As in all depressions, the healthcare Richard L. Clarke
466 Healthcare Financial Management Association (HFMA)
See also Centers for Medicare and Medicaid Services

(CMS); For-Profit Versus Not-for-Profit Healthcare; Healthcare Financial
Healthcare Financial Management Association
(HFMA); Medicaid; Medicare; Nonprofit Healthcare
Management Association
Organizations; Payment Mechanisms (HFMA)
Further Readings Founded as the American Association of Hospital
American Institute of Certified Public Accountants.
Accountants in 1946, the Healthcare Financial
Health Care Organizations: AICPA Audit and Management Association (HFMA) is a member-
Accounting Guide. New York: American Institute of ship organization for healthcare management
Certified Public Accountants, 2008. executives and leaders. With more than 34,000
Catlin, Aaron, Cathy Cowan, Stephen Heffler, et al. members, ranging from chief financial officers to
“National Health Spending in 2005: The Slowdown accountants, HFMA is a leader on the major
Continues,” Health Affairs 26(1): 142–53, July 1, 2007. financial trends and issues facing the nation’s
Dunn, Rose. Haimann’s Healthcare Management. 8th ed. healthcare industry. Its members are found in all
Chicago: Health Administration Press, 2006. areas of healthcare, including hospitals, managed-
Finkler, Steven A. Finance and Accounting for care organizations, physician practices, account-
Nonfinancial Managers. 3d ed. New York: Aspen, ing firms, and insurance companies.
CCH, Wolters Kluwer, 2003. At the chapter, regional, and national levels,
Finkler, Steven A., David M. Ward, and Judith J. Baker. the HFMA helps healthcare finance professionals
Essentials of Cost Accounting for Health Care Organi meet the challenges of the ever-changing health-
zations. 3d ed. Sudbury, MA: Jones and Bartlett, 2007. care environment by (a) providing education,
Gapenski, Louis C. Healthcare Finance: An Introduction analysis, and guidance; (b) building and support-
to Accounting and Financial Management. 4th ed. ing coalitions with other healthcare associations
Chicago: Health Administration Press, 2007. to ensure accurate representation of the health-
Hsiao, William C. “Why Is a Systemic View of Health care finance profession; (c) educating a broad
Financing Necessary?” Health Affairs 26(4): 950–61, spectrum of key, industry decision makers on the
July–August 2007.
intricacies and realities of maintaining fiscally
Nowicki, Michael. The Financial Management of
healthy healthcare organizations; and (d) working
Hospitals and Healthcare Organizations. 4th ed.
with a broad cross-section of stakeholders to
improve the healthcare industry by identifying
Zelman, William N., Michael J. McCure, Alan R.
Millikan, et al. Financial Management of Health Care
and bridging gaps in knowledge, best practices,
Organizations: An Introduction to Fundamental
and standards.
Tools, Concepts, and Applications. 2d ed. Ames, IA:
Blackwell, 2003.
Chapter Management
Web Sites The HFMA, which is headquartered in
American Institute of Certified Public Accountants Westchester, Illinois, comprises 11 geographic
(AICPA): http://www.aicpa.org regions and 68 local chapters. The local chapters
Centers for Medicare and Medicaid Services (CMS): are where most HFMA members make their first
http://www.cms.hhs.gov networking connections. Local chapters are the
Healthcare Financial Management Association (HFMA): source for much of the guidance and support
http://www.hfma.org members seek and receive. And chapter leader-
National Association of Health Underwriters (NAHU): ship often is a steppingstone to national leader-
http://www.nahu.org ship. Most chapters, either individually or jointly,
U.S. Securities and Exchange Commission (SEC) for hold annual events designed to promote educa-
Publicly Traded Healthcare Companies: tional, career, and networking opportunities for
http://www.sec.gov/edgar.shtml their chapter members.
Healthcare Financial Management Association (HFMA) 467
Educational Opportunities helps prepare for and demonstrate dedication to

professional development.
Through national and chapter programs, HFMA
annually offers its members more than 465,000
educational hours. Educational opportunities range Vendor Resources and
from traditional seminars and conferences to the Peer Review Process
audio Webcasts, e-learning courses, targeted forums,
HFMA offers healthcare industry vendors numer-
and communities of practice.
ous sponsorship, advertising, and exhibitor oppor-
tunities. Vendors can also have products and
Traditional Education Activities services reviewed through HFMA’s peer review
process. The peer review process is designed to
The centerpiece of HFMA’s educational offer-
provide healthcare financial managers with an
ings is its Annual National Institute (ANI). Held
objective, third-party evaluation of products and
annually in June, the ANI offers more than 80
services used in the healthcare finance workplace.
educational sessions, keynote addresses from
Peer review consists of a rigorous review by a peer
industry leaders, and an opportunity to network
review panel consisting of current customers,
with more than 4,000 healthcare professionals in
prospects who have not made a purchase, and
a relaxed yet focused environment. In addition,
HFMA members. After successfully completing
HFMA holds annual Executive Summit and
the process, vendors may use a “Peer Reviewed by
Revenue Cycle Strategies Conferences.
HFMA” mark to communicate their involvement
to potential customers.
Alternative Learning Activities
HFMA’s audio Webcasts offer a convenient HFMA’s Statements
way for members to obtain information on health-
Vision
care finance topics. HFMA offers on-site, educa-
tional training. And e-learning offers more than HFMA’s vision is “to be an indispensable
700 Web-based training courses, including avoid- resource for healthcare finance.”
ing claims denials, claims denial management,
finance, billing, and cost control.
Purpose Statement
HFMA’s purpose is to define, realize, and
Career Development
advance the financial management of healthcare
HFMA offers a variety of resources to assist its by helping members and others improve the busi-
members in developing their careers. Members ness performance of organizations operating in or
can receive HFMA’s free, biweekly newsletter, serving the healthcare field.
Career Opportunities; access free career advice;
and view job openings nationwide through the
Quality Statement
HFMA job bank.
Quality is the foundation of the association and
the keystone of its efforts to ensure member and cus-
Certification Programs tomer satisfaction. HFMA’s objective is to (a) consis-
Healthcare finance professionals seeking to pre- tently provide services and products that meet the
pare for increasingly responsible positions can com- quality expectations of its members, customers, and
plete one of HFMA’s certification programs. HFMA employees; (b) actively pursue a program of continu-
offers certification in the designations of Certified ous quality improvement that enables employees and
Healthcare Financial Professional (CHFP) and volunteers to do their jobs right the first time;
Fellow of the Healthcare Financial Management (c) make quality a major, strategic association goal,
Association (FHFMA). Achieving these designations lying at the heart of everything done for members
468 Healthcare Informatics Research
and customers; and (d) strive continually to improve Further Readings

the quality of services and products offered, the pro- Healthcare Financial Management (monthly magazine)
cesses and procedures used to produce them, and the Healthcare Financial Management Association
manner in which they are delivered. newsletters: Business of Caring, Patient Friendly
Billing, Revenue Cycle Strategist, Strategic Financial
Planning, Supply Chain Solutions
Values Statement
HFMA believes (a) that service to members is
our highest priority, (b) in excellence in all that we Web Sites
do, (c) that teamwork is essential in meeting the Healthcare Financial Management Association (HFMA):
objectives of the association, (d) in the importance http://www.hfma.org
of individuals, (e) in encouraging innovation and Patient Friendly Billing Project: http://www.hfma.org/
creativity, and (f) in conducting the association library/revenue/PatientFriendlyBilling
with financial responsibility and a prudent
approach to business.
Code of Ethics
Healthcare Informatics
Members of HFMA agree to endeavor to pro-
Research
mote the highest standards of professional conduct
by practicing honesty and maintaining personal Healthcare informatics is a specialty area that
integrity, including (a) avoidance of conflicts of integrates health science, computer science, infor-
interest with those of their employer or the HFMA; mation science, decision science, and management
(b) striving for the objective and fair presentation science to manage and communicate data, infor-
of financial information; (c) fostering excellence mation, and knowledge in healthcare practice and
in healthcare financial management by keeping management. In addition, healthcare informatics
abreast of pertinent issues; (d) maintaining the facilitates the integration of data, information,
confidentiality of privileged information; (e) pro- and knowledge to support patients, providers, and
moting a greater understanding of financial man- healthcare executives in their decision making in
agement issues by others in the healthcare field, all roles and settings. Specifically, healthcare
and seeking increased public understanding informatics research can be defined as a system-
through communication about such issues; and (f) atic process of compiling, analyzing, and simulat-
seeking to maintain a reasonable balance between ing data to produce verified and replicated findings
the quality and cost of healthcare. from observed facts or phenomena.
Analytical Strategies
Diversity
The analytical strategies of healthcare informatics
HFMA values and respects diversity. Individual research are shown in Figure 1. The specific strat-
differences are viewed as assets that promote the egies include the formulation of a data warehouse,
growth and success of HFMA and its members. In data mining, the application of confirmatory sta-
principle and in practice, HFMA encourages and tistical analysis, simulation and optimization via
supports diverse individual viewpoints and contri- an interface with computer and information sys-
butions. HFMA believes that a diverse member- tem technologies, and translational research.
ship is a quality membership.
Richard L. Clarke
Data Warehousing
(CMS); Healthcare Financial Management; Medicaid; Data warehousing is the systematic structuring
Medicare; Payment Mechanisms of data in a theoretically informed framework
Healthcare Informatics Research 469
care or services, identifying causal paths or root

Data causes for problems in service delivery, profiling
warehousing
best practice models, establishing benchmarks for
continuous performance enhancement, and dif-
Data mining
ferentiating the mechanisms for achieving high
performance in a healthcare delivery system.
Constraint-oriented
Exploratory statistical modeling
Structural equation modeling
reasoning methodology: Confirmatory Statistical Analysis
Simulation
Measurement models
Structural relationships
Optimization Confirmatory statistical analysis is the applica-
Benchmarking
tion of multivariate, statistical methods, such as
structural equation modeling, to validate or con-
firm a theoretically constructed model. This model-
Graphical user ing approach often involves latent variables,
interface (GUI)
particularly those related to perceptions of health
and the quality of care. Thus, the measurement
model of the theoretical constructs is designed and
evaluated to determine the validity and reliability
Decision making
of the measurement instrument used. Then, func-
tional or causal relationships among the study
Figure 1 Analytical Strategies for Healthcare variables are evaluated using a structural equation
Informatics Research model to determine its goodness of fit to the data
gathered from the field study. Relevant examples
Source: Adapted from T. T. H. Wan’s “Healthcare include nursing home quality measurement, patient
Informatics Research,” Journal of Medical Systems 30(1):
care outcomes, information technology application,
3–7, 2006.
system integration, and hospital performance.
shared by the disciplinary focus as a means to pro- Simulation and Optimization Methods
duce useful information for exploration. Analysts Simulation and optimization methods play an
extract data from multiple sources; build a rela- important role in healthcare research regarding
tional database, which is continuously maintained organizational performance, through which resear
and updated; and classify and populate the study chers develop interfaces between analytical model-
variables uniformly under a nosological or other ing and operations research. For instance, the
classification system. A more current approach to application of the data envelopment analysis (DEA)
data structuring is the reliance on a data-sharing to identify the best practice in community health
design that enables the functioning of a pooling or centers can suggest avenues for improving the cen-
pushing data system from multiple sources or units ters’ productivity and performance. The application
of healthcare organizations. Personal identifiers of tabletop exercises to simulate disaster manage-
are, generally, encrypted to ensure the confidential- ment and planning is another germane example.
ity and security of the shared data. Graphical user interface (GUI) presentations should
be developed so that simulated results can guide
managerial and constructional decision making.
Data Mining
Data mining is the use of myriad exploratory
and confirmatory statistical techniques to trans- Translational Research
late masses of raw data into valuable information Translational research plays an important role in
for managerial decision makers. The benefits of converting scientific knowledge into routine prac-
data mining include understanding the patterns of tices in the design and evaluation of healthcare
470 Healthcare Informatics Research
management interventions. With the aide of infor- The Evidence-Based Modeling Approach
mation and communication technology, practitio-
The field of evidence-based informatics is defined
ners, healthcare executives, and decision makers can
as the study of information science applications in
rely on evidence-based knowledge to improve the
the context of healthcare management to compile,
effectiveness of health management interventions.
manage, and process data and knowledge for
The most important use of information and
improving the performance of healthcare organi-
communication technology is to enhance patient-
zations. The process of evidence-based, healthcare
centric care so that the quality of healthcare
management modeling and simulation is presented
organizations can be improved and sustained.
in Figure 2. Specifically, the process begins with a
The national Institute of Medicine’s (IOM’s)
formulation of the study problem that is guided
Committee on Crossing the Quality Chasm:
by a theoretically informed framework to specify
Next Steps Toward a New Health Care System
the interrelationships among the study variables.
strongly advocates that, at the point of care, the
The analytical model is then specified and subse-
clinician and patient should review the results of
quently built iteratively with testable hypotheses.
the care the patient has received and then use
This approach can be used as the basis for
scientific knowledge to decide together on con-
designing an empirical study that can, in effect,
tinuing care.
serve as a launching point for constructing confir-
matory statistical models in which the measure-
Significance ment model and the causal models could be fully
developed and validated. The validated or veri-
The nation’s healthcare system is evolving in such a
fied results form the foundation and constraints
way that good evidence is both available and actu-
for simulation and multivariate optimization
ally used to stimulate effective performance by
modeling. Thus, a decision support system for
healthcare executives. The healthcare system’s
managerial operations can be formulated and
performance can benefit by integrating multidisci-
further tested. The simulation is run and evalu-
plinary perspectives to generate evidence-based
ated as a valid representation of the real-world
knowledge and decision support modeling. Thus,
system.
organizational performance at both the patient care
Upon completion of this validation, the simula-
and management levels can be improved. The sig-
tion model may then be used to assess the real-
nificance of healthcare informatics research has been
world system and prescribe the implementations
highlighted in numerous proceedings published by
for the desired effects for improving the perfor-
the American Medical Informatics Association
mance of healthcare organizations. In this case, the
(AMIA) and the International Medical Informatics
injection of artificial data emulating changes in
Association (IMIA). The knowledge generated and
input variables into the simulation that has been
transformed by healthcare informatics research can
validated as predictive of better performance is
be greatly enhanced by the effective use of informa-
used to guide the healthcare executives’ decisions
tion and communication technologies.
for performance enhancement. Empirical examples
There are limited interdisciplinary training pro-
illustrating the intricacies of applied healthcare
grams focusing on healthcare informatics in the
informatics research in optimizing inputs to achieve
United States. The National Committee on Vital
better outputs can be found in nursing home man-
and Health Statistics (NCVHS), public advisory
agement research, nursing care staffing, and infor-
body to the secretary of the U.S. Department of
mation system integration.
Health and Human Services (HHS), suggests that
a significant amount of investment is needed to
build a solid healthcare information infrastructure Future Implications
and to train a corps of health informatics pro-
fessionals. The U.S. Congress is considering the It is widely recognized that healthcare manage-
appropriation of funds for training and research in ment technology is underused and underdevel-
healthcare informatics under the auspices of the oped. To achieve improvements in access, cost,
National Science Foundation (NSF). and quality of care, patient-centric, information
Healthcare Informatics Research 471
Identify the study problem
Specify the relationships among study variables under a

theoretically informed framework
Build an analytic model with testable hypotheses
Develop causal Collect Identify controls

models data or confounders
Confirmatory statistical modeling
Validate Verify Validate

measurement model fit causal
model statistics model
Simulation and modeling
Design decision support system
Figure 2 Evidence-Based Modeling Approach in Healthcare Informatics
technology-based networks should be built to pro- the effects of clinical and managerial interventions
vide vital, medical information at the point of care on patient care outcomes through the development
to enhance patient care outcomes. Although the of evidence-based decision support systems for
establishment of empirical research on healthcare optimizing the performance of healthcare organi-
management is timely, the future of healthcare zations. Currently, the field of healthcare informat-
informatics research and development relies on the ics plays an important role in establishing knowledge
application of knowledge to actual practices. For management applications and information tech-
instance, translational research should generate nology services. This role will likely broaden and
evidence-based knowledge to guide the develop- greatly increase in importance in the future.
ment and implementation of consumer-oriented
health information technology that could be Thomas T. H. Wan and Keon-Hyung Lee
embedded in handheld devices (e.g., an i-Phone). See also Clinical Decision Support; Computers; Data
Research activities using massive amounts of clini- Privacy; Data Security; Data Sources in Conducting
cal and administrative data should be promoted. Health Services Research; Health Communication;
Another important step forward would be Health Informatics; Health Insurance Portability and
achieving a clearer and improved understanding of Accountability Act of 1996 (HIPAA)
472 Healthcare Markets
Further Readings and the diffusion of new technologies similarly

Haux, Reinhold. “Health Information Systems: Past, depends on defining markets.
Present, Future,” International Journal of Medical Although definitions vary across services, there
Informatics 75(3–4): 268–81, March–April 2006. are efforts to define healthcare provider markets on
Hebda, Toni, and Patricia Czar. Handbook of a national basis. Health Service Areas (HSAs), for
Informatics for Nurses and Healthcare Professionals. example, describe the geographic area from which
4th ed. Upper Saddle River, NJ: Pearson Prentice an individual hospital’s patients originate. Similarly,
Hall, 2008. Heath Referral Regions (HRRs) define the larger
Lee, Kwangsoo, and Thomas T. H. Wan. “Information geographic area from which patients travel for ter-
System Integration and Technical Efficiency in Urban tiary medical care (e.g., cardiac surgery). This dis-
Hospitals,” International Journal of Healthcare tinction illustrates the point that healthcare markets
Technology and Management 5(6): 452–62, May are not uniform; rather, they depend on specific
2003. clinical services, not to mention clinical quality, and
Steward, Duane, and Thomas T. H. Wan. “The Role of even intangibles such as bedside manner.
Simulation and Modeling in Disaster Management,” Although research on healthcare markets encom
Journal of Medical Systems 31(2): 125–30, April passes a broad literature, the followings sections
2007. on hospital and pharmaceutical markets illustrate
Tan, Joseph K. H., ed. Healthcare Information Systems key concepts.
and Informatics: Research and Practices. Hershey, PA:
Medical Information Science Research, 2008.
Wan, Thomas T. H. “Healthcare Informatics Research: Hospital Markets
From Data to Evidence-Based Practice,” Journal of
Hospital markets are among the most studied in
Medical Systems 30(1): 3–7, February 2006.
health services research. As with much of health-
Wan, Thomas T. H., Jackie Zhang, and Lynn Unruh.
care, hospital markets are wrought with complex-
“Predictors of Residents’ Outcomes in Nursing
ity. Insurers, for example, form networks of covered
Homes,” Western Journal of Nursing Research 28(8):
974–93, December 2006.
hospitals and physicians. Insurers heavily influence
consumers’ prices and thus influence hospital mar-
kets. Furthermore, hospitals are differentiated in
Web Sites
both service mix and quality. Each of these factors
plays a role in defining provider markets in general
American Medical Informatics Association (AMIA): and hospital markets in particular.
http://www.amia.org Historically, regulatory concerns such as anti-
Centers for Disease Control and Prevention, National trust laws have driven hospital market definitions.
Center for Public Health Informatics (NCPHI): In theory, markets are the smallest group of prod-
http://www.cdc.gov/ncphi ucts and the smallest geographic area in which a
International Medical Informatics Association (IMIA):
hypothetical monopolist could impose a small but
http://www.imia.org
significant nontransitory price increase (SNPI). Both
the U.S. Department of Justice and the Federal
Trade Commission define an SNPI as a 5% price
Healthcare Markets increase. A single hospital may, of course, face dif-
ferent markets for different services.
Healthcare markets define the set of consumers In practice, hospital markets have been difficult
and producers that influence healthcare price and to define. Initial efforts defined markets as a fixed
quality. Market definitions are of tremendous radius (e.g., 15 miles) about a hospital. Fixed dis-
policy importance and have been studied exten- tances were often determined by the distance refer-
sively. These definitions have, for example, been ring physicians would regularly drive to see patients.
crucial to understanding the relationship between A natural alternative has been to use urbanized
competition and both financial and health out- areas, such as metropolitan statistical areas (MSAs).
comes. Understanding medical expenditure growth Although these ad hoc definitions may be reasonable
Healthcare Markets 473
proxies for markets, they are undoubtedly imper- category. Although there is no single universally
fect. Furthermore, analyses of markets may differ accepted set of therapeutic categories, the intuition is
based on how they are defined. clear: Cardiac drugs, for example, might be part of
Subsequent research used patient flow data to one market, whereas asthma drugs are part of another.
define markets. Examples include the aforemen- Naturally, these categories may be further refined:
tioned HSAs and HRRs. Markets were, essentially, Cardiac drugs, for example, could be subdivided into
defined as the geographic areas (i.e., 5-digit zip arrhythmia and high cholesterol treatments.
codes) from which their patients originated. While under patent protection, a drug’s market
Although appealing, patient flow data may under- includes therapeutic substitutes—chemically differ-
estimate the true market size by excluding patients ent products that treat the same condition.
who might otherwise choose a given hospital were Subsequent to patent expiration, competitors are
its quality higher or prices lower. Conversely, such free to market chemically equivalent (i.e., generic)
data may overestimate the market size if some substitutes. Generic entry plays a crucial role in the
patients are willing to travel long distances to reach definition and function of pharmaceutical markets.
a specific hospital. This might occur if patients are As with other healthcare markets, insurance
aware of hospital quality, a factor that is unac- plays an important role. Insurers can influence
counted for in market definitions. pharmaceutical use by effectively setting the drug
Recent studies have recognized that hospitals prices for their beneficiaries. Insurers first define a
compete not only for patients but also for insur- drug formulary—that is, a set of drugs that are cov-
ance network inclusion. Empirical work in this ered by the insurer. Conditional on drug formulary
literature builds on patient flow data by modeling inclusion, insurers then set the prices paid by their
individual patient’s hospital choices. To date, these beneficiaries, typically a copayment. Markets for
studies indicate that actual markets are effectively Medicare beneficiaries, Medicaid recipients, and
smaller than those suggested by raw patient flow private insurance enrollees are typically distinct,
data. These findings suggest that consumers’ with further subdivisions within each category.
choices are heavily influenced by factors unob- From a geographic perspective, pharmaceutical
served by researchers. markets are largely national, a marked difference
The basic principles underlying hospital market from healthcare provider markets. Pharmaceutical
definitions likely apply to other healthcare provid- markets are, however, differentiated across nations.
ers as well. The markets for most providers, such as Prices, for example, are typically much higher in
physicians and long-term care facilities, are defined affluent nations than in less advantaged nations.
by a geographic area and a clinical specialty or Two policy initiatives threaten to undermine these
focus. Furthermore, insurers typically play a crucial differences. International reference pricing, often
role in forming a set of competing providers. used by European nations, sets one nation’s price
as a function of the prices used by other nations.
Similarly, reimportation breaks down cross-nation
Pharmaceutical Markets
price differences by allowing pharmaceuticals in
Pharmaceutical markets are drastically different one nation to be resold in another. Currently, reim-
from healthcare provider markets. These markets portation is allowed within the European Union
are characterized by tremendous research and (EU) but banned between most other developed
development (R&D) costs, often exceeding $1 billion nations. These policies effectively lower prices for
per new product. Patents, a government sanc- those who would otherwise pay the most. They
tioned monopoly right, are issued as an incentive may, however, raise prices for the relatively poor.
to firms to make R&D investments. Typically, a
pharmaceutical firm is guaranteed exclusive rights
Future Implications
to market a new chemical entity for the patent’s
term—that is, 20 years from the filing date. Further research is needed to understand the role
Pharmaceutical markets comprise drugs that treat of healthcare markets. Promising techniques from
the same condition; these drugs form a therapeutic the hospital market literature hold the potential to
474 Healthcare Organization Theory
address many research and policy questions. propositions have been applied to and tested in
Crucial questions regarding quality and competi- healthcare settings; healthcare organizations,
tion, as well as the role of new technologies, which exhibit somewhat distinctive features, have
remain to be addressed. Likewise, other markets, posed special problems for researchers, who have
such as for physician services and medical devices, contributed to the development of organization
remain understudied. theory.
Jeffrey S. McCullough
Background
See also Antitrust Law; Competition in Healthcare;
Health Economics; Health Insurance; Hospitals; Organization studies did not emerge as an aca-
Multihospital Healthcare Systems; Pharmaceutical demic discipline until the late 1950s; before that
Industry; Regulation time, organizations were not very significant play-
ers in healthcare. Hospitals were the major organi-
zational form, but most were small, nonprofit,
Further Readings “voluntary” structures closely connected to and
Bloom, Gerald, Hilary Standing, and Robert Lloyd. embedded in the local communities they served.
“Markets, Information Asymmetry and Health Care: Physicians worked as independent professionals,
Towards New Social Contracts,” Social Science and billing individual clients for service, often on a slid-
Medicine 66(10): 2076–87, May 2008. ing scale taking into account a client’s ability to
Capps, Cory, David Dranove, and Mark Satterthwaite. pay. Well into the 1950s, healthcare in the United
“Competition and Market Power in Option Demand States was a cottage industry—small in scale,
Markets,” RAND Journal of Economics 34(4): decentralized, and locally governed. What struc-
737–63, Winter 2003. ture there was came not from the government or
Federal Trade Commission and the U.S. Department of from healthcare organizations but rather from the
Justice. Improving Health Care: A Dose of controls exercised by professional occupations—in
Competition. Washington, DC: Federal Trade particular, the American Medical Association
Commission and the U.S. Department of Justice, 2004. (AMA).
Roth, Alvin E. “The Art of Designing Markets,” Organization studies have evolved over time,
Harvard Business Review 85(10): 118–26, 166, moving from more micro to more macro forces
October 2007. and structures. Early students of organizations
White, Joseph. “Markets and Medical Care: The United concentrated primarily on organization behavior—
States, 1993–2005,” Milbank Quarterly 85(3): the behavior of individuals and groups operating
395–448, September 2007. within the context of an organization. Later stu-
dents, during the 1960s, turned their attention to
organizations as themselves objects of study, as
Web Sites
collective actors varying in structure and opera-
Area Resource File (ARF): http://www.arfsys.com tions. This work—including comparative organi-
Dartmouth Health Atlas: http://www.dartmouthatlas.org zational studies, the development of contingency
Federal Trade Commission (FTC): http://www.ftc.gov theory, and transaction cost theory—emphasized
U.S. Department of Justice (USDOJ): the importance for an organization of the wider
http://www.justice.gov environment or context in which it was located.
More recently, beginning during the mid-1970s,
we witnessed the creation of a number of theoreti-
Healthcare Organization cal perspectives—resource dependence, population
ecology, institutional theory—that examine the
Theory operation of larger systems of organizations,
including organizational populations and organi-
The scholarly field of organization studies and the zational fields. The changing foci of scholarship
empirical world of healthcare organizations have are clearly reflected in the research on healthcare
grown up together. Organizational concepts and organizations.
Healthcare Organization Theory 475
Occupational Structure and Behavior were important factors in structuring a physician’s

Within Healthcare Organizations location and mode of practice. Informal connec-
tions were important for obtaining patient refer-
The earliest studies of the organization of health- rals and appointment to hospitals’ staffs. By the
care were conducted by students of occupations beginning of the 1950s, about 35% of physicians
and professions. During the 1930s, scholars such had moved into specialized practice, and physi-
as A. M. Carr-Saunders in England and Everett cians began to cluster in multispecialty, group
C. Hughes and Talcott Parsons in the United practice settings. Studies by numerous scholars,
States began to examine the distinctive control including Joseph Ben-David, Eliot Freidson, and
systems devised by professional groups—in par- George Silver, examined the effects on physicians’
ticular, physicians—to manage their work. behavior of differences in their practice settings.
Professional occupations sought control over the Such studies have, of course, become much more
structure and activities of training systems through common as more and more physicians locate their
accreditation, and they fostered the creation of practice in organizational settings. For example,
collegial controls both informal and formal, the James C. Robinson has recently examined the con-
latter exercised primarily through activities consequences for medical practice of variations in set-
ducted by the professional associations. The tings including “virtual” arrangements such as (a)
backing of the government was secured to ensure Independent Practice Associations (IPAs), (b) mul-
that only licensed practitioners had access to tispecialty medical groups, (c) physician practice
specified titles, positions, and activities. During management systems, and (d) physician-hospital
the 1950s and 1960s, important studies exam- organizations. Such settings vary greatly along
ined the structure, “power, purpose, and politics” dimensions such as the ways in which incentives
of the AMA, which by that time had become one are structured, the extent to which physicians are
of the most powerful professional associations in colocated in the same work setting, the type of col-
the nation. legial controls exercised, and the nature and extent
Gradually, scholars began to turn their atten- of managerial authority.
tion to the interaction of occupations and organi- While physicians have received much attention
zations. Professionals were not only operating in studies of healthcare organizations, an extensive
within and affected by their occupational associa- body of research also exists on organizational fac-
tions but also by the organizational settings in tors affecting other types of professions, including
which they increasingly trained and worked. nurses, chiropractors, pharmacists, and medical
During the early 1950s and 1960s, sociologists social workers.
such as Everett C. Hughes, Howard S. Becker, and
Robert K. Merton conducted insightful studies
Determinants and Consequences of
examining the nature of professional socialization
Structures in Healthcare Organizations
and training in medical schools. How do medical
students cope with the vast amount of material to Moving to the organizational level, far and away
be learned? How do they learn to conduct intimate more scholarly attention has been devoted by
physical examinations of patients or deal with organizational scholars to the study of hospitals
pain, disability, and death? On what basis do they than to any other type of organization. Informative
decide whether or not to specialize or choose historical investigations of changes in the nature
which specialty to pursue? of U.S. hospitals have been provided by Paul Starr,
Physicians are exposed to organizations not Rosemary Stevens, William D. White, and Charles
only in their training but, to an ever-increasing E. Rosenberg, among others. In the early 20th
extent, in their practice settings as well. Until late century, hospitals were places where indigent
in the 20th century, most physicians were solo patients went to die and where inquisitive physi-
practitioners, operating in small, private offices cians went to learn more about disease. However,
and looking after the health needs of their private aseptic procedures improved and medical care
patients. As studies by Oswald Hall during the practice became more complex, requiring ever
1940s revealed, ethnic and religious identification more expensive equipment, and by midcentury,
physicians had come to depend on hospitals for between physicians and trustees. Other research-
the care of their patients. Hospitals became indis- ers, such as W. R. Scott and Ann B. Flood, exam-
pensable to professional, medical practice, serv- ined structural sources of variation in quality of
ing, in Herman Somers and Anne Somers’s term, care, attending primarily to the structure of the
as “the doctor’s workshop.” medical staff and of the hospital wards. When,
during the 1960s, the costs of healthcare services
began their seemingly inexorable rise, economists
A Distinctive Structure
attempted to assess what hospital characteristics
In the United States, physicians and hospitals were associated with cost differences. They exam-
have developed a unique structure. As Harvey ined, variously, the effect on costs of features such
Smith pointed out in 1955, American hospitals as services and case-mix, size, teaching status, type
exhibited a “dual authority structure”—one of ownership, and membership in a hospital sys-
administrative, the other professional. With only a tem. More recently, researchers have examined the
few exceptions, such as pathologists, physicians diffusion across hospitals of various management
did not become hospital employees. Rather, they reforms, such as matrix management and the total
organized themselves as a “medical staff” to exer- quality management (TQM) approaches to improv-
cise control over the care of their individual ing quality.
patients, whom they admitted for specialized treat- Although most research attention has been
ment, as well as to govern their own members, devoted to hospitals, organization scholars have
through the formation of staff selection, tissue also examined the structure, operation, and perfor-
auditing, and other committees. Hospital adminis- mance of other, more specialized, healthcare orga-
trators, rarely themselves physicians, were respon- nizations, including multispecialty clinics, health
sible for the oversight of the building, equipment, maintenance organizations (HMOs), skilled-nursing
patient wards, housekeeping, and ancillary ser- facilities, home health agencies, and hospices.
vices. The patient received two bills: one for the
hospital and the other for medical (physician’s)
Healthcare Systems
services. The American model was exceptional: In
Europe, hospitals were typically directed by physi- From their beginnings as small, independent,
cians, employed a full-time staff of physicians, and widely scattered units, hospitals have grown enor-
were operated as public, not private, institutions. mously in size, complexity, and connectedness dur-
In contrast to physicians, other U.S. healthcare ing the past several decades. As technologies have
professions—in particular, nurses and social become more complex, physician services more
workers—while granted circumscribed decision- differentiated, and economic competition more
making autonomy were subordinated to the intense, hospitals have increasingly become more
administrative structure. A growing range of horizontally and vertically integrated. Initially,
paraprofessionals—such as laboratory technicians, hospitals entered into loose affiliations with neigh-
inhalation therapists, and radiological personnel— boring similar units—forming hospital chains—in
staffed hospital departments. All were subject to an effort to reduce competition, increase econo-
dual control: receiving orders and directions from mies of scale, and improve learning opportunities.
physicians but being coordinated and routinely The pioneers in system development in the United
supervised by managerial personnel. States were Catholic hospitals, but their systems
Not all organizational scholars focused their largely reflected the organizational structure of the
primary attention on the authority structure that church hierarchy and had little effect on the opera-
had evolved in hospitals. Many conducted research tional relations among other hospitals.
in healthcare organizations to apply and test the Since the 1970s, many hospital systems have
general propositions emerging from organization moved beyond the horizontal integration of simi-
theory. For example, Charles Perrow examined the lar organizations to build linkages among a diverse
way technological developments worked to shape set of organizations, including outpatient clinics,
the differentiation and structuring of hospitals as extended-care services, urgent-care facilities,
well as changing the power-dependence relations HMOs and other physicians groups, rehabilitation
Healthcare Organization Theory 477
units, home health agencies, and hospices. These of, and retention of organizational attributes as
connections may involve outright ownership, some these are affected by competition among organiza-
sharing of equity, or contractual relations. Studies tions in the same or related populations. Organi
by Stephen M. Shortell, Jeffrey A. Alexander, and zations of the same type not only compete but also
others point out that hospital systems vary in the look to one another for ideas as to how to act and,
loci of their integration: Some are constructed often, form associations to further their mutual
around hospitals, others around medical groups, interests.
and still others around insurance companies. They The population perspective on organizations rep-
also vary greatly in their governance structures, resents a fundamental shift in organization scholars’
some adopting a parent holding company model view of organizational change. Rather than stress-
of relatively lose integration; others a more cen- ing purposive—primarily managerial—choice, more
trally integrated model, with a systemwide gover- attention is given to the presence of situational con-
nance structure; and still others a full-fledged straints (the environment) and to random and emer-
corporate model, with specialized managers over- gent factors (chance and contingency). Selection
seeing strategic, financial, and marketing func- processes are emphasized over adaptation. Organi
tions. Although compared with other industrial zational ecologists emphasize the limits of manage-
and service sectors in the United States, hospitals rial control due to both cognitive factors and
were slow in moving toward more concentrated organizational inertia—that is, resistance to change
modes of operation and adopting the corporate due to sunk costs and vested interests.
form of governance, in recent decades they have Organizations of the same type often are formed
rapidly acquired most aspects of the modern orga- at roughly the same time, in response to some
nizational vocabulary. opportunity in the environment, and draw on
the same types of organizing resources. Thus, as
reported by Jeffrey A. Alexander and Terry
Organization of the Wider
Amburgey, community hospitals in the United
Healthcare Environment
States were founded in large numbers in the early
As suggested by the forgoing comments on the years of the 20th century, and the basic features of
growth of healthcare systems, organizing processes their organizational structure were laid down at
are not confined within the boundaries of a given that time. New organizational populations emerge
organization. Modern, societal structures are char- slowly, but when they become recognizable to their
acterized by the elaboration of cultural and rela- publics and are regarded as an improvement on
tional connections linking social actors and earlier, alternative forms, they can increase rapidly,
organizations across wider arenas. Organizational having acquired legitimacy. Sometimes, new popu-
scholars have examined these developments princi- lations result from changes in institutional rules.
pally in the course of research on organization Thus, the emergence and rapid growth of HMOs
populations and organization fields. during the 1970s was primarily the result of fed-
eral legislation supporting this form, as Douglas R.
Wholey has demonstrated.
Organization Populations
An organization population is analogous to a
Organization Fields
biological species. It comprises organizations shar-
ing roughly the same form and operating systems An analysis of organization fields shifts atten-
and reliant on the same resources. As developed by tion to an even higher level to examine the interde-
scholars such as Howard Aldrich, Joel A. C. Baum, pendence of diverse populations of organizations
and Michael Hannan, organization ecology exam- working in the same arena. The concept of field
ines the founding, growth, and decline of popula- exploits the insight that “local social orders” con-
tions of organizations in relation to changes in stitute the building blocks of contemporary
their material resources and institutional environ- societies. Fields are inhabited by a collection of
ments. The focus is on the operation and effects of competing and cooperating organizations together
such basic processes as variations among, selection with their major suppliers and consumers and by
the regulatory and funding bodies, often at distant was marked by the growing number and influence
locations, that profoundly affect their operation. of physicians in private practice, their professional
Key components of organization fields include associations (primarily, the AMA) and indepen-
(a) organization archetypes, (b) relational systems, dent community hospitals. Healthcare organiza-
(c) governance arrangements, and (d) cultural- tions were small and unspecialized. Connections
cognitive systems. Archetypes are models for the among actors were sparse, primarily informal,
basic types of organizations that inhabit the field. and local. Governance structures were dominated
In any given field, we find a delimited number of by professional associations, except for the state
models for organizing. For example, there are a agencies that enforced licensure provisions at the
relatively small number of types of organizations behest of these associations. Primary cultural-cog-
that deliver healthcare services in the United States nitive frames stressed a nonprofit, voluntary ethos,
at the present time. The organizations in a field are and the central institutional logics stressed quality
connected in a variety of ways, both directly and of care—as defined by the physician.
indirectly, in relational systems. In some fields, A surge in the number of healthcare profession-
these connections are infrequent and brittle; in als and facilities occurred following World War II.
others, they are routine and strong. They vary also Hospitals, with the help of federal funding, grew
in the extent of their fragmentation and centraliza- much larger and more differentiated, and indepen-
tion. Field-level governance systems are arrange- dent physicians increasingly organized themselves
ments that support the regularized control—whether in multispecialty groups. Large employers subsi-
by mutual agreement, legitimate authority, or coer- dized healthcare coverage for their employees, and
cive power—of some subset of actors by others. insurance companies became active and influential
These systems usually include changing combina- players in the field. After many failed attempts, the
tions of public and private actors. Cultural- federal government, in 1965, passed Medicare and
cognitive systems include both the cultural frames Medicaid legislation covering hospital services for
that enable actors to interpret events as well as the elderly and the indigent. This significant politi-
institutional logics that provide routines and sym- cal event marked the dramatic onset of the era of
bolic constructions defining appropriate ways to federal involvement. For the first time, the nation-
carry on work. As Paul J. DiMaggio and Walter W. state was a major player, purchasing more than
Powell have pointed out, organization fields vary half of all the health services delivered. Moreover,
in the nature and degree of their structuration: the because of rising healthcare costs, federal officials
extent to which a small number of recognizable quickly found themselves engaged in a variety of
archetypes exists, the density of relations among regulatory and planning activities to control costs.
them, the effectiveness of governance structures, Thus, governance structures, which had been pri-
and the degree of consensus on and coherence of marily private, and professionals were forced to
the cultural-cognitive systems used. share control with state and federal agencies.
Research by W. R. Scott and colleagues chroni- Cultural-cognitive frames expanded to include
cles changes over the latter half of the 20th century equity and the importance of access to healthcare
in the field of healthcare services in the San services, and patients began to assume a more
Francisco Bay area. Although by no means a rep- active, consumer orientation and to explore the
resentative case in the United States, this area was use of alternative healthcare providers.
often on the cutting edge of healthcare change. Early in the 1980s, a third era opened, marked
Moreover, although the care systems studied were by the urgent need to curtail rising costs and a reli-
limited to one geographic region, wider state and ance on managerial and market-based instru-
national forces were considered. ments. Hospitals increased in size as small hospitals
The study suggests that changes in the delivery were closed and others expanded, often through
of healthcare services are usefully partitioned into merger or acquisition. Numerous specialized organi-
three periods or eras: (1) professional dominance, zations appeared, including many freestanding
(2) federal involvement, and (3) managed care. organizations offering services—such as renal
The era of professional dominance, commencing dialysis—that had formerly been performed only
in the 1920s and extending until the mid-1960s, in hospitals. For-profit hospitals and care units
Healthcare Reform 479
multiplied. Physicians were increasingly organized Starr, Paul. The Social Transformation of American
in groups, both real and “virtual,” as insurance Medicine: The Rise of a Sovereign Profession and the
plans enlisted independent physicians for their Making of a Vast Industry. New York: Basic Books,
panels. Relations among all players in the field 1982.
became more dense and complex, with employers
forming coalitions to negotiate insurance rates;
insurance companies contracting with physicians; Web Sites
and hospitals buying or contracting with special- American Sociological Association (ASA):
ized providers, such as extended care facilities. http://www.asanet.org
Managers of healthcare organizations now hold American Sociological Association (ASA), Medical
master’s of business administration (MBA) degrees Sociology Section: http://dept.kent.edu/sociology/
and exercise broad powers in healthcare organi- asamedsoc
zations. To concern about quality and access, a
focus on efficiency and a faith in market-based
solutions are added.
Although federal agents and corporate manag-
ers have not supplanted physicians and other
Healthcare Reform
health professionals, the world of healthcare orga-
nizations has undergone significant change in the Families, businesses, and governments are strug-
past few decades. Organization forms have become gling with the ever-increasing costs of healthcare.
more diverse, more complex, and much more sig- Every year, about 1 million people are added to
nificant in the delivery of healthcare. The contin- the nation’s rolls of the uninsured, now number-
ued productive interaction of healthcare and ing about 47 million. People with insurance are
organization theory seems ensured. seeing their benefits dwindle and healthcare costs
consume an increasing portion of their wages.
W. Richard Scott Even people who have insurance find themselves
unable to pay medical bills, and many are going
See also American Medical Association (AMA); Health without needed care. Given these conditions, calls
Economics; Health Maintenance Organizations
for healthcare reform and reform proposals
(HMOs); Hospitals; Managed Care; Medical
abound, including calls to secure health insurance
Sociology; Multihospital Healthcare Systems;
Physicians
for all Americans, sometimes called universal cov
erage. This entry lays out how the United States
arrived at the mix of private and public insurance
it now has, how that mix impedes reform, and the
Further Readings
implications of healthcare reform.
Flood, Ann Barry, and W. Richard Scott. Hospital
Structure and Performance. Baltimore: Johns Hopkins
University Press, 1987. Historical Choices
Freidson, Eliot. Professional Dominance: The Social
Political efforts to achieve national health insur-
Structure of Medical Care. Chicago: Aldine, 1970.
ance were a regular—and regularly unsuccessful—
Mick, Stephen S., and Mindy E. Wyttenbach, eds.
Advances in Health Care Organization Theory. San
feature of social policy in the first half of the 20th
Francisco: Jossey-Bass, 2003. century. The focus here, however, is not on
Scott, W. Richard, Martin Ruef, Peter J. Mendel, et al. explaining the failure; rather, it is on examining
Institutional Change and Healthcare Organizations: the strategy for achieving health insurance cover-
From Professional Dominance to Managed Care. age that that failure produced—specifically, the
Chicago: University of Chicago Press, 2000. reliance on private, employer-sponsored insurance
Shortell, Steven M., Robin R. Gillies, David A. as the primary means to cover workers and their
Anderson, et al. Remaking Health Care in America: families, and the promotion of public health
Building Organized Delivery Systems. San Francisco: insurance to fill the gaps that private insurance
Jossey-Bass, 1996. would inevitably create.
480 Healthcare Reform
According to a growing body of scholarship, a late 1980s that even the subsequent, unprecedented
variety of forces contributed to the emergence of prosperity of the mid- to late 1990s left a smaller
employer-sponsored health insurance in the 1940s proportion of low-wage workers covered at the end
and 1950s: (a) the labor movement’s shift from of the 1990s than had been covered a decade before.
national politics to collective bargaining as the way The clear lesson of the 1990s was not only that a
to gain health insurance, (b) business interests’ pref- threatened economy reduces health insurance cov-
erences for fringe benefits over government-run (or erage but also that a prosperous economy cannot
labor-organized) health insurance, (c) insurance guarantee it. At least for the time being, employer-
industry capacity for and interest in providing those sponsored health insurance remains successful in
benefits, and (d) administrative actions, backed by serving the vast majority of better-off workers. But
legislation, establishing tax preferences (most employer-sponsored insurance inevitably excludes
important, the exclusion of employer-paid premi- significant numbers of low- and modest-wage
ums from employee taxable income) that subsidized workers in both large and small firms.
employer-sponsored health insurance. The result The public health insurance system also grew in
was the establishment of voluntary, employer- the second half of the 20th century. Medicare was
sponsored health insurance as the nation’s primary expanded in 1972 to include disabled beneficiaries
health insurance system, at the very same time of Social Security (after a 2-year waiting period)
other industrialized nations established universal and people with end-stage renal disease. But
and public health insurance systems not linked to Medicare was not extended to insure the younger
employers’ decisions about wages and benefits. population, as some proponents had hoped it
The establishment of employer-sponsored health would be. Although federal legislation in the 1970s
insurance, in turn, generated a strategy for achiev- actually narrowed the population covered by
ing public health insurance—that is, by focusing Medicaid, ultimately Medicaid was expanded to
on the nonworking population. From the 1950s, reach certain groups with ties to the workforce: (a)
national health insurance advocates shifted their children of lower-income workers; (b) pregnant
attention away from the general population and women in working, two-parent households; and
toward the elderly—a group unlikely to be covered (c) persons with disabilities who are able to return
by work-based or other private health insurance. to the workplace with supports. Medicaid’s most
However, the political compromise that established substantial expansion came in the 1980s and
the Medicare program as universal social insur- 1990s through enactment of national, income eli-
ance for the elderly also established the Medicaid gibility standards (higher than cash assistance eli-
program as means-tested health insurance for cer- gibility standards in many states) for children and
tain population subgroups—specifically, low- pregnant women. In the late 1990s, the State
income persons who receive care assistance based Children’s Health Insurance Program (SCHIP)
on age, blindness, disability, or (in the case of chil- provided a further, modest expansion of coverage
dren living with single mothers) dependency status. for children. But, except for its coverage of low-
The overall result was the creation of a public income, aged, and disabled persons, Medicaid has
health insurance system targeted to people not remained a program for children and, to a much
expected to work and built around the private lesser extent, their mothers. States have the option
(albeit tax-subsidized) insurance system for work- to cover parents (fathers as well as mothers), but in
ers and their families. most states, parents earning the minimum wage
Employer-sponsored health insurance expanded have too much income to qualify for Medicaid.
dramatically to cover more and more (and a grow- And federal law, today as in 1965, does not extend
ing share of) workers and their families through Medicaid eligibility to low-income adults who are
the 1970s. But then growth stopped. Through not the parents of dependent children. Except in a
the 1980s and 1990s, the numbers—and the few states that operate their Medicaid programs as
proportion—of working-aged Americans without special, federally sanctioned demonstrations that
health insurance coverage grew steadily. Indeed, waive traditional Medicaid eligibility restrictions,
lack of health insurance among low-wage workers the history of targeting public protections to
grew so substantially during the recession of the exclude workers, regardless of income, persists.
Healthcare Reform 481
Overall, employer-sponsored insurance and the But equally problematic is the policy difficulty of
programs designed primarily for people outside getting health insurance to the uninsured without in
the workforce—Medicare for the elderly and some some way disrupting the actual insurance of the
of the disabled, and Medicaid for children and already insured. National health insurance via a single-
pregnant women—cover about 85% of the U.S. payer or Medicare-for-all strategy actually intends
population. But their explicit structures mean that disruption—or, more accurately, replacement—of
they exclude people who work but nonetheless are employer-sponsored insurance with what its advo-
not offered health insurance coverage through cates believe would be a simpler, more equitable,
their jobs and who, primarily because they work, and more efficient system. Whether or not they are
remain outside the categories covered by public correct, the reluctance to disrupt Americans who
programs. have health insurance—specifically, to legislate
both the redistribution of financing and the shift
from private to public coverage that a single-payer
Barriers to Reform
system would entail—has inhibited many politi-
Given the health insurance-financing system cur- cians and policymakers from tackling “replace-
rently in place in the United States, a simple way ment” head on.
to explain the country’s failure to enact reform is Thus, the dilemma of reforming healthcare is to
that the “haves” have health insurance; it is the design a policy that can cover the uninsured with-
“have-nots” who do not. Although it is true that out affecting the already insured and at the same
anyone can fall out of employer-sponsored cover- time achieve political success, which is difficult if
age—for example, by losing one’s job or getting the already insured perceive that they will be
divorced—the vast majority of Americans can worse off as a result. This dilemma is not limited
count on receiving health insurance through their to expansions aimed at universal coverage.
jobs. The roughly 15% of Americans who are Incremental-expansion proposals that focus on
uninsured are overwhelmingly workers in low- achieving small improvements for low-income
and modest-wage jobs that do not offer health populations not only make redistribution from the
insurance and working-aged adults who do not haves to the have-nots explicit (as only the latter
qualify for Medicaid. The primary political and receive new benefits), they also affect the coverage
policy problem that the United States faces is that of the already insured. Except for a proposed
it is almost impossible to insure the have-nots expansion that would limit eligibility to individu-
without, in some way, disrupting the status quo of als with incomes below the federal poverty level (a
the haves. group in which hardly anyone has employer cov-
An obvious form of disruption comes from the erage), any coverage proposal is likely to make
need to raise the financial resources to subsidize new, publicly subsidized benefits available not
health insurance for the economically disadvan- only to the uninsured but also to significant num-
taged uninsured. The full cost of employer- bers of people who already have insurance. With
sponsored coverage of a typical family is more a new coverage option available, even individuals
than $12,000 per year. If comparable insurance with employer coverage might replace that cover-
were available to individuals outside employment, age with free or near-free benefits provided at
it would absorb more than 20% of their income public expense. And should those benefits be
for the great majority of the uninsured. Virtually made available, employers—particularly employ-
every health insurance expansion proposal, regard- ers whose employees earn relatively low wages—
less of its form, recognizes that the cost of health might decide to drop the coverage they currently
insurance is too high to expect the uninsured to offer, essentially forcing their employees to find
purchase it without subsidies. Subsidization entails coverage elsewhere.
redistribution—taxing those who have health Since 2000, rising premiums and reduced ben-
insurance to subsidize health insurance for those efits have increased concern among people who
who do not. Historically, the need for redistribu- have employer-sponsored health insurance that
tion has posed a substantial, political barrier to even with insurance they are no longer assured of
reform. access to affordable, quality healthcare when
482 Healthcare Web Sites
they need it. As a result, health reform is a key

issue in the 2008 presidential campaign. Whether Healthcare Web Sites
reform becomes a reality will depend on the lead-
ership of a new president and whether most Healthcare Web sites are electronic pages avail-
people come to have confidence that everyone— able on the Internet that are generally designed
the insured along with the uninsured—have more to serve one or more of three different groups: (1)
to gain than to lose from reforming the health- healthcare consumers, (2) healthcare practitio-
care system. ners, and (3) health services researchers. Many are
published by government agencies, private foun-
Judith Feder dations, or healthcare organizations; however, the
Internet as a publishing medium is open to anyone
See also Access to Healthcare; Health Insurance;
National Health Insurance; Public Policy; State-Based
with computer access. This freedom to publish
Health Insurance Initiatives; State Children’s Health can be a problem, especially in the case of health-
Insurance Program (SCHIP); Uninsured Individuals care Web sites, as people may make life-affecting
medical decisions based on the information they
read online. To this end, organizations exist that
Further Readings attempt to monitor healthcare Web sites and
provide standards or quality criteria by which to
Cunningham, Peter J., James D. Reschovsky, and Jack evaluate sites.
Hadley. The Effect of SCHIP on Children’s Health
Insurance Coverage. Washington, DC: Center for
Studying Health System Change, 2002. Healthcare Consumer Web Sites
Feder, Judith. “Crowd-Out and the Politics of Health
Many consumer Web sites aim to help people
Reform,” Journal of Law, Medicine, and Ethics 32(3):
461–64, Fall 2004.
maintain healthy lifestyles through their behav-
Gruber, Jonathon, and Larry Levitt. “Tax Subsidies for
ioral choices. More sophisticated sites offer online
Health Insurance: Costs and Benefits,” Health Affairs tools and calculators that provide customized
19(1): 72–85, January–February 2000. recommendations or advice based on one’s per-
Hacker, Jacob. The Divided Welfare State. New York: sonal data. One example is a body mass index
Cambridge University Press, 2002. (BMI) calculator, which determines whether some-
Kaiser Family Foundation. Health Insurance Coverage in one is in a healthy weight range for his or her
America: 2002 Data Update. Menlo Park, CA: Kaiser height. With an emphasis on preventive care,
Family Foundation, 2003. these types of consumer sites are motivated not
Klein, Jennifer. For All These Rights. Princeton, NJ: only by a humanitarian desire to improve public
Princeton University Press, 2003. health but also by the need to control healthcare
Meyer, Jack A., and Elliot K. Wicks, eds. Covering costs. Accordingly, the major publishers of these
America: Real Remedies for the Uninsured. types of sites are healthcare organizations such as
Washington, DC: Economic and Social Research hospitals, insurance companies, or those govern-
Institute, 2001. ment agencies that finance a substantial portion
Schneider, Andy, Risa Elias, Rachel Garfield, et al. The of their citizen’s medical care. As people publish
Medicaid Resource Book. Menlo Park, CA: Kaiser personal health data online or their healthcare
Family Foundation, 2002. providers or insurance companies do so, privacy
issues are of increasing concern. Sites that allow
users to create electronic clinical records, for
Web Sites instance, run a risk of being hacked into and
Center for Studying Health System Change (HSC): exposing patients’ medical histories. Nevertheless,
http://www.hschange.com these sites do provide valuable services to con-
Henry J. Kaiser Family Foundation (KFF): sumers by empowering them to be more active in
http://www.kff.org their own care. Some sites act as virtual, social-
Universal Health Care Action Network (UHCAN): support networks for patients by using interactive
http://www.uhcan.org technologies such as discussion boards or e-mail
Healthcare Web Sites 483
lists to foster communication among people with movement to monitor health information quality
similar medical conditions. online are the Health On the Net (HON)
Foundation and URAC. The HON Foundation is
an international effort based in Switzerland and
Healthcare Practitioner Web Sites started in 1995 by a group of telemedicine experts.
Its HON Code of Conduct (HONcode) lists eight
Web sites for healthcare practitioners offer types
principles for ensuring that healthcare Web sites
of information similar to that for consumers,
publish accurate, reliable, and valid information.
though the content is written for a professional-
Sites that respect all eight items (authoritative,
level audience. Practitioner sites feature things
complementarity, privacy, attribution, justifiability,
such as journal article summaries, continuing-
transparency, financial disclosure, and advertising
education opportunities, and reference materials
policy) can apply for free accreditation, which
from textbooks. Sites for practitioners are typi-
allows the sites to display the HONcode logo and
cally targeted to specific professions (e.g., physi-
be listed in the HON search database of accred-
cians, nurses, or physical therapists) and, within
ited, healthcare and medical sites. Approved sites
those professions, to specialty areas (e.g., cardiol-
are policed on a regular basis to ensure that they
ogy, geriatrics, or public health). Evidence-based
maintain the basic ethical standards set by HON.
practice Web sites are one type of site of particu-
Unlike HON, which is focused solely on online
lar value to busy healthcare providers who do
information provision, URAC offers accreditation
not have time to comprehensively search the lit-
to healthcare organizations in more than a dozen
erature, read all the original research, and formu-
program areas; their health Web site program is
late their own conclusions to drive decision
only one. Developed in 2001, the more than 50
making. As with consumer sites, healthcare prac-
URAC standards evaluate healthcare Web sites
titioner Web sites provide opportunities for net-
on disclosure and linking, health content and ser-
working.
vice delivery, privacy and security, and quality
oversight. Also unlike HON, URAC charges for
Health Services Researcher Web Sites its accreditation seal and covers only Web sites
from U.S. companies. The HON and URAC
Health services researchers have greatly benefited online directories of accredited sites are an effi-
from the advances in e-health. Never before has cient starting point for locating reliable healthcare
it been so easy to obtain data on healthcare Web sites.
access, cost, quality, and outcome. Rather than
being stored on individual computers or existing
solely in summarized written records, health ser- Health Information
vices data sets can be published online, down- Professionals and Organizations
loaded by other researchers, and manipulated Health information professionals specialize in the
and recombined to elicit new information. selection and organization of both print and elec-
The fact that these data sets are often assembled tronic materials. Since the early stages of healthcare
by government organizations means that the Web site development, these professionals—often
data are typically freely available. However, medical librarians—have led efforts to establish
restrictions on use may apply when individuals quality criteria and create virtual collections of
could potentially be identified by demographic health sites. At the forefront in the United States are
information. the National Library of Medicine (NLM) and the
Medical Library Association (MLA), a government
agency and a professional organization, respec-
Quality of Web Site Information
tively, that have published directories of top health-
Although data privacy concerns are a major con- care Web sites for consumers, practitioners, and
sideration in the development of healthcare Web researchers.
sites, of highest importance is the quality of the
information such sites provide. Two leaders in the Lisa C. Wallis
484 Health Communication
See also Computers; E-Health; Electronic Clinical risk information, health professional/patient inter-
Records; Health Communication; Health Informatics; actions, strategies for preventive health and popu-
Health Insurance Portability and Accountability Act of lation-based medicine, and the developing field of
1996 (HIPAA); Preventive Care; Telemedicine telehealth applications.
Further Readings Background

Cline, R. J., and K. M. Haynes. “Consumer Health The use of health communication dates back to
Information Seeking on the Internet: The State of the Aristotle who first described it in his anthology
Art,” Health Education Research 16(6): 671–92, The Rhetoric in the 4th century BCE. Today, the
December 2001. humanistic theory of Carl Rogers and Abraham
De Leo, G., Cynthia LeRouge, Claudia Ceriani, et al. Maslow has dominated the fields of health com-
“Web Sites Most Frequently Used by Physicians for munication theory. The 20th century saw the
Gathering Medical Information,” American Medical advent of better methodologies, incorporating
Informatics Association (AMIA) Annual Symposium insights from the fields of sociology, psychology,
Proceeding, p. 902, 2006. and linguistics. Mass communication media, such
Greenberg, Liza, Guy D’Andrea, and Dan Lorence. as radio, television, and the Internet, have estab-
“Setting the Public Agenda for Online Health lished social marketing and advertising as impor-
Search: A White Paper and Action Agenda,” Journal tant tools for health communication, with
of Medical Internet Research 6(2): 1–18, June 8, ever-broadening horizons in the 21st century.
2004.
Effective communication channels are critical
Huang, George J., and David F. Penson. “Internet
to the success of public health programs targeting
Health Resources and the Cancer Patient,” Cancer
health behavior change at the individual, commu-
Investigation 26(2): 202–7, February 2008.
nity, or population level. Communicating con-
sumer health information is vital as it enables
people to be aware of their health status and
Web Sites
needs and to make informed decisions about a
Health On the Net (HON) Foundation: variety of issues such as adopting a healthy life-
http://www.hon.ch style, seeking treatment, and choosing suitable
Medical Library Association (MLA): health insurance benefits, health retirement plans,
http://www.mlanet.org and long-term care. In a public health context, it
National Library of Medicine (NLM), MedlinePlus: encompasses the areas of disease prevention and
http://www.medlineplus.gov health promotion to improve the quality of life as
Pew Internet and American Life Project: well as the formulation of the health policies that
http://www.pewinternet.org support mass communication of healthcare strate-
URAC: http://www.urac.org
gies to individuals, communities, and the public.
U.S. Department of Health and Human Services (HHS):
The targets of health communication can be indi-
http://www.health.gov
viduals, as in physician–patient relationships;
communities or specific ethnic or racial groups, as
in many local and state programs or research-
based interventions; or the population in general,
Health Communication as in national programs such as the abstinence
program. Health communication should be cul-
According to the federal government’s initiative turally and linguistically targeted to reach all eth-
Healthy People 2010, health communication should nic groups and written in a way that can be easily
examine and advance communication strategies understood.
to inform and influence individual and commu- Effective communication is also vital for a suc-
nity decisions that lead to improved health. cessful physician–patient relationship. The explo-
Health communication is relevant in a variety of sion of information technology and easy access to
contexts: health literacy, dissemination of health the Internet has widened the use of these portals as
Health Communication 485
providers of health information. However, as how two individuals influence each other;
information available electronically is unregulated, (c) group dynamics, where many people interact
it may be unreliable. Such information can be mis- and influence one another; organizational, which
leading and even harmful if not properly under- can be public, private, or collaborative; and
stood by lay people. People have great faith in (d) community or population, where communi-
public communication channels and tend to blindly cation influences societal change on important
accept what is reported. issues.
Communication partnerships, usually forged Health behavior change models use communi-
between organizations serving similar clients and cation theories extensively. The health belief
settings, create functional linkages that avoid rep- model and the theory of reasoned action both rely
lication of services, ensure uniformity in message heavily on communication methods to encourage
creation, synergize expertise and effort, and are individuals to adopt healthy behaviors. Other
more cost-effective and successful. theories such as the social cognitive theory, diffu
sion theory, and the transtheoretical model are
used as catalysts for health behavior change at the
Objectives population level by using communication chan-
The objectives of health communication need to nels that influence an environmental as well as
be clearly identified before designing and imple- individual acceptance of better health habits. The
menting programs. The two fundamental objec- consumer information processing model works
tives are to promote change in individual on the premise that humans seek information
behavior and to promote change in larger groups only when motivated to do so. According to its
or the environment, such as in the workplace or concepts, to make health information acceptable
at the local, state, or national level. At the indi- to consumers, it must be readily available and
vidual level, two types of communication inter- perceived as innovative, helpful, and easily pro-
ventions are commonly used. In informed decision cessed or adaptable.
making, information is given to enable a person Interpersonal communication is the common
to make better health decisions, a method com- channel of communication used in health research
monly used in medical care. Persuasion-oriented and dissemination: Information and advice from
communication aims to convince people to peers or healthcare personnel about an innovation
change their health behaviors for the better. This often carries more weight in a decision to change
approach is useful in public health interventions than merely reading or hearing about it from
that promote well-established, evidence-based impersonal sources. This method is used in the
programs such as cancer and blood pressure community-based participatory action approach
screening, weight reduction, and the prevention to provide successful and sustainable public health
of sexually transmitted infections. For the sec- dissemination strategies.
ond objective of promoting change in large groups Applied communication perspectives are used
or the environment, advocacy interventions in public health to asses how communication
involve policy change or changes in the laws at strategies can negatively influence human behav-
various levels. Examples of these interventions ior, exemplified by tobacco and fast food adver-
are mandatory seatbelt and child seat use and tising, or positively influence behavior change,
improving safety and working conditions in the as seen in the success of antitobacco campaigns
workplace. and the promotion of condom use. Empirical
studies involve the application of scientific
methods to study the effects of a communication
strategy, as is frequently used in public health.
Communication Theory
Critical studies are more broad based as they
and Health Behavior Change
apply methods of cultural, literary, or normative
Communication has several levels of interac- criticism to the study of outcomes on how
tions: (a) intrapersonal, or how people process health-related media content influences behav-
information for themselves; (b) interpersonal, or ior change.
486 Health Communication
Methods of long-distance, clinical care is gaining popularity

because it is convenient and saves time and costs.
Health education, which is focused on improving Telemedicine (a subset of telehealth) is confined to
individual health behaviors by providing informa- the use of telecommunications and computer tech-
tion and instruction, is the most commonly used nologies in clinical care. Physicians of all special-
mode of health communication. The source of ties can use teleconsulting at the local, national,
such messages can be from healthcare profession- and global levels. Earning continuing medical-
als, public and private clinics and hospitals, education credits through the Internet is an increas-
community health centers, libraries, school and ingly accepted method for healthcare professional
worksite programs, television, radio, newspapers, organizations and is gaining popularity owing to
magazines, pamphlets, brochures, and posters. its ease of accessibility.
Printed materials are readily found in most public Health communication between health profes-
health agencies, private practitioner offices, health- sionals is just as important to maintain aware-
care institutions, and voluntary health organiza- ness of the latest trends and developments and
tions. The use of outdoor media—billboards and the needs of the healthcare sector. Electronic
signs, placards on commercial transport such as communication networks form the backbone for
trains and buses, flying billboards, blimps, and fast, inexpensive sharing, reporting, and dissemi-
skywriting—may have a fleeting impact. The mass nation of public health information. These net-
media are useful tools for the transfer of informa- works are particularly useful for communicating
tion, concepts, and ideas to both general and between agencies and to the public during public
specific audiences with the main functions of edu- health emergencies such as natural disasters and
cation, advocacy, and shaping public relations. epidemics.
However, mass media use is expensive and often
sensationalizes the messages to increase the num-
Hallmarks of Effective Communication
ber of viewers. Social marketing is a large-scale
activity that uses business principles to create Effective communication is critical to the success
mass media campaigns targeting population of programs targeting health behavior change
groups with messages for positive behavior either in individuals or at the population level.
change. Communication strategies are cost-effective only
The triad of information, education, and com- if the desired impact is achieved. Exploratory
munication (IEC) is a well-accepted continuum audience research during program development
promoted by the World Health Organization will identify the incentives and barriers to be
(WHO) for reproductive health programs. The addressed in communication strategies and the
IEC campaigns aim to forge links with existing most acceptable sources of information for and
programs and organizations to reinforce channels channels of communication to the target popula-
of communication and incorporate local commu- tion. Pretesting the final products and incorporat-
nity traditions into the communication strategies ing suitable recommendations ensures that the
to enhance acceptability. The campaigns also message is consumer-friendly, culturally appropri-
advocate using the audience segmentation ate, and understood by most people. Audience
technique—in which the audience is chosen from research at the end of a program is useful in
people with similar demographic and cultural evaluating the impact of health communication,
norms—for better health communication. This identifying shortcomings, and redesigning it for
approach exemplifies the use of sound, social- wider, more effective dissemination.
marketing techniques and behavioral-research It is important that communication be reliable
strategies to craft targeted messages that are short, and based on evidence derived from formative
sharp, attention grabbing, and easy to adopt. evaluation and communication research in the tar-
Telehealth is geared to support a variety of geted population. Research shows that public
health professionals involved in health communi- health information dissemination is most success-
cation, including physicians, nurses, public health ful when multiple communication channels are
professionals, and health administrators. Provision employed. A multidisciplinary approach that uses
Health Disparities 487
the media, academia, government, policymakers, involved in health communication practice,

private organizations, and community collabora- research, and training.
tion as vehicles for dissemination is most likely to
result in positive health behavior change. Integrated Karen E. Peters, Benjamin C. Mueller,
efforts have a symbiotic effect and are sharply Marcella Garces, and Sergio Cristancho
focused, more cost-effective, and more likely to
See also Ethnic and Racial Barriers to Healthcare; Health
have a sustainable impact. A preliminary needs
Disparities; Health Literacy; Healthy People 2010;
assessment should be conducted, before beginning Patient-Centered Care; Public Health; Quality of
a new initiative, using a mixed methods approach Healthcare; Telemedicine
to gather information on devising a communica-
tion strategy for the target audience. Ongoing
process evaluation allows for suitable modifica- Further Readings
tions throughout the course of a program. An
outcome evaluation is conducted to assess the Pagano, Michael P. Interactive Case Studies in Health
impact of the program in changing the patterns Communication. Sudbury, MA: Jones and Bartlett,
and attitudes of the study population during the 2009.
health intervention. Sheldon, Lisa Kennedy. Communication for Nurses:
Talking with Patients. 2d ed. Sudbury, MA: Jones
Media communications has a critical role to
and Bartlett, 2008.
play in public health, which aims to influence
Van Servellen, Gwen. Communication Skills for the
individual behaviors in large segments of the
Health Care Professional: Concepts, Practice, and
population. Because they are believed to provide
Evidence. 2d ed. Sudbury, MA: Jones and Bartlett,
factual and evidence-based information, those 2008.
messages from respected and legitimate media, Wright, Kevin B., and Scott D. Moore, eds. Applied
organizations, and academia have a huge public Health Communication. Cresskill, NJ: Hampton
impact in inducing or inhibiting behavior change. Press, 2008.
Successful health promotion campaigns have Wright, Kevin B., Lisa Sparks, and Dan O’Hair. Health
communication channels that are audience ori- Communication in the 21st Century. Malden, MA:
ented, gender friendly, culturally sensitive, and Blackwell, 2008.
easily understood by the public. Creation of such Zoller, Heather M., and Mohan J. Dutta, eds. Emerging
strategies is possible through multidisciplinary Perspectives in Health Communication: Meaning,
approaches involving input from media sources, Culture, and Power. New York: Routledge, 2008.
journalists, public health and medical profession-
als, academics, policymakers, and most impor-
tant, people from all segments of the target Web Sites
audience.
American Public Health Association (APHA):
http://www.apha.org
Future Implications Coalition for Health Communication (CHC):
http://www.healthcommunication.net
In effect, health communication must play an inte-
Healthy People 2010: http://www.healthypeople.gov
gral role in public health and medical practice,
National Communication Association (NCA):
with special attention to meeting the needs of vul-
http://www.natcom.org
nerable populations. Knowledge of health com-
munication theories and practices is essential for
healthcare professionals, health policymakers,
politicians, and collective action groups seeking to
develop cost-effective, consumer-oriented strate- Health Disparities
gies that will have a maximal impact on personal
or mass health and healthcare. Efforts are under Health disparities are major differences or inequal-
way to enunciate certification, quality assurance, ities in health status between majority and minor-
and ethical standards for people and organizations ity groups within a population. Health disparities
488 Health Disparities
also refer to differences between groups in access less use of healthcare services (including preven-
to health services or treatments and in the quality tive care), and therefore, they suffer worse health
of services or treatments received. They may be status. For instance, minority groups may be less
caused by differences in gender, race, socioeco- likely to have a usual physician or source of care,
nomic status, or insurance status or by higher that is, a specific primary-care physician. Not
environmental and behavioral risks. Ethnic and having a usual physician or usual clinic for rou-
racial minority groups in the United States dispro- tine healthcare may be due to a variety of factors
portionately experience poorer health status. such as lack of participating medical providers,
Health and healthcare disparities often derive lack of knowledge or trust in the medical system,
from and are embedded in the larger historical, lack of understanding about the importance of
geographic, demographic, sociocultural, eco- preventive care, lack of financial resources, or a
nomic, and political context. combination of these factors. The explanations
and specific causal factors are likely to vary for
each group.
Barriers to Addressing Healthcare Disparities
Barriers to accessing healthcare stem from many
Disparities in Access
factors: personal, financial (uninsured or underin-
sured), language, geographic, sociocultural, the Existing disparities in healthcare access based
institutional arrangements of health systems, and on minority status, health status, and urban ver-
the legal, regulating, and policy environment. sus rural status are well documented. National
Some of these factors may produce inconvenience surveys have consistently found that Blacks,
and frustration, while others may actually prevent despite their lower ambulatory-care use and
people from getting the healthcare they need. lower access to a usual source of care, were less
These barriers vary with population, location, and likely than Whites to report problems in getting
political situation and should be assessed by each needed care and were also equally likely to
community, especially those with medically under- report that they were very satisfied that their
served populations. family could get the healthcare they needed. In
contrast, Hispanics were more likely to report
problems with family members getting needed
Overview
treatment and less likely to report problems get-
The basic contours of socioeconomic and ethnic ting care for themselves. There are, in other
and racial disparities in health are wellknown. words, different perceptions of access difficul-
Socioeconomic status is inversely correlated with ties between groups.
virtually all the major indicators of health status, Getting some healthcare is different from get-
including functional impairments, self-rated ting the healthcare the individual needs, and this is
health, and disease-specific morbidity and mor- related to the issue of the quality of the healthcare
tality. Moreover, research demonstrates that received. Access to poor-quality care may still
socioeconomic position in society is linked to leave an individual with unmet needs and, there-
health through a variety of pathways, including fore, not truly achieving access to needed care.
access to care, environmental exposures, and life Knowledge, health literacy barriers, and patterns
stressors. Race and class are codeterminants of of use are affected by cultural norms, and these
disparities in health, each having its own additive also affect the utility of proxy measures of access
effect. Healthcare disparities are arguably a major (e.g., a usual source of care).
cause of health disparities; they include poorer A national telephone survey in 1991 found that
access to healthcare services and poorer quality 16% of all respondents lacked a regular source of
of the healthcare services received. One explana- ambulatory care. Other national surveys between
tion for the relationship between access to health- 1987 and 1996 showed a wide range, from 6% to
care and health status for low-income minority 45%, of uninsured persons reporting problems
groups is that they have less access to and make getting needed healthcare. Between 1994 and
1997, nearly one quarter of all American families Barriers to Healthcare

reported that it had become more difficult to get
medical care, and in the same surveys, Blacks or Barriers to access are those factors that contribute
Hispanics and young adults were more likely to to preventing a person from using a healthcare
report worsening access to care. Another study service when needed. Although researchers have
found that where an individual lives matters as speculated on the barriers to access faced by vari-
well: Only 15% of the variation across communi- ous ethnic and racial groups, few have quantified
ties in getting necessary healthcare was accounted or characterized the number and severity of the
for by differences in the characteristics of the unin- barriers faced, nor have they correlated them with
sured (e.g., their health status, age, gender, family the probability of achieving access to needed
income, and ethnicity or race). Also, the pattern of healthcare services. Researchers have noted that
variation in access for the uninsured and privately many of the existing disparities remain unex-
insured, in terms of their ability to obtain needed plained, presenting a challenge to the development
healthcare, does not correlate, meaning that the of policies to eliminate them. While the variation
communities with relatively high levels of access in health insurance coverage is the most studied,
problems among the uninsured do not necessarily possible explanation and a key area of emphasis
have the highest levels of access problems for the for recent health policy reforms, other studies sug-
privately insured. These studies documented dis- gest that variations in health insurance coverage
parities in access, but they did not examine what may be only a small part of the explanation.
factors most highly correlate with these disparities. Many studies have shown significant ethnic
In addition, a lack of standardization and method- and racial differences in experience with, access
ological differences in measuring access makes it to, and use of care in health plans; however, few
virtually impossible to draw any conclusion from of these studies have focused specifically on
the various surveys about trends in unmet health the free-clinic populations. In fact, many focus
needs over time. on insured populations and the disparities that
Different populations face various combina- persist even between people with the same insur-
tions of barriers to accessing healthcare. For ance coverage. In addition, few studies have tried
instance, members of ethnic and racial minority to further define or explain the cause of these dif-
groups may face barriers due to stereotyping ferences, and those that have, have had limited
prejudice as well as distrust owing to historic and success.
personal social conflicts or misunderstandings. There have been a number of different
Low-income populations may face difficulty with approaches to measuring these barriers. One study
finances, child care, getting appointments, and did a door-to-door survey of people living in pov-
medical debt. Underserved and rural populations erty asking about what they perceived to be per-
may struggle to find a physician in their area or sonal barriers to accessing healthcare services. In
have to travel long distances to get the healthcare that population, 74% reported having more than
they need. Recent immigrants may have more dif- one barrier. The researchers found that the most
ficulty navigating the bureaucratic red tape of an common barriers were the lack of information
unfamiliar healthcare system, compounded by about free or reduced-cost healthcare, anticipated
language and cultural barriers. A typical example costs, and the difficulty of accessing child care.
is recent immigrants of an ethnic and racial minor- Barriers were similar for working and nonworking
ity who have low incomes and live in an under- residents, with the exception that transportation
served area. Barriers to healthcare services are a was more of a barrier for the nonworking. This
cause of healthcare disparities and are a factor in study, however, only recorded the reported barriers
health disparities between different socioeconomic and did not correlate them with any measures of
groups in a population. Healthcare disparities access to healthcare. Other researchers have
(differences in the amount and type of healthcare attempted to construct questionnaires to measure
available and received) are arguably a major cause the barriers to healthcare faced by parents of chil-
of health disparities. dren with chronic health conditions. One group of
researchers has developed a 41-question survey Finances

instrument that divides barriers into 5 subscales:
Health insurance coverage is a major factor in
(1) skills, (2) marginalization, (3) expectations,
accessing healthcare services. In 2007, there were
(4) knowledge and beliefs, and (5) pragmatics.
an estimated 45.7 million uninsured Americans
Other researchers have divided healthcare bar-
below the age of 65 (about 18% of the popula-
riers into supply and demand sides: characterizing
tion). Specifically, 13% of Whites were uninsured,
them and suggesting policies for addressing them
while 17% of Asians, 22% of Blacks, 33% of
as market failures. They found that while demand-
American Indians, 36% of Hispanics, and 15% of
side barriers may be as important as supply-side
multiracial persons were uninsured.
factors in deterring patients from obtaining care,
Poverty and cost issues are also a major factor
relatively little attention was given, either by poli-
in accessing healthcare services. In 2005, 13% of
cymakers or researchers, to ways of minimizing
Americans were living in poverty. The poverty rate
their effect. These barriers are likely to be more
for Whites was 8.2% in 2006, compared with
important for the poor and other vulnerable
24.3% for Blacks, 10.3% for Asians, and 20.6%
groups, where the costs of access, lack of informa-
for Hispanics. Financial resources have a direct
tion, and cultural barriers impede them from ben-
effect on access to healthcare, but they also have
efiting from public spending. In this entry,
an indirect effect as they are the best proxy mea-
demand-side determinants are defined as those
sure for “class” (poverty vs. middle or upper class),
factors that influence demand and that operate at
which is a risk factor that is highly correlated with
the individual, household, or community level.
racial disparities. A recent national survey found
Table 1 presents some examples of demand-side,
that 55% of the respondents who owed money for
demand and supply interaction, and supply-side
medical bills found it harder to get medical care,
barriers to healthcare.
and 33% had been denied medical care because
they owed money for past treatments.
Correlating Barriers and Access
Beliefs and Knowledge
There are many factors other than insurance that
A study in Los Angeles, California, found that
affect access to healthcare, and access in the
homeless persons are willing to obtain healthcare if
United States varies between populations and by
they believe that it is important, and better health
the type of care needed. The preponderance of
outcomes were associated with having a usual
the research to date shows that local-area eco-
source of care. In the field of emergency medicine,
nomic indicators, income, and demographic
there is an ongoing debate regarding who should
characteristics are the most important factors,
use the hospital emergency department as their
while level of education attained explained little
usual source of care—a costly and arguably ineffi-
about access to healthcare. It is important to
cient pattern of use. However, there are little accu-
understand that there are significant, noninsur-
rate national data on the prevalence of such usage.
ance barriers to achieving access, including trans-
One study used the National Center for Health
portation, language, ethnicity, and immigration
Statistics’ (NCHS) 1998 National Health Interview
status. It is also important to understand that
Survey to estimate the number of Americans who
barriers have differential impacts on different
name the hospital emergency department as their
populations.
usual source of care, and compared their character-
istics with those of people who have a usual source
of care other than the emergency room. It found
Severity of Different Barriers
that 1.7 million or 0.9% of Americans reported
The severity of barriers to healthcare can also dif- that the hospital emergency department was their
fer. These barriers include the following: finances usual source of care. Those individuals tended to
(including cost, insurance, and debt), beliefs and have the following characteristics: low income,
knowledge, prejudice and racism, health status, lack of health insurance coverage, younger age,
and other barriers. Each of these barriers is dis- male gender, and a member of an ethnicity or racial
cussed below in more detail. minority group.
Table 1 Supply and Demand Barriers to the Utilization of Healthcare
Example of Barrier
Demand side 1. I nformation on healthcare choices and 1. Lack of knowledge about providers
providers
2. Education 2. L ow ability to assimilate health choices and
negotiate access to appropriate providers
3. Indirect consumer costs 3a. Lengthy and time-consuming travel to care
a. distance cost facilities
b. opportunity cost b. Need for patient (and caretaker) to leave
work for long periods to obtain care
4. Household preferences 4. Asymmetric control over household
resources
5. C
ommunity and cultural preferences, 5. Reluctance to seek healthcare for women
attitudes, and norms outside the home; community resistance to
using modern medical care to assist with
pregnancy
6. P
rice and availability of substitute 6. Patients seek treatment through providers
products and services that are inappropriate for their condition,
such as drug sellers
Demand and supply 1. Direct price of a service of a given level 1. High cost of services; large, unofficial
interaction of quality (including informal payment) payments to staff
2. Quantity rationing 2. Long waits to see medical staff
Supply side 1. Input prices and input availability 1a. Absenteeism, staff not attracted to the area
a. Wages and quality of staff b. Scarcity of supplies, weak cold chain
b. Price and quality of drugs and other
consumables
2. Technology 2. I nability to treat disease with given
technology
3. Management and staff efficiency 3. Poor quality of management training, lack
of management systems
Prejudice and Racism of sociodemographic and health status differences

across ethnic and racial groups. Prejudice and the
Ethnic- and racial-minority populations experi- history of segregation persist in health disparities
enced worse primary care, particularly in the first- today: The primary care provided to Blacks and
contact aspect, than did White Americans. Their Whites continues to be, to a large extent, more
usual sources of healthcare were more likely to be separate and unequal than hospital care and may
hospital settings than private clinics. They faced contribute to persistent disparities in referrals for
greater barriers accessing their usual source of diagnostic and specialized procedures.
care, finding it more difficult to get an appoint- Immigration status has a huge effect on access
ment and waiting longer during an appointment. to healthcare services, as well: In Los Angeles,
Many of the significant differences persist even California, only 17% of native-born citizens are
after adjustment for sociodemographic and health uninsured, while 41% of foreign-born, legal resi-
status characteristics. dents and citizens are uninsured, and 68% of
Ethnic and racial healthcare disparities in pri- undocumented immigrants are uninsured. One
mary-care experience are not simply a reflection study found that racial disparities in healthcare
are not explained by the commonly cited access Future Implications

factors.
Groups of people face health disparities, at least in
Interestingly, self-reported discrimination is also
part, because they face more barriers to accessing
significantly associated with physical and mental
good healthcare. Therefore, by eradicating the bar-
health. In a national sample of adult Americans,
riers to healthcare that some groups face, society
persons who reported a high level of day-to-day
can reduce the health disparities. The important
discrimination had more than twice the odds for
question society needs to address is, What barriers
major depression and more than three times the
are the most severe in terms of preventing people
odds for generalized anxiety disorders as people
from getting the healthcare services they need?
who did not, regardless of their race.
Although much research has been done document-
ing the disparities in health and access to health-
care, and many surveys have asked about the
Health Status barriers people face, very few have correlated these
Although many of the healthcare needs of indi- barriers with health services use, and none have
viduals with disabilities are similar to those of looked at a correlation between the number, type,
people without disabilities, the presence of a dis- and severity of barriers faced and the probability
abling condition can place the individual at of achieving access to needed healthcare services.
greater risk than the general population for sec- Clearly, much research needs to be conducted in
ondary conditions, greater use of downstream the future.
services, increased need for durable medical equip- Robert F. Rich and Cindy L. Elkins
ment such as wheelchairs, functional decline,
decreased independence, and psychological dis- See also Access to Healthcare; Cultural Competency;
tress. A study of another at-risk population, chil- Equity, Efficiency, and Effectiveness in Healthcare;
dren with special healthcare needs, showed that Ethnic and Racial Barriers to Healthcare; Health
they have higher levels of unmet needs for medical Communication; Health Literacy; National Healthcare
services than the general population. In addition Disparities Report (NHDR); Vulnerable Populations
to the importance of insurance, children are vul-
nerable because of their social circumstances (e.g.,
poverty) and have significantly greater odds of Further Readings
having unmet needs for routine and specialty phy-
Agency for Healthcare Research and Quality. 2005
sician care. National Healthcare Disparities Report. AHRQ Pub.
No. 06–0017. Rockville, MD: Agency for Healthcare
Research and Quality, 2005.
Other Barriers Bangs, Ralph L., Edmund Ricci, and Larry E. Davis,
eds. Racial Disparity in Mental Health Services:
Barriers in areas such as communication with
Why Race Still Matters. New York: Haworth Press,
healthcare providers, provider availability, 2008.
employee’s ability to get time off from work, Barr, Donald A. Health Disparities in the United States:
and the availability of child care services have Social Class, Race, Ethnicity, and Health. Baltimore:
not been adequately studied. Ethnic disparities Johns Hopkins University Press, 2008.
in healthcare are largely explained by differ- Escarce, Jose J. Racial and Ethnic Disparities in Access
ences in English language fluency (e.g., between to and Quality of Health Care. Princeton, NJ: Robert
Spanish-speaking Hispanics and other non- Wood Johnson Foundation, 2007.
Hispanic groups). Millions of American children Kronenfeld, Jennie J., ed. Inequalities and Disparities in
also lack access to healthcare because of poor Health Care and Health: Concerns of Patients,
transportation systems: Their parents may not Providers, and Insurers. Boston: Elsevier JAI, 2008.
have a car, and in many locations, particularly LaVeist, Thomas A. Minority Populations and Health:
in rural areas, there is little or no available pub- An Introduction to Health Disparities in the United
lic transportation. States. San Francisco: Jossey-Bass, 2005.
Health Economics 493
Satcher, David, and Rubens J. Pamies, eds. Multicultural Supply and Demand of Health
Medicine and Health Disparities. New York:
McGraw-Hill, 2006. A key distinction in health economics is that
Smedley, Brian D., Adrienne Y. Stith, and Alan R. between health and healthcare. There is no market
Nelson, eds. Unequal Treatment: Confronting Racial for “health” where health can be purchased.
and Ethnic Disparities in Health Care. Washington, Instead, health is produced by individuals and
DC: National Academies Press, 2003. families using healthcare services, time, and other
Wallace, Barbara C., ed. Toward Equity in Health: A market goods such as exercise. This focus on
New Global Approach to Health Disparities. New health production is the basis of the human capi
York: Springer, 2008. tal model of health. Moreover, health is a durable
Williams, Richard Allen, ed. Eliminating Healthcare good that yields a flow of services over time. As
Disparities in America: Beyond the IOM Report. such, health depreciates with time as an individual
Totowa, NJ: Humana Press, 2007. grows older. Purposeful changes in health are
achieved through investments in health, such as
the use of healthcare services and time spent exer-
Web Sites
cising. Therefore, health at any particular age is a
Agency for Healthcare Research and Quality (AHRQ): consequence of all past investments in health and
http://www.ahrq.gov past rates of health depreciation.
Health Disparities Collaborations: Another important tenet of health economics is
http://www.healthdisparities.net that health is simultaneously a consumption good
International Society for Equity in Health (ISEqH): and an investment good. As a consumption good,
http://www.iseqh.org good health is valued by the consumer for the
National Center for Health Statistics (NCHS): physical pleasure it brings and for facilitating the
http://www.cdc.gov/nchs enjoyment of life’s other activities. As an invest-
National Center on Minority Health Disparities ment good, however, good health also enhances a
(NCMHD): http://ncmhd.nih.gov
person’s ability to learn and earn, which leads to
greater consumption of all goods. In addition,
because health is a durable good that yields a flow
Health Economics of future services, health is similar to other types of
investments that require initial outlays in return
Health economics is the study of the supply and for future benefits.
demand of health and healthcare services. While The canonical model of the supply and demand
there are many types of healthcare services, health for health was developed in the early 1970s. In this
economics focuses on those related to medical model, a consumer desires health and other goods
care even though factors such as diet and exercise and chooses the optimal amount of health and
may be equally or more important determinants other goods depending on the price of those goods.
of health. Health economics provides a frame- The unique thing about health, however, is that it
work for identifying the determinants of the sup- is not purchased. Health is produced by the con-
ply and demand for healthcare services and sumer using medical care, time, and other goods.
describes how the structure of the market for The price or supply of health is determined by the
these services interacts with the supply and demand cost of producing health, which depends on
to determine the price and quantity of healthcare the costs of inputs used to produce health such as
services. Defining the efficient use of healthcare the cost of a person’s time (e.g., wage), price of
services and how it can be achieved is the ulti- medical care, and productivity of inputs used to
mate, normative goal of health economics. The produce health. The optimal amount of health, or
second major focus of health economics is the the optimal stock of health capital, is chosen to
broader study of the supply and demand of health. equate the marginal benefits to the marginal costs
Notably, there is no market for health per se, and of health capital. The marginal benefits of health
the supply and demand for health is largely deter- are the discounted lifetime benefits of an addi-
mined by individuals. tional unit of health capital and include the psychic
494 Health Economics
value of better health and the increase in earnings healthier than those with a lower life expectancy.
resulting from better health. The marginal costs of This point is most easily illustrated in the context
health are the costs of investment in health. of the differences in health between the developed
The human capital model of health results in and less developed countries. Persons in less devel-
three main predictions that can be used to explain oped countries have relatively low life expectancy.
differences in health. These predictions relate to the They are more likely to be affected by a variety of
relationships between the depreciation of health illnesses and accidents and to die at a relatively
capital and health, wages and health, and educa- young age. Therefore, their incentives to invest in
tion and health. The first prediction from the health, the benefits of which occur in later life, are
human capital model of health is that higher rates lower than for persons in more developed coun-
of depreciation of health capital will cause health tries with higher life expectancy. A similar dynamic
to be lower. The rate of depreciation of health occurs between ages and between diseases. Raising
increases with age, and therefore, health decreases the expected probability of surviving childhood
with age. At some point, the consumer will find it increases the incentive to make investments that
too costly to offset the growing rate of depreciation improve health at older ages. Advancements in
(sickness), and health will deteriorate to the point treating one disease increase the incentive to make
of death. Rates of depreciation may be lower investments in health that decrease the probability
because of genetic and biological factors, which are of contracting other diseases.
largely impervious to social intervention, or because In summary, the human capital model of the
of environmental factors, which are amenable to supply and demand of health provides a useful
social intervention. For example, government pro- framework to analyze and explain observed differ-
grams that improve the physical and social environ- ences in health and the potential value of health
ment of people may reduce the rates of depreciation interventions. The human capital model of health
of health and result in an increase in health. The is relevant to the most salient health policy issues
rates of depreciation are likely to be higher and such as racial and ethnic health disparities and
health worse in less developed countries because of how to improve the health of developing countries.
harsher environments and the biological disadvan- Researchers have widely used the human capital
tages resulting from poorer maternal health. model of health to assess the importance of differ-
The second prediction is that higher wages will ent determinants of health, most notably medical
improve health. Higher wages increase the marginal care and education.
benefits of health by increasing the value of earn-
ings capacity resulting from better health. Therefore,
Supply and Demand of Healthcare Services
persons with higher earnings capability will invest
more in health and be healthier. Higher wages also The second major focus of health economics is to
imply greater lifetime wealth and better health. analyze the market for healthcare services, in par-
Finally, education will be positively associated ticular physician services and hospital markets.
with health. Those with more education will be Kenneth Arrow wrote the seminal article for this
more productive at producing health, which lowers topic in 1963, which provides an early description
the cost of investing in health. Thus, more edu- of what makes the market for healthcare services
cated persons will be healthier. Moreover, because unique. Several aspects differentiate the health
more education raises wages, those with more edu- services market from the standard economic
cation will invest more in health because being model: (a) the uncertainty of demand caused by
healthy and able to work will be more valuable. the uncertainty of illness; (b) the absence of free
Recently, researchers have developed an alterna- entry and exit of firms; (c) the dominance of non-
tive model of the demand for health; it emphasizes profit firms, particularly in the hospital industry;
several issues that, historically, had been largely and (d) the nonobservability of quality of care. In
ignored by health economists. This model focuses sum, these factors clearly describe the ways in
on the complementarities that affect the demand which the market for health services departs from
for health. Most important, those with a greater the simple, competitive model of supply and
life expectancy will invest more in health and be demand.
Health Economics 495
Perhaps the most important departure from the know his or her diagnosis, the optimal course of
competitive model is the fact that providers have treatment, or the quality of care provided, the con-
market power—that is, competition does not drive sumer may trust a nonprofit hospital more because
the price of healthcare to marginal cost. Market it does not appear to have the same financial incen-
power stems from several sources, with the first tives to exploit this lack of information. While
being the personal relationship between the patient nonprofit status, therefore, is a signal of trust and
and the provider. Patients may be comfortable implies higher quality of care, this explanation is
with and trust a specific physician, making them inconsistent with the for-profit physician services
reluctant to switch providers. This gives the pro- market where information asymmetries are equally
vider some power to price above marginal cost, as important.
consumers do not choose providers solely on the The second explanation for the dominance of
basis of price. In addition, market power stems nonprofits is due to their provision of a public
from the patient’s lack of information about his or good. The positive externalities or social benefits
her health and healthcare needs. The physician has associated with medical research, public health,
better information about the patient’s illness and and uncompensated patient care requires public
treatment (quality and quantity of care) than the subsidies. This explanation suggests that for-profit
patient. The physician is the patient’s agent, and firms are only interested in profit and will not
this lack of information ties a patient to a provider. undertake the production of goods beneficial to the
The physician is likely to have better information community, whereas nonprofits can make the pro-
about the nature and type of illness than even the duction of these goods goals of the organization.
insurer, and therefore, even third-party payers can- This is inconsistent, however, with the absence of
not obtain prices that equal marginal cost. Finally, regulatory oversight about the nature of nonprofit
because information is costly to obtain, search hospitals’ output (e.g., there is no requirement that
costs are significant, and third-party insurance uncompensated care be provided).
deters patients from obtaining better information Finally, cartel theory or interest group theory
about the prices and quality of providers. has also been used to explain the dominance of
The ability of providers to price above marginal nonprofit hospitals. This explanation is predi-
cost is one of the most widely studied issues in cated on managers, physicians, employees, or
health economics. Some of the narrower topics of other stakeholders running the hospital for their
interest in this area are (a) whether providers can own gain (for-profits in disguise). Nonprofit sta-
induce demand (i.e., get consumers to use services tus allows surplus or profit to be larger than in
that are unnecessary); (b) whether physicians for-profit enterprises because of public subsidies
respond to financial incentives in ways that are not that lower costs. Nonprofit status makes it easier
clinically appropriate; (c) understanding the effect to “hide” rent due to the diffuse nature of own-
of competition, mergers, and concentration on ership where there are no explicit shareholders.
physician and hospital prices; and (d) understand- There is still much debate over which of these
ing the effects of government regulation on the explanations is the most appropriate, and research
prices, quality, and quantity of physician and suggests that there is little difference between for-
hospital services. profit and nonprofit hospitals in terms of the qual-
The dominance of nonprofit firms in the hospital ity of care they deliver and the amount of charity
industry is also a major concern of health econom- care they provide.
ics. Few other industries in the United States are
characterized by a mix of for-profit and nonprofit
Health Insurance
firms as is the hospital sector. Health economics
seeks to explain this characteristic of the market. A third major focus of health economics is exam-
There are several prominent explanations for the ining the demand for and consequences of health
dominance of nonprofit hospitals. The first arises insurance. The uncertainty of illness is one of the
from asymmetric information, which has promoted most important features that characterize choices
a greater level of trust in nonprofit hospitals than in regarding health and healthcare. The study of
for-profit hospitals. Because the consumer does not insurance in health economics builds on a long
496 Health Economics
tradition in economics, dating back to Arrow’s observable and this results in pricing such that some
study in 1963, that studies the effects of uncer- consumers, usually the healthy, pay relatively more
tainty on economic decisions. for insurance and other consumers, usually the sick,
The demand for health insurance stems from pay relatively less for insurance. A consequence of
the uncertainty associated with illness and disease. adverse selection is that it—in addition to other
It is assumed that consumers are risk averse and factors—causes the price of insurance to be high,
that people prefer a sure bet to a risky outcome which may contribute to the numbers of the unin-
even if, on average, the two alternatives would sured. Probably the most important reason why
leave the consumer equally well off. Consumers there are uninsured persons in the United States is
are, therefore, willing to pay to reduce risk; insur- that the price of insurance is often too high.
ance is a good that reduces the financial risk—and
to some extent the physical risk—associated with
illness. Health economics uses this simple theory of Future Implications
insurance to analyze patterns of insurance and After nearly 50 years of analysis, many of the basic
why people do or do not have insurance. Consumers questions that are central to health economics
are expected to purchase more health insurance as remain largely unanswered. For example, there is
the potential loss from illness (i.e., the severity of still much debate over what determinants of health
illness) increases, as the uncertainty of illness are the most important, and therefore, what
increases, and as an individual’s level of risk aver- accounts for differences in population health
sion increases. within and between countries. Related to this is the
There are two major issues that dominate the question of how population health affects eco-
study of health insurance: moral hazard and nomic growth. Will improvements in population
adverse selection. Moral hazard is the term used to health lead to faster rates of economic growth and
describe a change in consumer behavior due to subsequent improvements in health? How impor-
insurance. In the context of health insurance, there tant is population health to economic growth?
are two types of moral hazards, ex ante and ex Similarly, there is relatively little, credible research
post. Ex ante moral hazard refers to taking action on the consequences of competition in physician
that changes the probability or severity of illness. services and hospital markets. Does hospital con-
Insured persons may invest less in preventing dis- centration result in higher prices and lower quality
ease or the severity of disease because health insur- of care, or does it lead to lower costs because of
ance will pay for the costs of treatment. There is greater economies of scale? And it is still not
little study of the extent of ex ante moral hazard known whether nonprofit or for-profit hospitals
on the prevalence of illness. Ex post moral hazard provide better care. In the near future, research in
refers to actions the consumer takes after contract- health economics will continue to try to answer
ing a disease. Insurance may lead them to consume these fundamental questions. Furthermore, in the
more healthcare services than they otherwise future, health economics is likely to continue to
would. The latter type of moral hazard raises the integrate advances in medical science in the areas
cost of insurance, which will cause some people to of genetics and neuroscience to improve and
be uninsured. The extent and consequences of ex expand analyses of the supply and demand of
post moral hazard is one of the most widely stud- health and healthcare services. Medical science
ied issues in health economics. may also change the landscape for health insurance
Adverse selection refers to the view that consum- as the risk of illness becomes more knowable.
ers pay the wrong price for health insurance. From
an economics perspective, the price that the con- Robert Kaestner
sumer pays for health insurance should reflect the
true risk of illness: Those with a greater risk of ill- See also Economic Barriers to Healthcare; Healthcare
ness should pay more for insurance than those with Markets; Health Insurance; Market Failure; Moral
a lower risk of illness, because those with a greater Hazard; Nonprofit Healthcare Organizations; Public
risk of illness could end up using more healthcare Policy; Supplier-Induced Demand
services. The risk of illness, however, is not fully
Health Indicators, Leading 497
Further Readings health, those who are assessing health status

Arrow, Kenneth J. “Uncertainty and the Welfare must develop a mutually agreed on set of mea-
Economics of Medical Care,” American Economic surement tools. One of the best-known and most
Review 53(5): 941–73, December 1963. widely used sets of health indicators are those
Becker, Gary S. “Health as Human Capital: Synthesis developed by the federal government’s Healthy
and Extensions,” Oxford Economic Papers 59(3): People 2010 initiative. The initiative identified a
379–410, 2007. set of leading indicators based on their ability to
Cutler, David M., Allison B. Rosen, and Sandeep Vijan. initiate action and measure progress. Specifically,
“The Value of Medical Spending in the United States, it defined 10 leading health indicators with the
1960–2000,” New England Journal of Medicine objective of measuring the health status of all
355(9): 920–27, August 31, 2006. individuals in the United States over the 10-year
Ehrlich, Isaac, and Gary S. Becker. “Market Insurance, period from 2001 to 2010. The 10 leading health
Self-Insurance, and Self-Selection,” Journal of indicators are (1) physical activity, (2) overweight
Political Economy 80(4): 623–48, June–August 1972. and obesity, (3) tobacco use, (4) substance abuse,
Grossman, Michael. “On the Concept of Health Capital (5) responsible sexual behavior, (6) mental health,
and the Demand for Health,” Journal of Political (7) injury and violence, (8) environmental qual-
Economy 80(2): 223–55, March–April 1972. ity, (9) immunization, and (10) access to health-
Grossman, Michael. “Education and Non-Market care.
Outcomes.” In Erik A. Hanushek and Finis Welch,
eds. Handbook of the Economics of Education.
Amsterdam, the Netherlands: North-Holland, 2006.
Healthy People 2010
Murphy, Kevin M., and Robert H. Topel. “The Value of
Health and Longevity,” Journal of Political Economy The Healthy People 2010 initiative is a broad set
114(5): 871–904, October 2006. of health objectives for the United States to achieve
Newhouse, Joseph. Free for All? Lessons From the over the first decade of this century. The initiative
RAND Health Insurance Experiment. Cambridge, is designed to be used by many different popula-
MA: Harvard University Press, 1993. tion groups, communities, and professional orga-
nizations. The initiative attempted to develop
various programs to improve population health.
Web Sites Healthy People 2010 identified leading health
AcademyHealth: http://www.academyhealth.org indicators that represent the major public
American Economic Association (AEA): health concerns the nation faces in the first decade
http://www.vanderbilt.edu/AEA of the 21st century. Each of the leading indicators
American Society of Health Economists (ASHE): depends on the information individuals have
http://healtheconomics.us about their health.
International Health Economics Association (iHEA):
http://www.healtheconomics.org
National Library of Medicine (NLM), Health Economics Development of the
Information Resources: http://www.nlm.nih.gov/ Leading Health Indicators
nichsr/edu/healthecon
Selecting leading health indicators involved a
World Health Organization (WHO), Health Economics:
http://www.who.int/topics/health_economics/en
large interagency task force from the U.S. Depart
ment of Health and Human Services (HHS).
Additionally, many associations and professional
organizations provided comments and analysis at
various task force meetings and communicated
Health Indicators, Leading with it via e-mail and through the Internet. The
National Academy of Sciences, Institute of
To create national policies to alleviate health Medicine (IOM) conducted a study, using scien-
problems, it is imperative to define what consti- tific models, to support a given set of indicators.
tutes a healthy population. Before evaluating This systematic approach in determining the
498 Health Indicators, Leading
leading health indicators legitimized the impor- and adults who have not used these substances in
tance and significance of the resultant measures of the past 30 days. Another goal is to reduce the
the population’s health. number of adult binge drinkers.
The 10 Leading Health Indicators 5. Responsible Sexual Behavior

1. Physical Activity Unplanned pregnancies and sexually transmit-
Physical activity is an important leading health ted diseases (STDs), including infection with the
indicator because it is crucial for maintaining a human immunodeficiency virus (HIV) that causes
healthy body, enhancing psychological well-being, AIDS, can result from unprotected sexual behav-
and preventing early death. In 1997, 63% of ado- iors. The current objectives are to increase the
lescents engaged in the recommended amount of proportion of adolescents who abstain from inter-
daily physical activities: about 20 minutes of vigor- course or who use protection if sexually active.
ous physical activity, 3 or more days per week. Another goal is to increase the proportion of sexu-
During the same year, 15% of adults engaged in ally active adults who use protection.
the recommended amount of activity: 30 minutes
of moderate daily physical activity, 5 or more days 6. Mental Health
per week. The goal is to increase the proportion of
the nation’s adolescents and adults who engage in About 20% of the nation’s population is affected
daily physical activities. by mental illness during any given year. Of all men-
tal illnesses, depression is the most common.
Although mental health issues affect people of all
2. Overweight and Obesity ages, the objective here focuses only on adults
because of the large quantity of available data.
Being overweight and obese are major contribu-
Adults and older adults have the highest rates of
tors to many preventable diseases (e.g., heart dis-
depression. In fact, major depression is the leading
ease, stroke, diabetes, and hypertension). Higher
cause of disability and is the cause of more than
body weights are also associated with higher mor-
two thirds of suicides each year. Depression is
tality rates. Objectives for the future are to reduce
treatable with medication and therapy, and the
the proportion of children, adolescents, and adults
goal for this indicator is to increase the proportion
who are overweight and obese. Efforts to maintain
of adults who receive treatment.
a healthy weight must start in childhood.
7. Injury and Violence

3. Tobacco Use
More than 400 Americans die each day from
Cigarette smoking is the single most preventable injuries, primarily due to motor vehicle crashes,
cause of disease and death in the United States: firearms, poisonings, suffocations, falls, fires, and
Smoking results in more deaths each year than drowning. Many factors that contribute to injuries
AIDS, alcohol, cocaine, heroin, homicide, suicide, are also associated with violent and abusive behav-
motor vehicle crashes, and fires combined. ior such as low income, discrimination, lack of edu-
Objectives for the future are to reduce smoking cation, and lack of employment opportunities. The
rates in adolescents and adults. goals for this indicator are to reduce homicides and
deaths due to motor vehicle crashes. Although these
are the main goals, the initiative also aims to reduce
4. Substance Abuse
unintentional falls, fire deaths, abuse, and assault.
Alcohol and illicit-drug use are associated with
many of the nation’s most severe problems. Alcohol
8. Environmental Quality
abuse alone is associated with motor vehicle crashes,
homicides, suicides, and drowning deaths. A cur- An estimated 25% of preventable illnesses world-
rent goal is to increase the number of adolescents wide are attributed to poor environmental quality.
Health Informatics 499
Two indicators of air quality are the ozone level and Further Readings
environmental tobacco smoke. The main objective Chrvala, Carole, and Roger J. Bulger, eds., and the
is to reduce the proportion of individuals exposed Committee on Leading Health Indicators for Healthy
to air not meeting the U.S. Environmental Protection People 2010. Leading Health Indicators for Healthy
Agency’s health standards for ozone. Another People 2010: Final Report. Washington, DC:
objective is to reduce the proportion of nonsmokers National Academy of Sciences, 1999.
exposed to environmental tobacco smoke. Kandula, Namratha R., Margaret Kersey, and Nicole
Lurie. “Assuring the Health of Immigrants: What the
Leading Health Indicators Tell Us,” American Review
9. Immunization of Public Health 25: 357–76, 2004.
Immunizations can prevent disability and death McDowell, Ian. Measuring Health: A Guide to Rating
from infectious diseases and help prevent the Scales and Questionnaires. 3d ed. New York: Oxford
spread of infections within communities. The main University Press, 2006.
objective is to increase the proportion of young U.S. Department of Health and Human Services. Healthy
People 2010: Understanding and Improving Health.
children who receive all recommended vaccines
2d ed. Washington, DC: Government Printing Office,
and to increase the proportion of noninstitutional-
2000.
ized adults who are vaccinated annually against
Zahner, Susan J., and Derryl E. Block. “The Road to
influenza and ever vaccinated against pneumococ-
Community Health: Using Healthy People 2010 in
cal disease.
Nursing Education,” Journal of Nursing Education
45(3): 105–8, March 2006.
10. Access to Healthcare
Strong predictors of access to healthcare include
having health insurance, a higher income level, and Web Sites
a regular primary-care provider or other sources of Centers for Disease Control and Prevention (CDC),
ongoing healthcare. The goals for this leading Environmental Public Health Indicators Project:
health indicator are to increase the proportion of http://www.cdc.gov/nceh/indicators
individuals with health insurance and a source of Healthy People 2010: http://www.healthypeople.gov/LHI
ongoing care. Another goal is to increase the pro- Public Health Indicators and National Data (PHIND):
portion of pregnant women who start receiving http://www.communityphind.net
prenatal care in the first trimester of pregnancy. World Health Organization (WHO): http://www.who.int
Policy Implications
Equipped with the leading health indicators, Health Informatics
which identify problem areas and emphasize their
underlying factors, U.S. policymakers can likely Health informatics is the science of evaluating,
better serve the health needs of the nation. To implementing, and utilizing technology to manage
achieve certain health outcomes and to achieve the all information related to the patient care delivery
goals and objectives of Healthy People 2010, process at all levels: clinical, financial, technologi-
resources must be spent efficiently, effectively, and cal, and enterprise. It is a multidisciplinary field,
equitably. Research involving the leading health drawing from health information and computer
indicators will likely shape national healthcare science, psychology, sociology, and engineering.
policies for the future. The history of the term, itself, is relatively recent.
Jennifer Feld The Russian engineer and information scientist
Alexander I. Mikhailov (1905–1988) is credited
See also Access to Healthcare; Health; Healthy People with first defining, around 1968, the term infor
2010; Mental Health; Preventive Care; Public Health; matika as the field that studies the structure and
Public Policy; Tobacco Use general properties of scientific information and the
500 Health Informatics
laws of all processes of scientific communication. Pharmacy informatics, on the other hand, focuses
The English word informatics began to appear in on medication-related data and knowledge within
the literature in the 1970s, and throughout the the continuum of healthcare systems, including its
1980s, the umbrella term health informatics acquisition, storage, analysis, use, and dissemina-
emerged to encompass the continuum of information in the delivery of optimal medication-related
tion management, information science, and com- patient care and health outcomes. Finally, public
puter science focused on healthcare. When applied health informatics is the systematic application of
to a specific discipline, the application of infor- information and computer science and technology
matics is focused on solving the problems of the to public health practice, research, and learning.
discipline, such as medical informatics, nursing
informatics, and public health informatics.
Role of Professional Associations
Health informatics disciplines can be understood,
Types of Health Informatics
in part, through the interests of the membership of
Health informatics encompasses many individual their professional associations. As an example, the
disciplines, which have further refined their foci in Healthcare Information and Management Systems
the field. For example, bioinformatics researchers Society (HIMSS), established in 1961, regularly
develop or apply computational tools and holds an annual conference with published pro-
approaches for expanding the use of biological, ceedings. At the 1999 conference in Atlanta,
medical, behavioral, or health data. These tools Georgia, the HIMSS attendees’ foci of interest
include those used to acquire, store, organize, centered on the use of healthcare information sys-
archive, analyze, or visualize such data. Consumer tems in healthcare organizations from a business
health informatics, on the other hand, is a subspe- perspective, exploring ways to extract value from
cialty of medical informatics that studies the use these systems. The conference also looked at the
of electronic information and communication to emergence of a number of healthcare goals, among
improve medical outcomes and the healthcare them patient safety. By the 2007 conference in
decision-making process from a patient or con- New Orleans, Louisiana, the HIMSS had added
sumer perspective. Similarly, dental informatics sessions on information technology standards and
expands the knowledge and understanding of the building stronger connections between operations
biological and biomedical processes in dentistry to and technologies. Leadership emerged as a new
improve prevention, diagnosis, treatment, and fol- theme, and initiatives appeared in public policy
low up of diseases through the examination of and community health. The scope had expanded
information handling and processing. Another to better represent both technological and patient
type, health sciences librarianship and informat care perspectives. The business process focus on
ics, deals with health-related information, its quality had merged with patient safety and risk
structure, acquisition, and use. Health sciences management. Other emerging topics recognized
librarianship and informatics are overlapping dis- the need for research in clinical informatics to
ciplines with strong conceptual links to the theo- identify effective and efficient clinical practices
retical discipline of information science. and the need for both privacy and security mea-
Also within the broad field of health informatics sures to protect healthcare data.
is medical informatics, the field that concerns itself The innate dynamic nature of the field has chal-
with the cognitive, information processing, and lenged its ability to define the term health informat
communication tasks of medical practice, educa- ics. While examining nearly 800 articles retrieved
tion, and research, including the information sci- by the general search term health informatics,
ences and the technology to support these tasks. researchers found that the articles were indexed by
Nursing informatics is a related specialty that inte- 10 common terms. Top among them were medical
grates nursing science, computer science, and infor- informatics, computer science, information systems,
mation science to manage and communicate data, and healthcare sciences and services. Researchers
information, and knowledge in nursing practice. used a set of six keywords that included the term
Health Informatics 501
health informatics, and mapped conceptual changes At the end of that spring conference, the com-
over a period of 10 years in the MEDLINE litera- mittee’s efforts concluded in the acknowledgment
ture database. The study found a consistent focus of the following 10 competencies as central to this
on healthcare, electronic medical records, and diverse group of providers: (1) software use, such
information technology topics in general. as presentation graphics, word processing, simple
databases, e-mail, Internet searches, decision sup-
port applications, telemedicine, and home moni-
Training and Skills toring; (2) principles of interface design and
human-computer interaction; (3) principles of pri-
Despite its historical roots, however, it has been the
vacy, confidentiality, and security; (4) ethical uses
emergence of academic programs across the nation
of information technology and ethical decision
that has brought some stability to the term health
making in the digital age; (5) knowledge of termi-
informatics. Throughout the 1990s, the rapid
nologies, taxonomies, standards, and communica-
growth in the field led to a dearth of qualified indi-
tion methods; (6) the importance of user-driven
viduals capable of guiding the development and
clinical systems and structured data to support
implementation of healthcare information systems
evidence-based practice; (7) methods of evaluating
applications. System vendors and hospitals began
information and information technology; (8) basic
to create formal employee positions for informati-
methods of software development—the process
cists. Colleges and universities struggled with the
and how to get involved; (9) how to critically and
creation of new curricula because they lacked a
efficiently process information; and (10) under-
clear definition of the knowledge and skill sets nec-
standing the impact of technology use (and of its
essary for individuals to work successfully in the
lack of use) on public health.
field. Published in 1996, an examination of infor-
Researchers have recently reflected on three of
matics competencies across the disciplines appeared
these competencies when they described a number
to support a general trend: Those individuals
of core themes in health informatics: (1) establish-
involved in clinical informatics appeared to deal in
ing standardized definitions of data elements,
detail with the ongoing support and development
standard languages, and commonly accepted
of applications, while those in health informatics
vocabularies; (2) establishing standards for elec-
appeared more focused on how applications and
tronic data exchange; and (3) usability.
technology, both existing and proposed, would
affect enterprise-wide production of and access to
information; on management of that access; and
on optimization of the information available. Future Implications
By 1998, the Pew Commission recognized the There is no question that the field of health infor-
effective and appropriate use of communication matics has grown in complexity, matching the
and information technologies as one of its 21 growth in capabilities of healthcare computing.
essential competencies for all health professionals. Healthcare has depended on computer technology
In 1999, the International Medical Informatics to make important advances in the field, com-
Association’s (IMIA’s) Working Group 1: Health mencing in the 1950s—when most computer
and Medical Informatics Education published its applications were for signal processing, images,
Recommendations of the International Medical and laboratory tests—through the 1970s, when
Informatics Association (IMIA) on Education in the first clinical information systems emerged.
Health and Medical Informatics. In that same year, Today, the social and organizational effect of tech-
the American Medical Informatics Association’s nology acceptance is a major consideration. The
(AMIA’s) spring conference used invited panels term health informatics will continue to evolve,
and structured breakout discussion sessions to capturing the essence of the world of healthcare
focus on issues and predictions for health infor- and information systems and incorporating ever-
matics education of three groups of health infor- increasing subtleties within its definition.
matics: (1) researchers, (2) administrators, and
(3) health professionals. Annette L. Valenta and Michael Dieter
502 Health Insurance
See also Clinical Decision Support; Computers; E-Health; this knowledge to develop more effective, effi-
Electronic Clinical Records; Healthcare Informatics cient, and equitable health polices.
Research; Health Communication; Health Insurance Health insurance plays a vital role in the U.S.
Portability and Accountability Act of 1996 (HIPAA); healthcare system. Health insurance protects indi-
Quality of Healthcare
viduals and their families from the high and unex-
pected costs of injury and illness. It provides the
insured with a measure of financial security. Health
Further Readings
insurance may cover physician fees, hospital bills,
Gustafson, David H., Patricia Flatley Brennan, and prescription drugs, medical equipment, and long-
Robert P. Hawkins, eds. Investing in E-Health: What term care expenses, as well as lost wages. Without
It Takes to Sustain Consumer Health Informatics. health insurance, the costs of a serious injury or
New York: Springer, 2007. major illness could easily cause financial ruin for
Hagan, Stuart. Evidence on the Costs and Benefits of most individuals and families. In fact, medical debt
Health Information Technology. Washington, DC: is one of the leading causes of bankruptcy in the
U.S. Congressional Budget Office, 2008. United States.
Hebda, Toni, and Patricia Czar. Handbook of Health insurance is an important determinant
Informatics for Nurses and Healthcare Professionals. of access to care. It enables the insured to have
4th ed. Upper Saddle River, NJ: Pearson Prentice access to preventive healthcare services and to the
Hall, 2008. early treatment of injury and illness. An over-
Kropf, Roger, and Guy Scalzi. Making Information
whelming body of evidence shows that the unin-
Technology Work: Maximizing the Benefits for
sured get less medical care, get it later when it is of
Health Care Organizations. Chicago: Health Forum,
less value and usually more urgent, incur greater
American Hospital Association Press, 2007.
morbidity, and die younger than those with health
Tan, Joseph, ed. Healthcare Information Systems and
Informatics: Research and Practices. Hershey, PA:
insurance.
Medical Information Science Reference, 2008.
Health insurance is the largest source of revenue
for nearly all healthcare providers in the nation. It
enables healthcare providers to maintain high-
Web Sites quality care. Revenue from health insurance allows
the providers to maintain their practices and orga-
American Health Information Management Association nizations, and it enables them to purchase new
(AHIMA): http://www.ahima.org advanced medical technology.
American Medical Informatics Association (AMIA):
http://www.amia.org
American Nursing Informatics Association (ANIA): Function and Nature of Insurance
http://www.ania.org
There are many definitions of insurance. Most of
the definitions include such terms as risk, pooling
Society (HIMSS): http://www.himss.org
of risk, potential losses, and protection against
International Medical Informatics Association (IMIA):
losses. For this entry, insurance is broadly defined
http://www.imia.org
as a form of risk management that transfers or
shifts financial risk from an individual to a group
such as a private insurance organization or a gov-
ernment agency, where losses are pooled and
Health Insurance spread across the group.
Not all risks are insurable. A number of prereq-
Many health services researchers study the func- uisites are necessary for insurance to successfully
tion and nature of insurance, the various types of work.
insurance plans, and the impact of insurance on First, there must be a sufficiently large number
healthcare. They also study the use of health ser- of similar exposure units to make the losses rea-
vices and the outcomes of care of the insured sonably predictable. Insurance is based on the
compared with the uninsured. Researchers use law of large numbers. For example, it may be
Health Insurance 503
impossible to predict with any certainty whether changes in attitude and behavior on the part of
a specific individual will develop a rare disease or the insured. Submitting a fraudulent claim to an
not, but by looking at a large population of indi- insurance organization is an example of moral
viduals it may be possible to statistically predict hazard, while buying expensive designer frame
the total number of individuals who will develop eyeglass instead of cheaper less fashionable
the rare disease. frames because insurance pays for them is an
The losses produced by the risk must be mea- example of morale hazard. Morale hazard may
surable in terms of its cause, time and place of also change the attitude of persons who are not
occurrence, and its monetary value. The monetary insured. For example, a physician might hospi-
value for most material things can be relatively talize a person with a less than severe illness
easily determined. However, the monetary value of because the person has health insurance; but if
the loss of human life is much more difficult to the same person was uninsured, the physician
estimate. might treat him or her on an outpatient basis,
The losses must be fortuitous or accidental, and because the person could not afford the cost of
not intentional. hospitalization.
The losses must not be catastrophic. Insurance
is based on the notion that only a small percentage
Major Classifications of
of individuals will experience major losses, and
Insurance and Key Terms
that the losses will be shared across the group. If
all individuals experience major losses, the insur- There are many types of insurance. Insurance can
ance company would not be able to cover all the be broadly classified based on the particular risk
losses, and it may go bankrupt. An event such as a it insures against (i.e., fire, flood, and wind dam-
nuclear attack would be catastrophic and the age) or by the nature of what it insures (i.e., auto,
losses it caused would be so great that it is not home, life, and health). Insurance can also be clas-
insurable. sified based on whether it is provided by a private
Last, the cost of the insurance must be afford- organization or by a government agency. Insurance
able. If the cost of the insurance is too high, and provided by a government agency is sometimes
too few individuals can afford to purchase it, there called social insurance.
may not be a sufficiently large group to share the A number of key terms are associated with insur-
possible losses. ance: premiums, deductibles, copayments, coinsur-
ances, and maximum out-of-pocket expenses.
Premiums are the price of an insurance plan. In
Problems Faced by Insurance Organizations
healthcare, premiums are based either on commu
Insurance organizations face two major problems: nity rating or experience rating. In community
adverse selection and moral hazard. Adverse selec- rating, the premium price is based on the popula-
tion is the tendency of higher-risk persons or tion or group in a geographic area, and it ignores
groups to buy and maintain insurance. For exam- any differences among subgroups. In contrast, in
ple, people with poor health may be more likely to experience rating the premium price is based on
seek health insurance coverage, while those with differences in demographics, past healthcare utili-
excellent health may not. To protect against this zation, medical status, and other factors of various
type of adverse selection, health insurance policies groups. Generally, insurance premiums are cheaper
frequently exclude coverage for preexisting medi- under community rating.
cal conditions. However, the federal Health Deductibles are the amount paid out of pocket
Insurance Portability and Accountability Act of for medical services each year before insurance
1996 (HIPAA) now limits exclusions based on begins to pay. Deductibles vary greatly. Some
such conditions. insurance plans have no deductibles, while others
Moral hazard is sometimes divided into have a very high deductible.
two categories: moral hazard and morale Copayments are flat fees or percentages charged
hazard. “Moral hazard” describes immoral or each time an individual visits a physician or uses a
illegal conduct, while “morale hazard” describes medical service. There may be a set amount for a
physician visit, a different amount for laboratory insurance. With the nation’s postwar prosperity,
work, and various amounts for prescription drugs. employers increasingly offered health insurance to
Coinsurances are requirements that individual their workers.
policyholders must pay a percentage of the total Most working Americans obtain their health
cost of care. Individuals may have to meet deduct- insurance through their employers. Health insur-
ibles before coinsurance begins. ance is generally part of the worker’s employment
Maximum out-of-pocket expenses are the most benefits package. Employers offer health insurance
individual policyholder have to spend before all through the workplace because of the tax advan-
medical bills are covered. Out-of-pocket expenses tage of doing so, because of the increase in worker
include deductibles and copayments. productivity that results from improved health,
and because health benefits allow them to recruit
Types of Health Insurance Plans and retain high-quality workers.
Most employers offer their workers a selection
Health insurance can be classified as being proof health insurance plans to choose from. The
vided by either a private organization or a gov- plans tend to vary in their scope of coverage, the
ernment agency. However, many people, cost of the premiums, and the amount of coinsur-
especially the elderly, purchase both private as ance and deductibles they require. Employers and
well as government health insurance coverage. employees generally share the costs of the insur-
The elderly often purchase private, supplemental ance. Health insurance obtained through work is
health insurance, called Medigap insurance, to typically group insurance. Group insurance usu-
cover the costs or “gaps” not covered by govern- ally costs less and offers more benefits than indi-
ment insurance such as Medicare. Also, some vidual health insurance plans.
low-income elderly with limited resources are The health insurance plans offered by most
dual eligible and are covered by two government large employers generally include indemnity insur-
health insurance programs, Medicare and ance and various types of managed-care plans.
Medicaid. Below is a brief description of the The three major types of managed-care plans are
major types of private and government health (1) health maintenance organizations (HMOs),
insurance in the United States. (2) preferred provider organizations (PPOs), and
(3) point-of-service (POS) plans. And some employ-
ers are beginning to offer their workers health sav-
Private Health Insurance
ings accounts (HSAs).
Private health insurance began in the nation Indemnity or fee-for-service insurance is a tradi-
during the Great Depression. At that time, many tional kind of health insurance. Today, this type of
people could not afford healthcare, and hospitals insurance is uncommon. Under this type of plan,
were closing. In 1929, Baylor University Hospital the insured individual may go to any physician or
in Dallas, Texas, contracted with local public hospital to receive care. After receiving the care,
school teachers to provide them with hospital care. the individual or the healthcare provider sends the
For a prepayment of 50 cents per month, the hos- bill to the insurance company, which typically pays
pital guaranteed that each teacher would receive a certain percentage of the bill, after the individual
up to 21 days of hospitalization in a semiprivate meets the policy’s annual deductible. For example,
room, as needed. Similar plans began forming fee-for-service plans may pay 80% of a medical
across the country. Ultimately, these plans became bill, leaving 20% to be paid (coinsurance) by the
Blue Cross and Blue Shield organizations. With the individual. Most plans limit the amount that the
growing success of the Blue Cross and Blue Shield, individual must pay per year (i.e., the deductible)
other commercial insurance companies also began to, for example, $500 per year maximum.
to market health insurance. During World War II, HMOs are prepaid health insurance plans. HMO
when the federal government established ceilings members pay a monthly premium. In exchange, the
on wages, many employers began offering their HMO provides comprehensive care, including phy-
workers fringe benefits such as paid vacations, sician visits, hospital stays, laboratory tests, and
retirement benefits, and company-financed health therapy. HMOs include a variety of arrangements
but consist mainly of three types: (1) the staff model, The costs of POS plans are generally higher than
(2) the group model, and (3) the independent prac HMOs and PPOs, but the patient has greater free-
tice association (IPA). Under the staff model HMO, dom to choose healthcare providers.
healthcare services are provided by a group of phy- A new type of health insurance that is beginning
sicians who are salaried employees of the HMO. to be offered by employers is health savings
Under the group model HMO, healthcare services accounts (HSAs). HSAs were signed into federal
are provided by a multispecialty group of physicians law in 2003. To open an HSA, an individual must
who are independent of the HMO but who contract have coverage from a qualified high deductible
with the HMO to provide services. Under the IPA, health plan (HDHP). The employer, the worker, or
healthcare services are provided by private-practice both can make contributions to HSAs. However,
physicians who contract with the HMO to provide the total contributions are limited annually. Funds
care to HMO patients in a private office setting. In in HSAs are tax free, and they are completely por-
most HMOs, members are assigned or choose a table, meaning that they can be kept if individuals
physician who serves as their primary-care physi- change jobs, become unemployed, or change their
cian. The primary-care physician monitors the marital status. Money in HSAs can be used to pay
patient’s health, provides basic medical care, and is for routine health expenses, while the HDHP covers
also responsible for referring patients to a specialist the costs of a serious injury or major illness. Money
and other healthcare professionals as needed. Most in HSAs can be saved for future medical expenses,
HMOs do not require a deductible each year, but and it can grow through investment earnings.
they do generally require a small copayment for a Although not generally covered by employers,
visit. Because HMOs receive a fixed fee per member another type of private health insurance is long-
per month, they may provide more preventive term care (LTC) insurance. LTC insurance covers
healthcare services such as immunizations, mam- care generally not covered by other types of private
mograms, and physicals. health insurance or government health insurance
The most common type of private health insur- programs. It covers individuals with disabling inju-
ance in the United States is the PPO. PPOs are ries and illnesses such as spinal cord injuries,
generally less flexible than traditional health insur- stroke, and Alzheimer’s disease. Depending on the
ance plans but more flexible than HMOs. policy, LTC insurance can pay for home health
Individuals or members enrolled in PPOs may go care, adult day care, respite care, and nursing
to any physician (including a specialist) or hospital home stays. The cost of LTC insurance is typically
to receive care, but the coinsurance is higher for based on the size of the policy and the age and
health providers who are not preferred providers. health status of the individual. About 10% of
Preferred providers have contracts with PPOs, and Americans over the age of 55 have LTC insurance.
they agree to provide PPO members discounts on In 2006, the U.S. Congress passed legislation
the costs of their care. PPOs generally require their authorizing changes in state laws allowing indi-
members to obtain prior approval before entering viduals to purchase LTC insurance that coordi-
a hospital. nates with the government health insurance
POS plans combine some aspects of HMOs and Medicaid program.
PPOs. POS plans provide a range of healthcare
services. Like HMOs, POS plans use primary care
Government Health Insurance
physicians to coordinate patient care. Like PPOs,
POS plans contract with healthcare providers to The first government health insurance program
provide services to plan members. However, unlike in the United States was workers’ compensation,
PPOs, which require members to select a preferred which was adopted by the individual states during
provider in advance, PPOs plans allow members to the early 1900s. Every state has workers’ compen-
choose at the time they need healthcare whether or sation. Under the laws of each state, workers’
not to seek care within the plan’s network of care compensation provides medical care and compen-
providers or to go outside the network for care. sation, regardless of fault, for employees who are
And like PPOs, if the member goes outside the injured or disabled during the course of their
plan, they will have to pay a higher coinsurance. employment.
The Social Security Act of 1935 established the offered through private insurance companies. It
Old Age, Survivors, and Disability Insurance helps pay the costs of prescription drugs. The
(OASDI) Program, commonly known as Social Medicare Modernization Act (MMA) of 2003
Security. This comprehensive, federal benefits pro- established Part D for all individuals entitled to or
gram includes retirement benefits, disability enrolled in Medicare Parts A and B. It went into
income, veterans’ pensions, public housing, and effect on January 1, 2006.
the food stamp program. The U.S. Congress Medicaid (Title XIX of the Social Security Act)
amended the Social Security Act in 1965 and is a federal-state health insurance program for indi-
included the Medicare and Medicaid programs. As viduals and families with low incomes and limited
part of the Balanced Budget Act of 1997 (BBA-97), resources. Although the federal government estab-
Congress again amended the Social Security Act lishes broad guidelines for the Medicaid program,
and included the State Children’s Health Insurance each state establishes its own eligibility standards,
Program (SCHIP). benefits packages, payment rates, and program
Medicare (Title XVIII of the Social Security Act) administration. As a result, there are essentially 56
is the federal healthcare program that covers different Medicaid programs—one for each state,
almost everyone in the United States age 65 years territory, and the District of Columbia.
or older, individuals under age 65 with certain dis- Medicaid is the largest payer of LTC services in
abilities, and individuals of all ages with perma- the nation, paying about 50% of the care being
nent kidney failure requiring dialysis or a kidney provided in nursing homes. Because Medicaid has
transplant. Although Medicare coverage is com- strict financial eligibility criteria, it generally
prehensive, it provides very limited LTC services. requires recipients to deplete their savings, or
Medicare consists of four parts: Part A (hospital “spend down,” before it will pay for nursing home
insurance), Part B (medical insurance), Part C services.
(managed-care plans), and Part D (prescription Medicaid does not provide medical assistance
drug coverage). Medicare Parts A and B are some- for all poor persons, unless they are in a desig-
times referred to as “traditional Medicare.” nated eligibility group. All Medicaid programs are
Medicare Part A is hospital insurance. It helps required to include certain eligibility groups, but
provide basic coverage for hospital stays; posthos- they may also include other groups as well. All
pital, skilled-nursing facility care; home health programs must include three groups: (1) the cate-
care; and hospice care. Part A is financed by pay- gorically needy (i.e., families who meet the states’
roll taxes levied on employers and employees. Aid to Families With Dependent Children (AFDC)
Medicare Part B is medical insurance that can eligibility requirements, pregnant women and chil-
be purchased by paying a monthly premium. It dren under age 6 whose family income is at or
pays most of the basic physician and laboratory below the federal poverty level, individuals receiv-
costs and some outpatient medical services, including Supplemental Security Income (SSI), and indi-
ing medical equipment and supplies, home health viduals and couples in medical institutions with a
care, and physical therapy. It also pays for some monthly income with a certain monthly income
preventive services such as cardiovascular screen- level; (2) the medically needy (i.e., pregnant
ing, diabetes screening, glaucoma tests, and pros- women through a 60-day postpartum period, chil-
tate cancer screening for individuals joining dren under age 18, certain newborns for 1 year,
Medicare for the first time. and certain protected blind persons, and special
Medicare Part C or Part C Medicare Advantage groups); and (3) special groups (i.e., Medicaid
was formerly known as Medicare + Choice plans. pays the Medicare premiums, deductibles, and
Individuals with Medicare Parts A and B can volun- coinsurance for certain individuals who are below
tarily choose to receive all their healthcare services the federal poverty level, qualified working dis-
from Medicare managed-care plans, which are pro- abled individuals, and LTC services for individuals
vided through private insurance companies. who are Medicaid eligible and qualify for institu-
Medicare Part D is a voluntary, prescription tional care).
drug coverage program that can be purchased by Medicaid programs generally cover physicians’
paying a monthly premium. The program is services, inpatient and outpatient hospital care,
nursing facility services, prescription drugs, dental Future Implications

care, physical therapy, rehabilitation services, and
Health insurance is important for individuals
hospice care. The programs also cover pregnancy
and their families, and for the nation’s health-
and postpartum related services and early and
care delivery system. It protects individuals and
periodic screening, diagnosis, and treatment
their families from the high and unexpected
(EPSDT) for children under age 21.
costs of serious injury and major illness. Health
The State Children’s Health Insurance Program
insurance provides access to healthcare services.
(SCHIP) (Title XXI of the Social Security Act)
And health insurance is the largest source of rev-
assists states in providing healthcare services to
enue for nearly all healthcare providers. Many
uninsured, low-income children up to the age of
private organizations and government programs
19. Like Medicaid, SCHIP is jointly financed by
provide health insurance, but their insurance
the federal and state governments and is adminis-
plans vary greatly in terms of benefits, coverage,
tered by the states. SCHIP is designed to provide
and eligibility. In the future, as the costs of
coverage to targeted low-income children. A tar-
healthcare increase and the nature of American
geted low-income child is one who resides in a
business practices continues to change, the num-
family with income below 200% of the federal
ber of employers offering health insurance will
poverty level or whose family has an income up to
likely continue to decline. The ranks of the unin-
50% higher than the state’s Medicaid eligibility
sured will increase. And federal and state gov-
threshold. However, states differ in terms of their
ernment insurance programs will need to expand
eligibility requirements. In some states, SCHIP is
to cover them.
part of the state’s Medicaid program; in some
states, it is a separate child health insurance pro- Ross M. Mullner
gram, while in other states, it is a combination of
the two programs. States including SCHIP in their See also Blue Cross and Blue Shield; Employee Health
Medicaid programs must provide full Medicaid Benefits; Health Insurance Coverage; Medicaid;
benefits. For states with separate SCHIP programs, Medicare; National Health Insurance; State-Based
the states must provide primary and preventive Health Insurance Initiatives; Uninsured Individuals
benefits, including immunizations, well-child care,
and emergency services.
The federal and state governments offer a Further Readings
number of other health insurance programs, and
they also provide healthcare services to specific Black, Kenneth, Jr., and Harold D. Skipper, Jr. Life and
groups. For example, the U.S. Department of Health Insurance. 13th ed. Upper Saddle River, NJ:
Defense’s TRICARE program provides healthcare Prentice Hall, 1999.
Buchmueller, Thomas C., Kevin Grumbach, Richard
services to active duty military personnel, retired
Kronick, et al. “The Effects of Health Insurance on
members of the uniformed services, and their
Medical Utilization and Implications for Insurance
families. The U.S. Department of Veterans Affairs
Expansion: A Review of the Literature,” Medical
(VA) provides medical assistance to eligible veter-
Care Research and Review 62(1): 3–30, February
ans of the armed forces. The U.S. Department of 2005.
Health and Human Services’ Indian Health Committee on the Consequences of Uninsurance, Board
Service (IHS) provides healthcare services to on Health Care Services, Institute of Medicine.
American Indians and Alaska Natives. Many Coverage Matters: Insurance and Health Care.
state governments operate or sponsor health Washington, DC: National Academies Press, 2001.
insurance high-risk pools that provide coverage Darling, Helen. “Employment-Based Health Benefits and
to those who are denied private health insurance Public-Sector Coverage: Opportunity for Leadership,”
because they have serious preexisting medical Health Affairs 25(6): 1487–89, November–December
conditions (i.e., cancer, HIV/AIDS). A few states 2006.
(i.e., Illinois, Maine, and Massachusetts) also Iglehart, John K. “Medicaid Revisited: Skirmishes Over a
have established new programs to expand health Vast Public Enterprise,” New England Journal of
coverage to the uninsured. Medicine 356(7): 734–40, February 15, 2007.
508 Health Insurance Coverage
Kronenfeld, Jennie Jacobs. Expansion of Publicly Funded health insurance coverage. Individuals who are
Health Insurance in the United States: The Children’s 65 years of age or older, disabled, or have end-
Health Insurance Program and Its Implications. stage renal disease are eligible for health insur-
Lanham, MD: Lexington Books, 2006. ance coverage through the federal Medicare
Maioni, Antonia. Parting at the Crossroads: The program; certain low-income individuals, fami-
Emergence of Health Insurance in the United States lies, and the disabled may be eligible for coverage
and Canada. Princeton, NJ: Princeton University through state Medicaid programs; children and
Press, 1998. families may be eligible for coverage through the
Nyman, John A. The Theory of Demand for Health
State Children’s Health Insurance Program
Insurance. Palo Alto, CA: Stanford University Press,
(SCHIP); and individuals may purchase private
2003.
insurance coverage on their own.
Pitcher, Timothy J. How to Make Sense of Health
Insurance in America. Victoria, BC, Canada: Trafford
Publishing, 2006. Background
Robinson, James C. “The Commercial Health Insurance
Industry in an Era of Eroding Employer Coverage,” Health insurance is key to accessing the healthcare
Health Affairs 25(6): 1475–86, November–December system. Individuals who are insured are more
2006. likely to receive preventive, primary, and special-
Vaughan, Emmett J., and Therese Vaughan. ized care. The American system of health insur-
Fundamentals of Risk and Insurance. 9th ed. New ance coverage includes a patchwork of private
York: Wiley, 2003. sector and publicly funded programs. Approxi
mately 160 million individuals have employer-
sponsored health insurance and about 13 million
Web Sites individuals purchase health insurance directly
through a health maintenance organization
(HMO) or insurer. Although the majority of indi-
http://www.ahip.org
viduals have private, employer-based coverage, a
Blue Cross/Blue Shield Association:
growing segment of the population is uninsured.
http://www.bluecares.com
Since employer-sponsored insurance is voluntary
by employer and employees, not all businesses
Consumer Insurance Guide: http://www.insure.com/ offer coverage, individuals may not choose to pur-
health chase or be able to afford the health insurance
Employee Benefit Research Institute (EBRI): offered by their employer, and some workers may
http://www.ebri.org not be eligible for coverage.
Insurance Information Institute (III): http://www.iii.org As the nation shifts from an industrial to a ser-
National Association of Health Underwriters (NAHU): vice-based economy and labor patterns change,
http://www.nahu.org health insurance coverage is diminishing. The
National Association of Insurance Commissioners nation’s service industry tends not to offer health
(NAIC): http://www.naic.org insurance coverage. Additionally, employers
increasingly employ workers who do not qualify
for coverage, such as part-time and contract
employees. Because of this trend, fewer workers
Health Insurance Coverage have employer-sponsored insurance. Many small
employers are unable to offer their employees
Health insurance coverage includes an insurance health insurance coverage because of the rising
policy of covered healthcare benefits and services cost of healthcare. Employers that do offer health
between an individual and an insurance com- insurance to employees generally require them to
pany. In the United States, most individuals pay a larger portion of the costs for their coverage.
receive health insurance coverage through their This increased cost-sharing burden has caused
employer or the employer of a family member; many employees to forgo employer-sponsored
however, being employed does not guarantee health insurance entirely.
Health Insurance Coverage 509
Health insurance coverage in the United States health insurance coverage for local teachers. From
differs greatly from that of other developed nations. this early beginning, the Blue Cross plans devel-
For example, Canada, Germany, and the United oped across the nation with the support of the
Kingdom have national health programs that pro- American Hospital Association (AHA).
vide healthcare to all their citizens. However,
rather than adopt a socialist model in which the
Medicare, Medicaid, and the HMO Act
government provides health insurance coverage for
everyone, the United States has opted for a volun- The urbanization of the nation and the growth in
tary, market-based system in which individuals the retiree and indigent populations led to the intro-
must seek out their own health insurance coverage, duction of the Medicare and Medicaid programs in
generally through an employer-sponsored plan. 1965. Medicare is a federally administered program
In the United States, there are six types of vol- that provides health insurance coverage for those 65
untary health insurance: fraternal societies and years of age and older, the disabled, and individuals
mutual benefit associations; contract physicians; with end-stage renal disease. The Medicare program
private physician plans; county medical-bureau provides coverage for hospital care and nursing
plans; hospital service plans; and group insur- home care for 100 days through Part A, physician
ance operated by private, commercial insurance visits through Part B, and prescription drug cover-
companies. age through Part D. Medicare’s Part C offers cover-
Health insurance coverage grew out of the age through private managed-care plans.
marine, fire, and life insurance policies sold by Medicaid, a joint federal-state program, pro-
commercial insurers. The Civil War was a major vides insurance coverage for certain low-income
impetus for the development of injury insurance, individuals, families, and people with disabilities.
which eventually evolved into health coverage. Coverage through Medicaid is based on need, and
Several major events—including the Stock Market eligibility is determined by income; the state-ad-
Crash of 1929, the Great Depression, and World ministered programs must meet broad federal
War II—also had an influence on establishing a guidelines, but each establishes its own eligibility
health insurance coverage system in this country. requirements and service provisions.
The federal and state government support for The State Children’s Health Insurance Program
health insurance was directly related to the eco- (SCHIP), created in 1997 by the federal govern-
nomic conditions in the country. ment, represents the largest expansion of health
Prior to 1920, health insurance was thought to insurance coverage for children since Medicaid
be unnecessary because it was viewed as income started. Administered by the states, SCHIP pro-
replacement for working people. During the growth vides health insurance coverage for children and
in the economy after World War II, employers for families with low incomes who earn too much
began providing health benefits to their workers: to qualify for Medicaid.
Employee wages, which had been frozen during With the continued growth in the nation’s
the war by the government, began to include fringe healthcare expenditures, a new form of insurance
benefits such as pensions and health insurance. For was introduced through the Health Maintenance
employers, there was no payroll tax on health ben- Organization Act of 1973. This legislation required
efits, and employees did not have to pay income employers with 25 or more employees to offer a
tax on the benefits provided by employers; both federally certified HMO as an option alongside the
these amounted to government subsidies for traditional indemnity insurance.
employer-sponsored health insurance. The federal Employee Retirement Income
As the nation’s hospitals expanded and modern- Security Act (ERISA) was established in 1974. It
ized in the early 20th century, new expensive allowed private employers to self-insure, and it
equipment and services developed. As commercial required employers to publish the rules and regula-
carriers were starting to introduce health insurance tions that governed their benefit plans on an
to their portfolio of products, the forerunner to the annual basis and report any modifications to the
nonprofit Blue Cross plans was established in benefit packages. This measure was designed to
Houston, Texas, in 1929. This early plan provided provide protection to employees.
510 Health Insurance Coverage
Changes in Health Insurance Coverage Plan type defines the nature of the insurance
product under which a person is covered. It includes
In 2007, employer-sponsored insurance covered
organizational entities or products such as HMOs,
59% of the nation’s population, while the remain-
preferred provider organizations (PPOs), Health
der of the population was either covered through
Savings Accounts (HSAs), indemnity, Medicare,
Medicare, Medicaid, individual nongovernmental
and Medicaid, among others.
programs, or were uninsured. In recent years, the
The risk falls on the individual or entity that is
number of people who are covered by employer-
responsible for payment when services have been
sponsored insurance has been steadily declining,
delivered.
leading to a greater number of uninsured adults
Enrollment refers to membership in an insur-
and children. It is estimated that about 47 million
ance product or program when premium dollars
or 16% of Americans do not have any form of
are paid, whereas disenrollment means a transfer
health insurance coverage.
to a new plan or termination of coverage because
From 2001 to 2005 alone, the percentage of
of nonpayment.
workers covered by employer-sponsored insurance
Patients must meet eligibility for benefits or ful-
decreased by approximately 4%. Nearly half of this
fill the membership criteria to participate in an
decline was due to the loss of employer sponsorship.
insurance product or program.
In 2005, about 15% of employees did not have the
Out-of-pocket expenses are services that are not
availability of employer-sponsored insurance through
covered by an insurance product or program and
their work site, and nearly 70% of the uninsured did
are, therefore, paid by the enrollee.
not have access to employer-sponsored insurance
Each insurance product or plan provides cover-
through their family. Although there has been an
age for a range of services; there is a negotiated
increase in the number of Medicaid recipients and of
contract that specifies the services included in the
others with public coverage or private nongroup
premium payment. Those providers—such as hos-
coverage, an increase in working adults without
pitals, physicians, and ancillary providers—that
health insurance coverage still remains.
are included in a contract, are considered to be
Because of the rising healthcare costs in recent
in-network, and so preferred rates are paid for
years, employers have been faced with either
those services. When a member goes to a provider
passing these additional costs on to employees or
who is not under contract with the insurance
dropping employer-sponsored insurance entirely.
company, those services are considered to be out-
As a result, employees have had to pay a growing
of-network. Members will commonly have to pay
share of premiums, their wages have increased
a financial penalty for using an out-of-network
more slowly, and they have lost coverage or
provider.
decided not to take up employer-sponsored
Copayment refers to a provision in an insurance
insurance.
plan that requires members to pay some portion of
the bill at the time of service, usually a flat fee dol-
lar amount. For example, for a hospital emergency
Health Insurance Concepts
department visit, the member might have to pay a
Several concepts are key to understanding health $50 copayment at the time services are rendered.
insurance coverage: plan type, risk, enrollment Coinsurance, on the other hand, is a provision
and disenrollment, eligibility for benefits, out-of- in an insurance plan that pays up to a given per-
pocket expense, in- or out-of-network use, copay- centage of services and care. For example, the plan
ment, coinsurance, deductible, limitations on will pay 80% for services rendered; the member
coverage, dependent coverage, preexisting condi- must then pay the remaining balance.
tion, lifetime maximum coverage, premium The deductible refers to the portion of a mem-
payments, the Consolidated Omnibus Budget ber’s healthcare expenses that must be paid out of
Reconciliation Act (COBRA) continuation, the pocket before the insurer will pay the balance on
Health Information Portability and Accountability the bill. For example, a health plan may specify
Act (HIPAA), consumer protection, access stan- that a $500 deductible must be met before the
dards, and appeals and grievances. insurer begins to pay for services.
Health Insurance Coverage 511
Services not included in the insurance benefits provision made after the insurer makes a decision
are called limitations on coverage. For example, and the member wants to challenge the decision.
blood and blood products may not covered for an The appeal is usually conducted internally to the
inpatient surgical procedure. insurer but at a different organizational level. A
Any person included on the insurance plan who grievance can include a host of comments that the
is not the primary beneficiary of the insurance member would like to make to the insurer, which
policy has dependent coverage. For example, spouses can include issues with customer service, coverage,
and children may receive dependent coverage billing, or claims payment.
through a family member’s insurance plan.
Preexisting conditions, or medical conditions
that the member had prior to the insurance effec- Future Implications
tive date, are often excluded from coverage. For Health insurance coverage is an integral compo-
example, prior treatment for fibroids that could nent of the American healthcare system. Private
lead to a possible hysterectomy would not be cov- coverage and public programs such as Medicare
ered under a new insurance plan. and Medicaid shoulder some of the financial bur-
The lifetime maximum coverage is when an den of the costs for routine and specialty
insurance plan covers services up to a given limit healthcare services. As the number of uninsured
and then will not provide additional payments Americans grows and the costs associated with
once the threshold has been reached. For example, healthcare continue to rise, the structure and
the plan may cover a maximum of 60 days of inpa- function of health insurance coverage will shift
tient psychiatric services for the life of the insur- and change. Public policy and current economic
ance contract. trends will help shape the future of health insur-
Premium payments refer to payments made on ance coverage.
a monthly or quarterly basis to continue insurance
coverage. Diane M. Howard
The COBRA continuation, a provision in the
Consolidated Omnibus Budget Reconciliation Act See also Coinsurance, Copays, and Deductibles;
of 1998, allows workers who have been displaced Compensation Differentials; Employee Health Benefits;
from their jobs to purchase insurance under their Employee Retirement Income Security Act (ERISA);
former employer’s group health plan. COBRA Health Insurance; Health Insurance Portability and
coverage is usually available for 18 months postem- Accountability Act of 1996 (HIPAA); Medicaid;
ployment. Medicare
The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) prohibits a for-
mer employer from refusing to provide COBRA to a Further Readings
displaced worker who has a preexisting condition.
Clemans-Cope, Lisa, Bowen Garrett, and Catherine
The HIPAA also has important patient-confidential-
Hoffman. Changes in Employees’ Health Insurance
ity provisions on sharing patient information.
Coverage, 2001–2005. Washington, DC: Kaiser
State and federal government programs and Commission on Medicaid and the Uninsured, October
commercial insurance plans recognize the need for 2006.
consumer protection, establishing measures and Cleverley, William O., and Andrew E. Cameron.
policy provisions that allow members to appeal the Essentials of Health Care Finance. 6th ed. Sudbury,
decisions made by the insurer. MA: Jones and Bartlett, 2007.
Each insurance company should have access stan DeNavas-Walt, Carmen, Bernadette D. Proctor, and
dards or guidelines on administrative-support issues Jessica Smith. Income, Poverty, and Health Insurance
such as telephone waiting times, mailing of identifi- Coverage in the United States: 2006. U.S. Census
cation cards after enrollment, scheduling physician Bureau, Current Population Reports, P60–233.
appointments, and receipt of specialist referrals. Washington, DC: Government Printing Office, 2007.
The terms appeals and grievances are often Morrisey, Michael A. Health Insurance. Chicago: Health
used, mistakenly, interchangeably. An appeal is a Administration Press, 2007.
512 Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Web Sites standards now in place override weaker state laws

America’s Health Insurance Plans (AHIP): but do not interfere with states that have adopted
http://www.hiaa.org more aggressive policies to protect patients.
Employee Benefits Institute of America (EBIA):
http://www.ebia.com General Provisions
http://www.kff.org HIPAA was primarily intended to reduce employee
barriers to maintaining health insurance coverage
by guaranteeing that most of the nation’s workers
who change or lose their jobs will have access to
Health Insurance Portability coverage. The legislation also established new,
and Accountability Act of federal, patient privacy rules to give individuals
more control over how their personal, health
1996 (HIPAA) information is used and disclosed. It requires
health insurance plans and medical providers to
The Health Insurance Portability and Accountability have written privacy procedures, to train employ-
Act of 1996 (PL 104–191), commonly referred to ees involved in handling protected information,
as HIPAA, is federal legislation that mandates and to establish a grievance procedure. Providers
extensive requirements for group health insurance with direct treatment relationships are required to
plans and medical providers. HIPAA significantly make a good-faith effort to obtain an individual’s
expanded the notion of privacy and the protection written acknowledgment that he or she is aware
of individual patient records, it expanded protec- of the provider’s privacy practices.
tion of individuals with preexisting medical condi-
tions from being denied healthcare coverage, and
Title I
it allowed for the portability or transfer of indi-
vidual healthcare coverage from one employer to Title I of HIPAA regulates the availability and
another. breadth of group and individual health insurance
There are two titles of HIPAA. Title I protects plans. It amended both the Employee Retirement
health insurance coverage for workers and their Income Security Act (ERISA) and the Public
families when they change or lose their jobs, Health Service Act. Title I prohibits any group
commonly referred to as portability. Title II, the health insurance plan from creating eligibility
Administrative Simplification provisions, requires rules or assessing premiums for individuals in the
the establishment of national standards for elec- plan based on health status, medical history,
tronic healthcare transactions and national identi- genetic information, or disability. However, this
fiers for healthcare providers, health insurance does not apply to private individual insurance.
plans, and employers. Title I also limits the restrictions that a group
After passing HIPAA in 1996, the U.S. Congress health insurance plan may place on benefits for
instructed the Department of Health and Human preexisting conditions. Group health insurance
Services (HHS) to issue specific privacy guidelines plans may refuse to provide benefits relating to
to protect health information that was being sent preexisting conditions for a period of 12 months
and viewed electronically. The proposed rules after enrollment in the plan, or 18 months in the
were first written by the Clinton administration case of late enrollment.
and then edited by the Bush administration. The
final rules were issued in February 2003, and they
Title II
took effect on April 14, 2003.
The HIPAA standards represent a national, uni- Title II of HIPAA defines numerous offenses
form, federal floor of privacy protections for patients’ relating to healthcare and sets civil and criminal
medical information. Until the standards were penalties for them. It also creates several programs
passed, patients’ medical privacy was governed by to control fraud and abuse within the healthcare
a spotty patchwork of state laws. The federal system. However, the most significant provisions
Health Insurance Portability and Accountability Act of 1996 (HIPAA) 513
of Title II are its Administrative Simplification benefit inquiry; (f) healthcare claims status requests
rules. Title II requires the HHS to draft rules aimed and notifications; (g) service review information;
at increasing the efficiency of the healthcare system and (h) functional acknowledgment, which is used
by creating standards for the use and dissemina- to define the control structures for a set of acknowl-
tion of healthcare information. These rules apply edgments to indicate the results of electronically
to covered entities as defined by HIPAA and the coded documents.
HHS.
Enforcement
Covered Entities
The enforcement rule sets civil, monetary pen-
Covered entities include health insurance plans; alties for violating HIPAA rules, and it establishes
healthcare clearinghouses, such as billing services procedures for investigations and hearings for vio-
and community health information systems; lations. Failure to comply with the standards may
and healthcare providers that transmit healthcare result in severe civil and criminal penalties. The
data in a way that is regulated by HIPAA. The penalties range from $50,000 to $250,000 in fines
Administrative Simplification standards adopted and from 1 to 10 years in prison for an offense
by HHS under HIPAA apply to any entity that is a committed with the intent to sell, transfer, or use
healthcare provider that conducts certain transac- individually identifiable health information for
tions in electronic form, a healthcare clearinghouse, commercial advantage, personal gain, or mali-
or a health insurance plan. An entity that is one or cious harm.
more of these types of entities is referred to as a
covered entity in the Administrative Simplification
regulations. Effects on Research and Clinical Care
In the wake of HIPAA implementation, there
Privacy Rule have been effects on patient trust in deciding to
The Privacy Rule took effect on April 14, 2003, share their medical records. This may be the
with a 1-year extension for certain small plans. It result of increased awareness of the need for pri-
established regulations for the use and disclosure vacy of personal medical records. It has been
of protected health information. Protected health shown that those patients who have less trust in
information is any information about the health researchers are more likely to recommend a more
status, provision of healthcare, or payment for stringent process for obtaining individual consent
healthcare that can be linked to an individual. This for the release of their medical records.
includes any portion of a patient’s medical record Furthermore, with the advent of personal digital
or payment history. assistants (PDAs), many clinicians now keep
patient medical records in electronic format on
mobile devices. Physicians can improve their
Transactions and Code Sets Rule access to information by downloading patient
There are multiple electronic data interchange data onto their personal handheld computers,
(EDI) provisions in HIPAA. The Electronic Health which are available whenever decisions need to
Care Claim Transaction set is used to submit health- be made.
care claim billing information, encounter informa-
tion, or both. It can be sent from the providers of
healthcare services to payers, either directly or via
Implications for Marketing
intermediary billers and claims clearinghouses. Other A key provision in HIPAA includes a prohibition
EDI provisions include guidelines for (a) pharmacy on marketing. The privacy rules specifically set
claim transactions; (b) healthcare claim payment new restrictions and limits on the use of patient
transactions; (c) benefit enrollment; (d) payroll information for marketing purposes. Healthcare
deductions and other group premium payments for providers, health insurance plans, and other cov-
insurance products; (e) healthcare eligibility and ered entities must first obtain an individual’s
514 Health Literacy
specific authorization before disclosing their Health Care: What Do Physicians Think?” Health
patient information for marketing. At the same Affairs 24(3): 832–42, May–June 2005.
time, the rules permit physicians and other cov- Wu, Stephen S., ed. A Guide to HIPAA Security
ered entities to communicate freely with patients and the Law. Chicago: American Bar Association,
about treatment options and other health-related 2007.
information, including health screenings, immu-
nizations, and disease management programs.
Web Sites
American Hospital Association (AHA): http://aha.org/
Future Implications
aha/issues/index.html
HIPAA has provided for the portability of health- American Medical Association (AMA): http://ama-assn.org
care insurance, increased the protection of per- Centers for Medicare and Medicaid Services (CMS):
sonal medical records, and allowed for the http://www.cms.hhs.gov/hipaaGeninfo
migration to a set of standards for electronic data HIPAA.ORG: http://www.hipaa.org
exchange of clinical information among patients, Office of Civil Rights (OCR): http://www.hhs.gov/ocr/
providers, and payers. However, there have been hipaa
some negative effects on patients’ willingness to
share their personal medical records for research
purposes based on their low level of trust that
information is kept strictly confidential, despite Health Literacy
the more stringent HIPAA regulations. It can be
argued that patients are now much more aware of Health literacy is considered a variation of func-
what is being done with their personal healthcare tional literacy, and for that reason, many defini-
records and are, generally, better-informed con- tions of health literacy build on the definition of
sumers as a result. Finally, HIPAA has required literacy: the ability to read and write and the qual-
that healthcare providers become more vigilant in ity of being knowledgeable in a particular subject
the protection of personal patient information or field. The Center for Health Care Strategies
under their care. (CHCS) significantly extends the definition of lit-
eracy by adding the concepts of understanding
Edward M. Rafalski and action; it defines health literacy as the ability
to read, understand, and act on health informa-
(CMS); Computers; E-Health; Electronic Clinical tion. The American Medical Association’s (AMA’s)
Records; Employee Retirement Income Security Act Ad Hoc Committee on Health Literacy uses a
(ERISA); Fraud and Abuse; Informed Consent; slightly broader definition; it considers health lit-
Regulation eracy to be the constellation of skills required to
function in the healthcare environment, including
the ability to perform basic reading and numerical
Further Readings tasks such as the ability to read and comprehend
prescriptions, appointment slips, and other essen-
Annas, George J. “HIPAA: A New Era for Medical
Record Privacy?” New England Journal of Medicine
tial health-related materials.
348(15): 1486–90, April 10, 2003. The national Institute of Medicine (IOM), U.S.
Beaver, Kevin, and Rebecca Herold. The Practical Guide Department of Health and Human Services (HHS),
to HIPAA Privacy and Security Compliance. Boca and the National Library of Medicine (NLM)
Raton, FL: CRC Press, 2004. define health literacy as the degree to which indi-
Ness, Roberta B. “Influence of the HIPAA Privacy Rule viduals have the capacity to obtain, process, and
on Health Research,” Journal of the American understand the basic health information and ser-
Medical Association 298(18): 2164–70, November vices needed to make appropriate health decisions.
14, 2007. Some critics find this definition overly broad
Slutsman, Julia, Nancy Kass, John McGready, et al. because it includes the individual’s ability to obtain
“Health Information: The HIPAA Privacy Rule and both health information and services. They argue
Health Literacy 515
that the capacity to obtain services is more a func- domain of vocabulary. The TOFHLA and REALM
tion of resources than of literacy. are frequently used in research studies because they
The World Health Organization (WHO) uses are relatively short and have been shown to predict
an even broader definition: Health literacy repre- knowledge, behaviors, and outcomes.
sents the cognitive and social skills that determine The health literacy component of the 2003
the motivation and ability of individuals to gain National Assessment of Adult Literacy (NAAL)
access to, understand, and use information in survey, conducted by the U.S. Department of
ways that promote and maintain good health. Education, provides a more comprehensive mea-
Health literacy means more than being able to sure of health literacy. Twenty-eight health literacy
read pamphlets and successfully make appoint- tasks were added to the NAAL survey to measure
ments. By improving people’s access to health respondents’ skill in understanding and locating
information and their capacity to use it effectively, health-related services and information. These
health literacy is critical to empowerment. This tasks address three domains of health and health-
definition emphasizes that it is not enough for care information and services: clinical, prevention,
people to have health information; they must also and navigation of the healthcare system. The clini-
have access to healthcare. The WHO moves cal domain addresses activities associated with
healthcare providers beyond providing health clinical encounters, diagnosis and treatment of ill-
information to initiating the process of empower- ness, provider-patient relationship, and medica-
ment so that individuals can become active par- tion. The prevention domain addresses activities
ticipants in their own healthcare. associated with preventing disease, self-manage-
Health literacy exists when health information ment of illness, maintaining and improving health,
and services are provided in a manner easily under- and engaging in self-care. Finally, the navigation of
standable and appropriate for their audience. the healthcare system domain addresses activities
An individual’s health literacy skills depend on his associated with individual rights and responsibili-
or her culture, education, and language. Equally ties and understanding how the healthcare system
important are the skills of those who provide works.
health information, such as health workers, the More instruments are needed to measure health
media, the marketplace, and government agencies. literacy and to understand the skills necessary to
To maximize health literacy, it is crucial that those successfully navigate the health system. This under-
who provide health information and services align standing will help guide efforts to educate
their skills, expectations, and preferences with individuals about health issues and to create
those of the individuals who are seeking health health- related information better tailored to con-
information. sumers. For research, instruments that more pre-
cisely measure an individual’s reading fluency,
without posing an undue response burden, are
Measurement
necessary. Additional studies are also needed to
The most commonly used measures of health liter- compare instruments such as the TOFHLA and
acy are the Test of Functional Health Literacy in REALM with more comprehensive tests such as
Adults (TOFHLA) and the Rapid Estimate of Adult the 2003 NAAL survey to better understand their
Literacy in Medicine (REALM). Both of these tests strengths and weaknesses.
measure selected domains that are considered to be
markers of an individual’s overall capacity. The
Prevalence
TOFHLA measures adult literacy in a healthcare
setting; it assesses the individual’s abilities in Limited health literacy skills are common among
numeracy—the ability to use numerical informa- adults living in the United States. Results from the
tion in printed materials—and reading comprehen- 2003 NAAL survey show that the majority of
sion. Its 17-item numeracy section measures an adults, 53% of the population, have intermediate
individual’s ability to read and understand actual health literacy; 22% have basic health literacy;
hospital documents and labeled prescription vials. 14% have below basic health literacy; and 12%
The REALM is a 66-item test that measures the have proficient health literacy. As defined by the
516 Health Literacy
NAAL, health tasks that mapped to the below literacy levels, more than 300 studies of health-
basic level required adults to locate straightfor- related materials, such as medication package
ward pieces of information in short, simple texts inserts and informed consent forms, have shown
or documents. Health tasks reflecting the basic that health-related materials are written in lan-
level required finding somewhat more complex guage that is far above the high school reading
information in texts or documents that were lon- level. In fact, most of the studied materials
ger. Tasks at the intermediate level required respon- exceeded the reading skills of the average high
dents to apply or interpret information that was school graduate. Because of the disconnect between
presented in complex graphs, tables, or other the high complexity level of health information
health-related documents. Finally, health tasks and the low health literacy skills of its audience, a
that mapped to the proficient level required com- very large proportion of the nation’s population is
paring and/or contrasting multiple pieces of infor- denied the full benefits of health information and
mation within complex texts or documents, services.
drawing abstract inferences, or applying abstract
or complex information from texts or documents.
Effect on Health Outcomes
Health literacy varies across demographic
groups. Results from the 2003 NAAL survey show A number of studies have shown that low health
that the average health literacy score for women literacy is associated with poor health outcomes.
was 6 points greater than the average health literacy Compared with patients who have a higher health
score for men. Results also showed that White and literacy level, those with limited health literacy
Asian/Pacific Islander adults had a higher average and chronic illness have less knowledge of illness
health literacy score than Hispanic, Black, American management, lower use of preventive healthcare
Indian/Alaska Native, and multiracial adults. services, and higher hospitalization rates. When
Hispanic adults had the lowest average health lit- compared with patients who have an adequate
eracy score of all the ethnic or racial groups assessed health literacy level, those with limited literacy
in the survey. The NAAL results also showed that have a lower adherence to anticoagulation ther-
adults who spoke only English before starting apy, lower self-reported health status, higher like-
school had higher average scores than adults who lihood of poor glycemic control and retinopathy,
spoke only a language other than English before and decreased ability to share in decision making
starting school. Additionally, starting with adults about prostate cancer. Studies have also shown
who had graduated from high school or earned that low health literacy is a barrier to the treat-
their GED (general equivalency degree), the average ment of sexually transmitted diseases and a poten-
health literacy score increased with each higher tial contributor to depression.
level of educational attainment. Also, adults living Poor health outcomes in patients with low
below the federal poverty level had lower health health literacy may be the result of inadequate dis-
literacy scores than adults living above the poverty ease knowledge. A study of diabetic patients in one
level. Adults in the oldest age group, those 65 years clinic showed that 94% of the patients with ade-
of age and older, had lower health literacy scores quate literacy levels knew the symptoms of hypo-
than adults in any other age group. glycemia compared with only 50% of the patients
Within the United States, a sizeable proportion with low health literacy levels. Similarly, women
of the adult population may not have the literacy with low health literacy were found to have incor-
skills needed to effectively use the healthcare sys- rect knowledge about the purpose of a pap smear,
tem. Findings from the 1992 National Adult and pregnant women with low literacy had less
Literacy Survey showed that literacy was low knowledge and concern about smoking during
among adults in the nation. An estimated 47% of their pregnancies.
the population had literacy skills that tested below Studies also suggest that low health literacy is
the high school level, and of these adults, 40 to 45 associated with increased healthcare utilization and
million had trouble finding information in com- costs. For example, new Medicare managed-care
plex or unfamiliar texts, including medicine labels, enrollees with low health literacy were found to be
forms, or newspaper articles. Despite these low twice as likely to be hospitalized as those with
Health Literacy 517
adequate health literacy, increasing the demands achieve such standards; (b) professional healthcare
they place on healthcare resources. Similarly, a schools should incorporate health literacy into
study of a small sample of Medicaid patients found their curricula and areas of competence; (c) public
that individuals whose reading levels were at or and private healthcare systems should develop and
below the third-grade level had average Medicaid support demonstrations to identify the most effec-
charges $7,500 higher than those of patients whose tive ways in which the healthcare system can
reading skills were above the third-grade level. reduce the negative effects of limited health liter-
Another study found that in 1996 there were $29 acy; and (d) the National Committee for Quality
billion in additional health expenditures attribut- Assurance (NCQA), Joint Commission, Centers
able to inadequate reading skills, and that, if half of for Medicare and Medicaid Services (CMS), and
the individuals studied were also health-illiterate, other accreditation bodies should incorporate
the estimate would increase to $69 billion. health literacy into their standards.
Interventions Research
Several different interventions have been pro- As recommended by the IOM, research to
posed and are under way to improve health liter- increase the understanding of health literacy and
acy. Federal and state agencies, educational its effects on health outcomes is under way. In
institutions, healthcare systems, professional asso- 2004, and again in 2006, the National Institutes of
ciations, and community and advocacy groups Health (NIH) and the Agency for Healthcare
have all attempted interventions in this area. Research and Quality (AHRQ) released a Program
Although many promising efforts are under way, Announcement with Special Review (PAR) titled
few have been formally evaluated, and most of “Understanding and Promoting Health Literacy.”
the interventions are single approaches that are The goal of this program is to increase research on
not part of a systematic approach to increasing health literacy concepts, theory, and interventions.
health literacy. To better understand which inter- Specifically, the PAR encourages researchers to
ventions are the most effective and appropriate, a address health literacy and its relationships to
greater understanding is needed of the causal rela- chronic-disease management, patient-based health-
tionship between health and education, the role care, prevention, healthy living, health disparities,
of literacy, and the contribution of health literacy and cultural competence. The results of the research
to health. will help the NIH provide the public and health-
The national IOM’s Committee on Health care providers with scientific health information.
Literacy assessed the problem of limited health About $9 million was awarded to fund 19 research
literacy and proposed a set of recommendations projects from 2005 to 2009.
for improvement. The committee determined that
health literacy is based on the interaction between
Healthcare Providers
an individual’s health literacy skills, the healthcare
system, the education system, and culture and soci- Many proposed strategies for dealing with low
ety, and they, therefore, judged that the responsi- health literacy focus on healthcare providers. Some
bility for health literacy improvement must be approaches highlight the need for creating print
shared by these various sectors. Based on this view, materials in different languages and at varied read-
it recommended an urgent increase in federal and ing levels that providers can distribute. Other
nonfederal funds for health literacy research and approaches emphasize developing healthcare pro-
the development and evaluation of new measures viders’ skills in determining patients’ health literacy
of health literacy. levels and creating literacy-specific communication
The committee also recommended that (a) strategies that providers can adopt based on their
accreditation requirements for schools should assessments. Other solutions emphasize the role of
mandate the implementation of National Health providers in increasing awareness among all staff
Education Standards and that demonstration pro- members about the prevalence of low health literacy
grams should be funded to support state efforts to among patient populations.
518 Health Literacy
Providers are also recommended to adopt spe- improvement for low-literacy individuals. By
cific strategies to help their patients compensate providing individuals with appropriate written
for limited literacy. Such strategies include (a) ask- materials and the training to use them, these rec-
ing patients to restate their understanding of the ommendations should result in improvements in
material presented; (b) identifying and using visual health literacy.
aids; (c) teaching in a step-by-step process, with
the most important information presented first; (d)
using simple words and phrases; and (e) avoiding Education
complicated medical terms and jargon. Finally,
The educational system can also play a major
healthcare providers are also instrumental in creat-
role in increasing health literacy. Childhood liter-
ing a shame-free environment in which patients
acy education and childhood health education
with low literacy can feel comfortable admitting to
form a foundation for health literacy in adulthood.
their providers if and when they need help or do
Although most elementary, middle, and high
not understand. Training providers on the best
schools require students to take health education
ways to assist and approach those with limited
classes, requirements decrease, for the most part,
literacy will also help patients feel comfortable
as students get older. Nationally, 33% of schools
with and trust their providers.
require health education in kindergarten, 44%
mandate it in the 5th grade, 10% require health
Health Information education in the 9th grade, and only 2% of schools
require it in the 12th grade. Without a coordinated
Many interventions call for a decrease in the
health education program across grade levels, stu-
complexity of health information. Even individu-
dents likely do not learn the needed health literacy
als with strong literacy skills may have trouble
skills.
obtaining and using health information and ser-
To address this issue, the Joint Committee on
vices because the signs, directions, and official
National Health Standards published the National
documents (e.g., social service forms, public health
Health Education Standards in 1995. In this pub-
information, informed consent forms, and health
lication, the committee details the knowledge and
education materials) frequently use technical lan-
skills necessary for health literacy; the informa-
guage and jargon that makes them very difficult to
tion and skills students should know and have in
understand. The problem is worse for the esti-
health education by the end of Grades 4, 8, and
mated 90 million American adults who lack func-
11; and the framework for curriculum develop-
tional literacy skills. Measures can be taken to
ment and student assessment that will help achieve
reduce the complexity of health materials and bet-
these standards. Although some progress has been
ter match them to the literacy levels of the general
made, these standards have not been widely
public.
achieved.
Recommendations for health literacy improve-
ment addressed in the HHS’s Healthy People
2010 initiative focus on two areas. First, health
Future Implications
literacy can be improved by developing appropri-
ate, written health material and by creating health With its many definitions, roles, and measurement
communications that are culturally and linguisti- tools, health literacy influences not only under-
cally appropriate; using plain language; and fol- standing and communication but also health sta-
lowing the principles of organization, layout, tus and health outcomes. By focusing on its
writing style, and design used in professional pub- complex role in both medicine and public health,
lications and in federal documents. Second, it can the nation’s healthcare system can maximize
also be achieved by improving the skills of per- health literacy’s effectiveness at helping patients
sons with limited health literacy: by offering better manage their acute and chronic medical
health literacy programs—at public and medical conditions, enable researchers to disseminate their
libraries; to voluntary, professional, and commu- new findings and recommendations, and allow the
nity groups; and in schools—that target skill general public to shift its attitudes and health
Health Maintenance Organizations (HMOs) 519
behaviors. Although much progress has been

made in understanding health literacy, much more Health Maintenance
work needs to be done. Organizations (HMOs)
Elizabeth A. Calhoun and Anna M. S. Duloy
A health maintenance organization (HMO) is a
See also Access to Healthcare; Cultural Competency; form of group health insurance that entitles
Ethnic and Racial Barriers to Healthcare; Health enrollees to the services of participating hospi-
Communication; Health Disparities; Healthy People tals, clinics, and physicians. While HMO premi-
2010; Vulnerable Populations ums are usually prepaid, the structure of the
provider network, method of reimbursement,
and the scope of their utilization management
Further Readings and disease management programs can vary
Joint Commission. What Did the Doctor Say? Improving
greatly between HMOs. Paul M. Ellwood coined
Health Literacy to Protect Patient Safety. Oakbrook the term health maintenance organization in
Terrace, IL: Joint Commission, 2007. 1970 as a way of describing an organization that
Kars, Marge, Lynda M. Baker, and Feleta L. Wilson, eds. would compete on the bases of price and quality
The Medical Library Association: Guide to Health by combining health insurance and healthcare in
Literacy at the Library. New York: Neal-Schuman, a single organization.
2008.
Mayer, Gloria G., and Michael Villaire. Health Literacy
in Primary Care: A Clinician’s Guide. New York: History
Springer, 2007.
Nielsen-Bohlman, Lynn, Allison M. Panzer, David A.
Health insurance began to appear in the United
Kindig, et al., eds. Health Literacy: A Prescription to States around 1850. Initial coverage was limited to
End Confusion. Washington, DC: National individuals who were disabled by accidental work-
Academies Press, 2004. place injuries. The Western Clinic in Tacoma,
Osborne, Helen. Health Literacy From A to Z: Practical Washington, began providing prepaid physician
Ways to Communicate Your Health Message. services for the lumber industry in 1910. A similar,
Sudbury, MA: Jones and Bartlett, 2005. prepaid program for providing medical care to
Schwartzberg, Joanne G., Jonathan B. VanGeest, and lumber and mine workers was also started in
Claire C. Wang, eds. Understanding Health Tacoma in 1917. However, this program was run
Literacy: Implications for Medicine and Public through a county medical services bureau and not
Health. Chicago: American Medical Association, a single clinic or medical group. This program was
2005. later expanded to include 20 sites in Oregon and
Zarcadoolas, Christina, Andrew F. Pleasant, and David Washington.
S. Greer. Advancing Health Literacy: A Framework With the beginning of the Great Depression in
for Understanding and Action. San Francisco: Jossey- 1929, hospitals and physicians began to search
Bass, 2006. for reliable methods to ensure reimbursement for
their medical services. The Baylor Plan—the first
Blue Cross plan—was started to provide hospital
Web Sites coverage for teachers in Dallas, Texas. During
Agency for Healthcare Research and Quality (AHRQ): this period, a number of physicians pioneered the
http://www.ahrq.gov/browse/hlitix.htm development of HMOs. For example, Michael
National Assessment of Adult Literacy (NAAL): Shadid started a rural, farmer’s, cooperative
http://nces.ed.gov/naal health plan in Elk City, Oklahoma, in which he
National Institute for Literacy (NIFL): http://www.nifl.gov enrolled several hundred families for a predeter-
National Library of Medicine (NLM): mined fee and used the funds to build a hospital
http://www.nlm.gov/services/health_literacy.html and provide physicians’ services. Donald Ross
National Patient Safety Foundation (NPSF): and H. Clifford Loos (Ross-Loos Clinic) con-
http://www.npsf.org/askme3 tracted with the Los Angeles Department of Water
520 Health Maintenance Organizations (HMOs)
and Power to provide comprehensive services for with emphasis on preventive care, immunizations,
2,000 workers and their families. well-child care, and other services not usually cov-
One of the most noted HMO pioneers was ered by other health insurance programs. In addi-
Sidney Garfield. Garfield was caring for the men tion, enrollees were subject to few exclusions,
building the Los Angeles aqueduct through the limitations, or copayments.
Mojave Desert in 1933. Many of the men did not Organized medicine—the American Medical
have insurance, and payment was difficult for Association (AMA) and state and local medical
those that did. Garfield contracted with the insur- societies—were strongly opposed to prepaid plans
ance companies to prepay a fixed amount of five and cooperatives. Throughout the 1930s and
cents per day, per worker for coverage of their job- 1940s, organized medicine attempted to suppress
related, healthcare needs. For an additional five the growth of group health plans and ostracized
cents per day, non-job-related illness could also be physicians who participated in them through boy-
covered. This funding mechanism also enabled cotts and denial of hospital privileges. As a result,
Garfield to focus on maintaining health and job the AMA was indicted and convicted of violating
safety, in addition to treating illness and injury. the Sherman Antitrust Act for its efforts to suppress
In 1938, as the aqueduct project was nearing the new plans. The U.S. Supreme Court upheld this
completion, Garfield was asked by Henry J. Kaiser conviction in 1947. In spite of the conviction, the
to provide care for 6,500 workers, who were AMA’s campaign to impede the growth of prepaid,
building the Grand Coulee Dam in Washington, group practice succeeded via the passage of numer-
and their families. Garfield recruited a team of ous state laws that required freedom of choice of
doctors to work in a “prepaid medical practice.” physicians; restricted provider reimbursement
With the outbreak of World War II, tens of methodology; and prohibited consumer-run, medi-
thousands of new employees began working at the cal-service plans. As a result of the legal impedi-
Kaiser Shipyards in Richmond, California. Kaiser ments and other barriers, prepaid healthcare
was faced with the problem of how to meet the remained a minor factor until the early 1970s when
healthcare needs of nearly 30,000 people. Kaiser the accelerating healthcare costs and lack of access
again called upon Garfield, who organized and ran to care by the poor, minorities, and a growing num-
a prepaid medical practice for the workers and ber of uninsured brought cost containment and
their families. With the ending of the war in 1945, efficiency of care to the political forefront.
the shipyard’s employment dropped. Garfield and In 1971, just 5 years after the passage of the
his physicians wanted to keep practicing their new Medicare and Medicaid programs, the Nixon
form of healthcare delivery, and with the assistance Administration announced a new health strategy to
of Kaiser, they opened the Kaiser Permanente control skyrocketing healthcare costs—a strategy
Health Plan to non-Kaiser employees. that would focus on preventive services and health
Throughout the 1930s and 1940s, several other maintenance. This led to the passage of the Health
prepaid, group practice plans developed across the Maintenance Organization Act of 1973 (HMO
country. Employees of the Federal Home Loan Act), and was a significant attempt to change the
Bank organized the Group Health Association in underlying structure of the nation’s healthcare
Washington, D.C., in 1937. In 1945, unions and delivery system. While the goal of the legislation
local supply and food cooperatives in Seattle, was to encourage integrated, prepaid, group prac-
Washington, formed the Group Health coopera- tice, the AMA successfully lobbied for inclusion of
tive of Puget Sound as a healthcare option. The an Individual Practice Association (IPA) Model
Health Insurance Plan (HIP) of Greater New York HMO in the legislation. IPAs were loosely affiliated
was launched in 1947 to provide care to city networks of mostly solo-practice, fee-for-service
employees and their families. physicians that did not offer the integration of
Each of these plans was structured and gov- clinical services or acceptance of financial risk that
erned differently; however, each was committed to characterized prepaid group practices.
comprehensive and coordinated healthcare. Their The HMO Act set aside $375 million to help
coverage and benefits were more comprehensive develop HMOs; preempted state laws that banned
than the prevailing health insurance of the time prepaid groups; and required companies with at
least 25 employees to offer a federally qualified proportion of health insurance coverage. However,
HMO, if the HMO asked to be offered. However, their presence began to influence traditional health
the HMO Act also imposed several conditions for insurers’ product design and benefit coverage. To
federal qualification that placed federally quali- compete with HMOs, traditional health insurers
fied HMOs at a competitive disadvantage in the began offering coverage for preventive health ser-
marketplace. vices, immunizations, and pharmaceuticals. To
The HMO Act mandated (a) a comprehensive make these plans affordable and keep costs down,
minimum-benefits package that included immuni- insurers negotiated contractual relationships with
zations, preventive health exams, therapy services, providers that required price discounts and sub-
low copayments, annual limits on the amounts jected reimbursement to preauthorizations and
patients could be charged through copayments, second opinions. These new relationships were the
and no maximum lifetime benefit limitations; (b) introduction of managed care outside traditional
an annual open-enrollment period, during which HMOs and lead to the development of new types
an HMO was required to accept all applicants, of health insurance programs such as preferred
regardless of preexisting conditions (as a result, provider organizations (PPOs), exclusive provider
high-risk individuals had easier access to federally organizations (EPOs), and point-of-service plans
qualified HMOs than to any other insurer); and (c) (POS).
premiums based on the cost of providing care to
the entire community (community rating), rather
Structures
than on the cost of providing care to a specific
group or employer. The initial structures of HMOs were codified
Although the HMO Act stimulated the growth in the Federal Health Maintenance Act of 1973;
of HMOs by providing planning grants and loan however, to expand and remain competitive, some
guarantees, removing legal impediments, and man- plans have evolved from one of the initial struc-
dating their offering as an insurance option, their tures to a hybrid of several. There were three basic
growth was inhibited by the administrative require- structures of HMOs as established in the HMO
ments and benefit mandates that placed federally Act: the staff model, group model, and individual
qualified HMOs at a competitive disadvantage in practice association model. However, by default
the marketplace. there is a fourth model—the mixed or network
The HMO Act was amended in 1976 to limit model, which is a combination of the three basic
the open-enrollment mandate to plans that had models.
been operational for at least 5 years, had at least
50,000 enrollees, and were not operating at a
Staff Model HMO
financial deficient. However, community rating
and generous benefit packages continued to pre- In a staff model HMO, there is a single entity—
vent federally qualified HMOs from offering com- the HMO. The HMO offers insurance to its mem-
petitive rates to employers. bers or enrollees. Most of the physician services
During the late 1970s and early 1980s, state are provided by physicians who are employed by
legislatures began enacting their own HMO legis- the HMO and only see HMO members. Some spe-
lation. Most state legislation used the federal cialty care may be provided by nonemployee spe-
HMO Act as a foundation; however, state regula- cialists who are contracted by the HMO. The
tions initially imposed fewer administrative require- HMO may own and operate its own network of
ments (e.g., community rating), and benefit hospitals, or it may contract out for some or all its
mandates (e.g., mandatory open-enrollment peri- hospital services. There are only a handful of staff
ods). As a result, fewer organizations sought the model HMOs remaining in the country. Group
federal qualification status that subjected them to Health Cooperative of south central Wisconsin is
the restrictions of the HMO Act, electing instead an example of a local staff model health plan. For
to become state-licensed, prepaid health plans. economic reasons, many of the former staff model
Federally qualified and state-licensed HMO HMOs have spun off their physicians into separate
membership in the early 1980s remained a small but affiliated medical groups. The medical groups
522 Health Maintenance Organizations (HMOs)
can then contract with additional payers and care Reimbursement Methodologies
for a larger patient population. Examples of for-
mer staff model HMOs would be Cigna Health Any reimbursement methodology has the poten-
Plan (originally Ross-Loos Health Plan) in tial to influence behavior. Under any reimburse-
California and Harvard Community Health Plan ment strategy, there is an unstated reliance on the
in Massachusetts. professional integrity of hospitals, physicians, and
others to provide only medically necessary care,
neither too much nor too little. However, any sys-
Group Model HMO tem of reimbursement can be manipulated to
The archetypical HMO—Kaiser Permanente—is maximize financial gain for the provider, to the
often thought of as a staff model HMO; however, potential harm of the patient.
it is a group model HMO. Kaiser Permanente is a The initial method of hospital and physician
consortium of three distinct groups of entities: the reimbursement was fee-for-service, in which a pro-
Kaiser Foundation Health Plan, Inc. and its regional vider was reimbursed for each service delivered.
operating organizations Kaiser Foundation This methodology provides greater financial
Hospitals and the Permanente Medical Groups. reward for delivering more services and does not
The health plan offers health insurance to mem- encourage preventive care, which if effective,
bers or enrollees. The physicians work for the would ultimately lead to lower reimbursements.
Permanente Medical Group, and the Medical Fee-for-service reimbursement has the potential to
Group contracts exclusively with the Kaiser encourage unnecessary medical visits, hospitaliza-
Foundation Health Plan to provide medical care to tions, surgeries, and diagnostic testing.
its enrollees. Therefore, the health plan is a group An alternative method of reimbursement is
model HMO. capitation, in which a provider (hospital, physi-
A group model HMO is not limited to only cian, or medical group) receives a fixed reimburse-
contracting with one medical group to form its ment for specified services during a defined period
network. A group model HMO can contract with of time. As the reimbursement is fixed, the pro-
a series of medical groups across a geographic vider (hospital, physician, or medical group) does
region to form its network of physicians. not receive additional payments for hospitaliza-
tions, surgeries, or diagnostic testing. Under
capitation, the provider is best off financially by
Individual Practice Association Model HMO providing the fewest services possible and thus has
the potential to encourage rationing of care or
As discussed earlier, the Individual Practice underutilization.
Association (IPA) model HMO was lobbied for by There has been a great deal of discussion regard-
the American Medical Associations as an option for ing the method and timing of payment for health
private practice physicians to participate in HMOs. service coverage through HMOs. Most of the
IPAs are loosely affiliated networks of small groups attention is focused on the prepayment of premi-
and solo-practice, fee-for-service physicians. IPA ums or capitation for medical services. However,
model HMOs manage care by forming virtual prepayment of premiums for insurance is the stan-
“medical groups” through risk pools, specialty dard practice for nearly all types of insurance. The
capitation, and utilization review committees. insured pays an insurer a predetermined amount of
money to purchase defined insurance coverage for
a specific risk or set of services (e.g., health, auto,
Mixed-Model HMO
fire, life). Prepayment of premiums by employers or
To expand their capacity and geographic service individuals to health insurers has been and contin-
areas, HMOs need to develop large physician net- ues to be standard practice for fully insured (non-
works. A mixed-model HMO is a hybrid of all the self-funded) products. Premiums are set based on
above models. The composition of its network will actuarial estimates of the future year’s costs of pro-
vary and likely include medical groups, IPAs, and viding the health services. In the event that insurers
independent physicians. underestimate the future costs, they incur a loss for
that year, which usually results in a larger increase insurance and healthcare. In response to competi-
in premiums the following year to compensate for tion from HMOs, health insurers expanded benefits
the underestimate and to recoup the losses. to include preventive and pharmacy services. Kaiser
Although HMOs were envisioned to function Permanente attempted to expand outside its west-
as both the insurer and the provider of healthcare, coast base with mixed results, but it continues to
very few HMOs currently operate as direct pro- thrive. Most staff and group model HMOs that
viders of healthcare. Most HMOs function exclu- developed after the HMO Act, as well as old stal-
sively as health insurers and have reverted to warts such as Ross-Loos, have reorganized and been
reimbursing physicians on a fee-for-service basis acquired by large insurance companies. Even with
and hospitals on a case rate, percentage-of- advances in computer technology—which allow
charges, or daily-rate basis. A few HMOs con- for better coordination and analysis of
tinue to operate as an integrated system of insurer, medical claims, laboratory, diagnostic, and phar-
hospital system, and physician group (e.g., Kaiser macy data—there has been limited success in real-
Permanente). izing Ellwood’s vision of an HMO. Except for a
Some HMOs differ from standard health insur- handful of regional healthcare systems such as
ance in the way they reimburse healthcare provid- Kaiser Permanente, Intermountain Healthcare, and
ers. Staff model HMOs employ their own physicians the U.S. Veterans Administration health system,
and allocate a portion of the premium to cover the Ellwood’s vision of combining the delivery of health -
costs of providing physicians’ services. In a group care with its funding to deliver improved quality
model HMO, such as Kaiser Permanente, the and lower costs has yet to be realized.
HMO (insurer) provides the medical group with a
fixed monthly premium for each member to cover Bruce A. Weiss
all the necessary physician services. If the HMO See also American Medical Association (AMA); Blue
owns its own hospitals, it may allocate a portion Cross and Blue Shield; Cost of Healthcare; Ellwood,
of the premium to cover the costs of providing Paul M.; Health Insurance; Managed Care; Medicare;
hospital care. If it does not own the hospitals, it Payment Mechanisms
may either capitate a hospital system to provide
the care, or it may negotiate some other method
of reimbursement, such as case rate (Diagnosis Further Readings
Related Group [DRG]), per-day basis (per diem) or
on a percentage of billed charges. Adams, E. Kathleen, and Bradley Herring. “Medicaid
In an IPA model HMO, networks of indepen- HMO Penetration and Its Mix: Did Increased
dent physicians organize into an IPA to accept Penetration Affect Physician Participation in Urban
capitated risk for physician services from an Markets?” Health Services Research 43(1 pt. 2):
363–83, February 2008.
HMO. The IPA can then capitate primary-care
Basu, Jayasree, and Lee R. Mobley. “Do HMOs Reduce
and specialty physicians to provide care, or as an
Preventable Hospitalizations for Medicare
alternative, it can reimburse physicians on a dis-
Beneficiaries?” Medical Care Research and Review
counted fee-for-service basis. The amount of the
64(5): 544–67, October 2007.
discount is adjusted based on the volume of ser- Coombs, Jan Gregoire. The Rise and Fall of HMOs: An
vices delivered to match the allocation of the pre- American Health Care Revolution. Madison:
mium—more services would require a greater University of Wisconsin Press, 2005.
discount. This model puts the IPA and indepen- Enthoven, Alain C. “The History and Principles of
dent physicians at risk for the high utilization of Managed Competition,” Health Affairs 12(Suppl.):
services and provides the potential for additional 24–48, 1993.
financial reward for lower utilization. Gabel, Jon. “Ten Ways HMOs Have Changed During the
1990s,” Health Affairs 16(3): 134–45, May–June 1997.
Galvin, Robert S., and Arnold Milstein. “Large
Future Implications
Employers’ New Strategies in Health Care,” New
Since the passage of the HMO Act in 1973, there England Journal of Medicine 347(12): 939–42,
have been remarkable changes in the nation’s health September 19, 2002.
524 Health Planning
Mayer, Thomas R., and Gloria Gilbert Mayer. “HMOs: The nature and organization of American health
Origins and Development,” New England Journal of planning has varied over time. In the late 1800s,
Medicine 312(9): 590–94, February 28, 1985. epidemics led to attempts to reduce the environ-
Newhouse, Joseph P. “Consumer-Directed Health Plans mental conditions that gave rise to illness. In the
and the RAND Health Insurance Experiment,” Health early 20th century, health planning was focused on
Affairs 23(6): 107–13, November–December 2004. medical care. Late in that century, there was a
Robinson, James C. “The End of Managed Care,” paradigm shift from “medical care” to “health-
Journal of the American Medical Association 285(20): care” and a concomitant shift from medical-care
2622–28, May 23, 2001.
planning to healthcare planning. Although health
planning still includes medical and other health
services, there is a focus on community-based plan-
Web Sites
ning and a renewed interest in shaping the urban
Blue Cross and Blue Shield Association: environment to improve health.
http://www.bcbs.com
Dartmouth Atlas of Health Care:
http://www.dartmouthatlas.org
Sanitary Reform Movement
Henry J. Kaiser Family Foundation (KFF): In the late 1800s, American cities were growing
http://www.kff.org rapidly, resulting in conditions that repeatedly
Managed Care Museum: led to epidemics. The sanitary reform movement
http://www.managedcaremuseum.com responded based on the “filth theory”: the idea
MCOL: http://www.mcol.com that miasmas or “bad airs” either directly gave
rise to illness or were associated with contagion.
Miasma could be traced to the cesspools and
sinks used to store human waste. It was believed
Health Planning that by removing the waste, disease could be
checked.
The term health planning refers to conscious efforts Three tools were created that facilitated health
to assess the current and future health-related needs planning. First, epidemiological mapping of the
of a population and identify ways to best meet environmental conditions of streets and building
those needs effectively and efficiently with limited as they correlated to the incidence of disease set the
resources. However, there is no consensus on this foundation for the planning process. This tech-
definition, perhaps because planning is a practice- nique was used most notably by the public health
based discipline rather than a theory-based one. It reformer Edwin Chadwick (1800–1890) in the
may also be due to the uneasy association many England of the 1840s and by the Citizens’
Americans have with government planning and to Association in the New York of the 1860s. The
preferences for incrementalism and pluralism. second resource was sanitary sewerage technology
Although doubtful about government power, peo- that allowed solid waste to be carried away
ple are also duly skeptical about the ability of the through pipes and sewers. Finally, the Progressive
market to fully meet their health needs. Planning Era political reform led to the belief that govern-
helps mediate this conflict of views. ment should effectively serve the public interest by
The United States has a lack of health planning tackling issues such as public health problems.
compared with most developed nations, including With these tools in place, sanitary survey planning
most of Europe, Canada, and Japan, where developed as a response to a yellow fever epidemic
healthcare has a strong centralized government in the Lower Mississippi Valley in the late 1870s.
element and where there are long histories of top- Tennessee authorities requested that the newly created
down, government-oriented health services plan- National Board of Health develop a plan for the
ning. Furthermore, health planning in these future and conduct a complete sanitary survey. They
nations is often well integrated into social and made a comprehensive reconstruction plan based on a
economic planning, resulting in a comprehensive house-to-house survey. It suggested specific, local-area
approach. remediation; designed a sewage system; and proposed
Health Planning 525
employing a sanitary officer. It also recommended the beds available were counted, and the extent of
damming of bayous, the creation of public parks, unmet needs estimated. These estimates of unmet
repaving streets, and the enactment of a sanitary code needs were the basis for funding hospitals, which
raising buildings off the ground. were then required to provide some level of charity
The sanitary reform movement also shaped care. Amendments in 1962 required the devel
urban designs and plans that were intended to pre- opment of regional health-planning agencies, which
vent health problems by providing access to clean were generally voluntary agencies that advised
air and water and by reducing organic waste, ground states. There were 8 agencies in 1962, 33 in 1964,
moisture, and congestion. Frederick Law Olmsted and increased to 50 by 1965.
(1822–1903), the father of landscape architecture,
was influenced by this consciousness in his design of
Federally Funded,
public parks such as Central Park in New York City.
Comprehensive Health Planning
This influence can also be seen in Progressive Era
housing reforms and in zoning codes that used In the 1960s, concerns over access to healthcare
police power to regulate land use for the protection gave rise to the Medicaid and Medicare programs.
of health, safety, and public welfare. Government became a major payer and the high
cost of medical care became a focus. As a result, the
federal government expanded its role in medical-
Toward Medical-Care Planning
care planning. First, the 1966 Partnership for Health
By the early 1900s, germ theory was institutional- Action established Comprehensive Health Planning
ized in hospitals and the medical profession, fol- (CHP) agencies. The National Health Planning and
lowing the Carnegie Foundation’s Flexner Resources Development Act of 1967 featured the
Report—a survey of American and Canadian work of these agencies. The act established local
medical schools that resulted in the eventual clo- Health Systems Agencies (HSAs), State Health
sure of 29 medical schools between 1910 and Planning and Development Agencies (SHPDAs) and
1914. With these changes, the nation’s hospitals included the Certificate of Need (CON) process
and the medical profession became much more intended to control the development and expansion
effective than before. of medical-care facilities and services.
In line with this newfound effectiveness, the Local HSAs were the basic unit of health plan-
nation’s voluntary hospitals greatly expanded in ning, with about 200 nationwide. Consumers
the 1920s, but during the Great Depression, were mandated to have a majority of positions on
patients were priced out and turned to the over- their governing bodies. HSAs were required to
burdened public hospitals. This gave rise to the develop long-range plans, with open public hear-
first voluntary regional planning agencies. These ings, and to review facilities every 5 years.
agencies were representative of the wealthy classes Quantitative analysis and a systems approach
and worked to raise funds for hospitals. Health were encouraged. The early focus was on inpatient
studies done during this period, before World War and long-term care, but in 1979, amendments
II, were usually not comprehensive but were added a focus on prevention, home health, and
directed toward specific health problems. alcohol and drug abuse.
After World War II, the U.S. Congress passed SHPDAs were overseen by Statewide Health
the Hospital Survey and Construction Act of 1946, Coordinating Councils, and they were expected to
also known as the Hill-Burton Act. This act hold their deliberations in public. The functions of
brought about the first public-initiated, statewide, the SHPDAs included completing a state plan,
health-planning bodies and significantly funded coordinating with HSA plans, implementing por-
local, areawide, health-planning bodies with tions of the state plan, and assisting the Statewide
matching dollars, thus marking the beginning of Health Coordinating Councils in their reviews of
federally sponsored health planning. medical facilities.
Catchment or hospital service areas were identi- As part of the process, CON applications had to
fied, the numbers of hospital beds needed by the be submitted for proposed new or expanded health
population were calculated, the numbers of hospital facilities, equipment, or services. These were to be
526 Health Planning
reviewed on the basis of need as identified in the the form of operations planning, facility planning,
plans. Initially, the CON process had little impact budget planning, and marketing planning.
on the availability of facilities, services, and equip-
ment because health planning agencies were not
Community-Based, Problem-Specific Planning
given the power to enforce the decisions made on
CON applications. Later, however, the impact of Just as funding for comprehensive health planning
CON varied by state, with a significant effect in began to decline, the HIV/AIDS crisis appeared.
some and a limited effect in others. Voluntary organizations were formed to respond,
Federally supported, CHP came to an end when including the Citizens Commission on AIDS for
the U.S. Congress repealed the National Health New York City and Northern New Jersey and the
Planning and Resources Development Act of 1967 AIDS Foundation of Chicago. At about the same
in 1986. President Ronald Reagan had campaigned time, a coalition approach to funding services was
for a reduced, more businesslike government, and being developed by the Robert Wood Johnson
healthcare costs continued to escalate despite Foundation: Successful applicants had to ensure
health-planning efforts. The planning process had some level of collaboration, often in the form of a
few supporters. coalition. This effort facilitated a structure for
With the end of federal support, health planning community-based planning or, at the very least,
at the national level has been almost nonexistent. service coordination.
One exception has been Healthy People 2010, The federal government adopted this approach
sponsored by the federal Office of Disease in HIV Health Service Planning Councils as man-
Prevention and Health Promotion; it identified dated by Title I of the Ryan White Comprehensive
national healthcare goals in the late 1980s and AIDS Resources Emergency Act of 1990 (the
later began tracking progress toward them. Many CARE Act). The funded HIV/AIDS agencies used
states retained health-planning structures, and a unique type of planning organization, working
some continue to develop state health plans. Most as community-based, participatory-planning enti-
of these entities are voluntary and have little fund- ties. Similar models of planning also are required
ing or regulatory power. in maternal-child health and many other federal-
Today, health planning continues in a number grant-funded programs.
of different forms but not always under the rubric
of planning. These include institutional planning;
Local Public Health Agency Planning
community-based, problem-specific planning;
local, public health agency planning; and an In the 1980s and 1990s, strategic planning was rec-
emerging focus on health in urban planning. ommended for local public health agencies. The
Assessment Protocol for Excellence in Public Health
(APEX/PH) provided by the National Association of
Institutional Planning
County and City Health Organizations (NACCHOs),
Most health planning today takes place in health- had some strategic-planning elements. In 2001,
care organizations rather than at the community Mobilizing for Action through Planning and
or regional level. Hospitals in the mid-1980s faced Partnership (MAPP) was developed by the NACCHOs
rapidly changing environments of competition, and the Centers for Disease Control and Prevention
reduced reimbursement, and declining use. Strategic (CDC) to help public health agencies do community
planning, which had been developed by banks, health planning and programming. MAPP includes
was well suited to the needs of hospitals. Strategic elements from both strategic planning and compre-
planning involves identifying a mission and strate- hensive health planning.
gies for achieving that mission, given internal and
external constraints and opportunities. It does not
Health in Urban Planning
prevent hospitals from addressing community
needs, but overall, strategic planning is focused on Health planning is becoming broader in its scope
the institution. Institutional planning also takes as it seeks to shape the urban environment to
Health Professional Shortage Areas (HPSAs) 527
promote health. In 1986, the World Health Further Readings

Organization Regional Office for Europe (WHO/ Barton, Hugh, and Catherine Tsourou. Healthy Urban
Europe) established the Healthy Cities project, Planning. New York: Spon Press, 2000.
which is designed to involve local government in Corburn, Jason. “Confronting the Challenges in
health promotion. In 1997, it created the health, Reconnecting Urban Planning and Public Health,”
urban-planning initiative to integrate health- and American Journal of Public Health 94(4): 541–46,
sustainable-development planning. April 2004.
Physical inactivity, a cause of obesity and related Frank, Lawrence D., Peter O. Engelke, and Thomas L.
chronic health problems, has been targeted by the Schmid. Health and Community Design: The Impact
Active Community Environments (ACES) initiative of the Built Environment on Physical Activity.
from the CDC and by the Robert Wood Johnson Washington, DC: Island Press, 2003.
Foundation’s Active Living by Design initiative. Frumkin, Howard, Lawrence Frank, and Richard
Both of these initiatives support the development Jackson. Urban Sprawl and Public Health: Designing,
of environments that promote physical activity. Planning, and Building for Healthy Communities.
The spatial forms of cities can lead to health Washington, DC: Island Press, 2004.
problems: Urban sprawl forces hours of driving time Hodges, Bonni C., and Donna M. Videto. Assessment
that make people inactive, pollute the air, cause inju- and Planning in Health Programs. Sudbury, MA:
ries, cause stress, and take people away from activi- Jones and Bartlett, 2005.
ties that build protective social capital. Efforts to Lenihan, Patrick. “MAPP and the Evolution of Planning
reduce urban sprawl and improve health include the in Public Health Practice,” Journal of Public Health
Management and Practice 11(5): 381–86, September–
New Urbanism, a set of principles that seeks to use
October 2005.
participatory planning to create compact, walkable
Thomas, Richard K. Health Services Planning. 2d ed.
communities that are connected to their surrounding
New York: Kluwer Academic, 2003.
regions by public transit. Similarly, Smart Growth
promotes the concentration of growth in urban
centers, with mixed-use development and access by Web Sites
public transit. Both sets of principles are intended to
Active Living by Design: http://www.activelivingbydesign.org
guide urban planning in its application of land-use
American Health Planning Association (AHPA):
tools such as building codes, zoning codes, growth
http://www.ahpanet.org
management, and public transportation systems.
American Planning Association (APA):
These close ties between urban form and health have
http://www.planning.org
led to calls for greater collaboration between the
professions of public health and urban planning. http://www.apha.org
Congress for the New Urbanism: http://www.cnu.org
Future Implications National Association of County and City Health
Officials (NACCHO): http://www.naccho.org
Health planning had its roots in shaping the environ- National Association of Mental Health Planning and
ment to improve health. Although much of the his- Advisory Council (NAMHPAC):
tory of health planning is dominated by medical and http://www.namhpac.org
healthcare planning, there is an increasing focus on
community-based planning and a renewed interest in
shaping the environment to improve health status.
Curtis R. Winkle Health Professional
See also American Health Planning Association (AHPA);
Shortage Areas (HPSAs)
American Public Health Association (APHA);
Certificate of Need (CON); Healthcare Organization Health professional shortage areas (HPSAs) are
Theory; Health Systems Agencies (HSAs) Public geographic areas, population groups, or medical
Health; Public Policy; Regulation facilities that are designated by the Secretary of the
528 Health Professional Shortage Areas (HPSAs)
U.S. Department of Health and Human Services The Shortage Designation Branch within the
(HHS) as having a shortage of health profession- Bureau of Health Professions (BHPr), which is part
als. HPSAs may be lacking primary-care, dental, or of the Health Resources and Services Administration
mental health providers as judged by established (HRSA), administers the designation of HPSAs.
norms for the provision of adequate healthcare. Different criteria are set for primary-care physi-
cians, dentists, and mental health professionals in
determining need. For population group requests,
Types of HPSAs
applicants must describe the barriers that the pop-
There are several types of HPSAs: geographic ulation experiences in accessing quality healthcare
parts of a county or a whole county; geographic services in the community. Areas with low clini-
service areas with portions of one or many coun- cian-to-population ratios are also eligible for desig-
ties; population groups, such as low-income nation, along with areas where there is restricted
populations; state mental hospitals; correctional access to services due to language or cultural barri-
institutions; Federally Qualified Health Centers ers. The latter include areas where private practi-
(FQHCs) and FQHC look-alikes; comprehensive tioners do not accept Medicaid patients and areas
health centers; rural health clinics; American with a high proportion of Native American resi-
Indian, Alaskan Native, and Indian Health Service dents or other population groups with limited
clinics; and “other,” including public or private access to care. The scoring for primary care takes
nonprofit medical facilities. Additional classifica- four factors into account: (1) population-to-primary-
tion criteria include geography, demographics, or care-physician ratio, (2) percentage of the popula-
institutions. tion with incomes below 100% of the federal
poverty level, (3) infant mortality and low-birth-
weight rates, and (4) travel time or distance to the
Scope of Coverage
nearest available source of healthcare. Local data
About 20% of the population of the United States on the population density, travel time and distance
resides in primary-medical-care HPSAs. Because the from the population-weighted center of the prima-
demand for services exceeds the available resources, ry-care service area, percentage of users living
residents of these areas have inadequate access to below the federal poverty level, and primary-care
primary-healthcare services. Approximately three physicians are used to calculate the scores.
of five White Americans outside metropolitan areas The NHSC scholarship and loan repayment
live in HPSAs, compared with three of four African programs, the NHSC Ready Responders Program,
American and Hispanic minorities. Furthermore, and the Federal J-1 Visa Waiver program use the
84% of counties where African Americans or HPSA scores to allocate resources. The NHSC, a
Hispanics constitute the majority of the popula- component of HHS and HRSA, is dedicated to
tion qualify as HPSAs. In 2008, there were 5,987 providing primary-healthcare clinicians to HPSAs.
primary-care HPSAs, 3,951 dental HPSAs, and It has supplied more than 27,000 clinicians since
2,947 mental health HPSAs in the nation. 1972. NHSC scholars are required to fulfill their
commitments by serving in HPSAs with the great-
est need. For the NHSC loan repayment program,
Designation
which has the largest pool of clinicians, contracts
Designation as an HPSA indicates eligibility for are approved in descending order of the HPSA
federal-grant funds, placement of practitioners score. Most J-1 Visa Waiver physicians are placed
from the National Health Service Corps (NHSC), through the Physician Visa Waiver Program (also
and Medicare reimbursement bonuses to physi- known as the State Conrad 30 programs, called
cians in efforts to enhance healthcare provision. the State 30 program because it is limited to 30
To bolster healthcare, foreign physicians are foreign-medical-graduate waivers per state), which
encouraged to practice in selected HPSAs by are not subject to the scoring restrictions. Therefore,
waiving restrictions on entry into the United the score should have a limited impact on recruit-
States. ment opportunities for most entities. All HPSA
Health Report Cards 529
designated entities can seek the assistance of

NHSC in providing physicians, nurse practitio- Health Report Cards
ners, physician assistants, certified nurse-midwives,
dentists, and other clinicians, with placement pri-
ority based on scoring. Health report cards are collections of health-
related measures developed to report and high-
light specific health-related information. Health
Future Implications
report cards can include measures of individual or
The number of HPSAs has grown during the past population health status, measures of healthcare
20 years, as has the ratio of practitioners-to-pop- system or healthcare provider performance, and
ulation in these areas. Such changes can be attrib- other health-related information. The content of
uted to the efforts of the federal government to health report cards is typically arrayed in a man-
widen the scope of HPSA designation to include ner that displays a point-in-time snapshot of
factors other than physician-to-population ratios, health-related measures pertaining to particular
and thereby provide improved and more equitable health concerns, populations of interest, geogra-
healthcare to underserved populations. In the phies, or healthcare providers. Current measures
future, it seems likely that the number of HPSAs are usually arrayed to allow comparisons with
in the nation will continue to grow. previous time periods. In some instances, the
health report cards also use defined criteria or
Karen E. Peters, Sunanda Gupta, methodologies for grading, scoring, or ranking the
Nicole E. Stoller, and Benjamin C. Mueller health information conveyed, resulting, for exam-
ple, in reports of the relative healthiness of the
See also Access to Healthcare; Health Resources and 50 states, the relative performance of healthcare
Services Administration (HRSA); Inner-City providers, the deadliest health threats or risks, or
Healthcare; National Health Service Corps (NHSC);
changes in health status related to established
Physicians; Primary Care; Public Health; Rural Health
benchmarks or objectives. The scope and format
of health report cards can range from basic com-
parative measures familiar to consumers to more
Further Readings advanced sets of metrics useful for health services
Hendryx, Michael. “Mental Health Professional research and public policy development. Report-
Shortage Areas in Rural Appalachia,” Journal of card-like information sources are becoming
Rural Health 24(2): 179–82, Spring 2008. increasingly available on the Internet, with fea-
Liu, Jiexin. “Health Professional Shortage and Health tures that include query tools for rapid, focused
Status and Health Care Access,” Journal of Health information retrieval.
Care for the Poor and Underserved 18(3): 590–98, A variety of entities have developed health report
August 2007. cards for numerous distinct purposes. Government
Reese, Valerie, Jessica L. McCann, Andrew W. agencies at the federal, state, and local levels not
Bazemore, et al. “Residency Footprints: Assessing the only collect and store health-related data but often
Impact of Training Programs on the Local Physician also disseminate health-related information in
Workforce and Communities,” Family Medicine report-card-like publications for the public.
40(5): 339–44, May 2008. Advocacy and consumer groups focused on specific
populations or health issues frequently use a health
report card format to present information.
Web Sites Healthcare providers and health benefits plans pro-
Bureau of Health Professions (BHPr): http://bhpr.hrsa.gov vide patients and plan beneficiaries with personal
Centers for Medicare and Medicaid Services (CMS): reports designed to promote the patient’s health and
http://www.cms.hhs.gov care management. Professional associations and
Health Resources and Services Administration (HRSA): accreditation and certification entities have also
http://www.hrsa.gov developed report cards that portray changes in mea-
sures designed to reflect the quality of healthcare.
530 Health Report Cards
Types of Health Report Cards more chronic medical conditions, and appropriate
measures for a person at risk of developing health
Health report cards are produced for various pur-
problems due to their family health history.
poses and can include equally varied content.
Report cards often include metrics developed to
allow ratings, using grading schemes with stan- Population Health Status Report Cards
dards or benchmarks, or rankings portraying a
spectrum of best to worst. Report cards can also Population health status is a common feature of
focus primarily on factors measured at points in many health report cards. Rates of incidence and
time and show trends in change. Health report prevalence related to morbidity, mortality, and
cards vary widely depending on the intended audi- determinants of health are frequently used to
ence: The content and format of reports devoted develop measures that compare and contrast pop-
to informing health services researchers, for exam- ulation health at different points in time or in dif-
ple, are quite different from that of report cards ferent geographical areas. These report cards are
intended to support patient awareness and con- particularly useful in demonstrating progress, or
sumer healthcare decisions. the lack thereof, in meeting benchmark objectives
Health report cards can be grouped by general related to population health status goals. Population
types depending on the scope, purpose, and con- health status report cards are also useful in reach-
tent of the report cards. These groupings include ing conclusions regarding the priority health issues
report cards focused on personal health, popula- of a population and the success or failure of public
tion health status, subpopulation health status, programs in protecting and improving the popula-
healthcare provider performance, and health sys- tion’s health.
tem capacity and performance. Within each group-
ing, the content displayed in a particular report Subpopulation Health Status Report Cards
card can concentrate on health measures within or
Health report cards that focus on the health
across geographical boundaries or portray distinc-
status and healthcare system experiences of a par-
tions on the basis of age, gender, ethnicity and
ticular population group or groups are useful in
race, level of education, income, provider type, or
comparing the status of that group with the status
particular health concerns.
of other groups and the general population.
Population groups can be segmented in terms of
ethnicity and race, age, gender, place of residence,
Personal Health Report Cards
level of education, participation in particular
Personal health report cards can be produced by health benefit plans, or other attributes. Such
healthcare providers and health benefit plans to report cards can demonstrate serious disparities in
depict individual health status and related health- health and access to appropriate healthcare and are
determinant information for individual patients useful in supporting public policy development and
and health plan beneficiaries. Personal health program implementation. Population subgroup
report cards are useful tools for engaging individu- report cards are often hampered by data limita-
als in their own healthcare decision making and tions such as inadequate ethnicity, race, and gender
health-promoting behaviors. Additional uses of detail and the small numbers of cases or individu-
personal health report cards can include advancing als, which may prohibit the use of the available
patient health literacy; encouraging health risk data due to accuracy and privacy concerns.
avoidance; and ensuring culturally competent,
patient-centered care. An individual’s health report
Healthcare Provider Report Cards
card requires current data that reflect the health
issues of concern for that particular individual: For Health report cards that describe and compare
example, body weight, body mass, blood pressure, provider performance measures have gained atten-
and cholesterol levels should be augmented with tion as providers focus on quality improvement,
prenatal care measures for an expectant mother, consumers focus on the relative quality of care
disease-specific measures for a person with one or delivered by healthcare providers, and payers focus
Health Report Cards 531
on maximizing value and containing costs. resource allocation decisions. The importance of
Development of healthcare provider report cards health system capacity reporting has gained atten-
gained momentum during the 1990s, partly in tion recently with the realization of system vulner-
response to the need for metrics to support the abilities and the potential surge in demands for
evolving managed-care and managed-competition healthcare services that would follow cataclysmic
initiatives of that decade. Currently, provider per- events such as a bioterrorism attack or natural
formance reporting and the availability of reports disaster.
are components of the efforts to enhance transpar-
ency in the delivery of healthcare services, improve
Data Sources for Health Report Cards
the quality of care and contain costs, and link pro-
vider payments to value-based criteria. Health report cards rely on a variety of primary
Common elements of healthcare provider report and secondary data sources. The strengths, limita-
cards include measures designed to reflect the tions, and utility of health report cards are deter-
structures, processes, outcomes, and costs of mined by the quality and timeliness of the data
healthcare delivery. Healthcare provider health used, the underlying assumptions and techniques
report cards can be produced by healthcare facility of any data analyses, and the methodologies
trade organizations, consumer and advocacy employed to develop the measures included in the
groups, and government entities. These report report. Health report cards should include disclo-
cards are often presented in sophisticated Web- sure of the data sources and methodologies for
based formats featuring query capabilities for development of the metrics, and report card users
focusing on the performance of particular provid- should understand the distinction between the
ers in specific locations during recent time periods. data and the report card’s metrics, which use the
To maintain accuracy and equity in measuring and data to portray changes and relationships.
comparing provider performance, provider report All health report cards are hampered to some
cards should acknowledge the important distinc- extent by certain data limitations. In provider per-
tions in the types of providers, and they should formance and population health status report
contain explanations of the risk adjustment meth- cards, for example, small numbers of events or
odologies used to compensate for variations in the categories of characteristics can lead to statistical
volume, severity, and complexity of the cases inaccuracies and potential privacy violations.
treated by those providers. Statistical techniques to aggregate data, such as
merging data collected over longer time periods,
can be employed in some instances, but report
Health System Capacity and
cards should carefully explain the data limitations
Performance Report Cards
and methodologies at a level appropriate for the
Health status, both of the individual and the targeted audience.
population, results from a complex and dynamic Data for report cards pertaining to an individ-
context of health determinants. Healthcare is an ual’s health characteristics and health status can
equally complicated enterprise. Broad, system- be drawn from a patient’s medical records and
level reports and report cards are developed to basic health profile, often with a focus on family
support assessment of the capacity and perfor- health history and lifestyle choices such as smok-
mance of systems for facilitating the interplay of ing. Personal health report cards often include
health-related programs and care providers. For some population level data in measures used for
example, reports based on the state, local, or comparison of the individual with the general
national government assessment tools of the population.
National Public Health Performance Standards are Population-based health report cards commonly
very valuable for raising awareness of public health depict information in terms of estimates, rates of
system capacity and priority issues. Similarly, disease incidence, or other measurements that
reports on the overall healthcare system of a region, require census data, such as that obtained by the
state, or community are essential for identifying U.S. Census Bureau’s decennial census and inter-
quality improvement concerns and informing censual-population estimates.
532 Health Report Cards
Survey data are another critical data resource and healthcare of individuals and populations.
for population health report cards; for example, Health report cards can translate complicated con-
the Current Population Survey, conducted by the cepts into comprehensible information suitable for
U.S. Census Bureau, and the Behavioral Risk dissemination methods that favor rapid and
Factor Surveillance System (BRFSS), conducted by efficient forms of communication. The utility of
the states with support from the Centers for health report cards in decision support, education,
Disease Control and Prevention (CDC), are valu- advocacy, and continuous quality improvement
able sources of useful, survey-based estimates will increase as data sources and data analysis
related to healthcare and determinants of health. methods improve.
Most states and the federal government require Health report cards in a wide variety of formats
extensive healthcare provider reporting of clinical will most likely continue to proliferate and become
and administrative data. Government entities, essential knowledge management tools in the years
such as the Centers for Medicare and Medicaid ahead, as growth in the demand for reliable,
Services (CMS) and the National Center for understandable health information accelerates.
Health Statistics (NCHS), collect data on hospital The demand for health information will be fueled
discharges, claims data related to publicly funded by evolving efforts to measure, manage, and
healthcare plans, public health data such as vital improve health status and healthcare delivery.
statistics and reportable infectious diseases, reports Factors influencing this demand will include
of adverse health events in clinical settings, and improved levels of health literacy in society, broader
regulatory data pertaining to providers and health acceptance of the individual’s growing role in deci-
insurance plans. These mandatory submissions are sions related to the management of his or her
a rich source of data for health report cards, and healthcare, and growing concern for continuous
many government entities produce or are develop- improvement and accountability in healthcare
ing provider report cards to inform consumers and delivery. The general pressures of expanding scien-
payers. tific and medical knowledge, progress in technical
innovation, the promise of more robust data
sources, and expanding social awareness of health
Future Implications
issues will also contribute to the demand for useful
The value, utility, and future evolution of health health report cards.
report cards depend on several factors. The primary Numerous factors will undoubtedly continue to
purpose of all report cards is to translate data into drive the future demand for health report cards as
understandable information and convey that infor- well as the forms those report cards will take,
mation so that it becomes useful knowledge. It is including the following: increasing efforts to bring
essential in all cases that the underlying data be transparency to the delivery of healthcare services
accurate; that underlying assumptions be reason- and inform better public policies; continuing
able and unbiased; and that the information, efforts to enable informed consumer choice and
purpose, and format of the report card be compre- patient and family participation in healthcare deci-
hensible to the target audience. It is also critical that sions; incentives for improving the continuity and
any report card contain explanations of the meth- management of care, especially with regard to
ods used to derive the measures portrayed and that chronic-disease conditions; initiatives to raise the
the report card relate the measures included to the level of health literacy and promote healthy life-
broader universe of information that is not included. style behavior and the avoidance of health risks;
The report card should also contain specific caveats and continuous work to improve the quality of
detailing the limitations of the data, metrics, or healthcare.
general use of the report card.
Health report cards that are constructed with Michael C. Jones
careful attention to accuracy, timeliness, health See also Centers for Medicare and Medicaid Services
literacy, and cultural competency can be valuable (CMS); Health Literacy; Joint Commission; Leapfrog
and constructive tools for expanding useful knowl- Group; Outcomes Movement; Quality Indicators;
edge and, ultimately, improving the health status Quality of Healthcare; Volume-Outcome Relationship
Health Resources and Services Administration (HRSA) 533
Further Readings of Health and Human Services (HHS), making it

Castle, Nicholas G., Darren Liu, and John Engberg. a component of the executive branch of the fed-
“The Association of Nursing Home Compare Quality eral government. HRSA’s major focus is on ensur-
Measures With Market Competition and Occupancy ing access to healthcare for the uninsured and
Rates,” Journal for Healthcare Quality 30(2): 4–14, other vulnerable populations and providing peo-
March–April 2008. ple with appropriate services at the appropriate
Kelly, Adam, Joel P. Thompson, Deborah Tuttle, et al. times. Pursuing that mission involves funding
“Public Reporting of Quality Data for Stroke: Is It programs to train, recruit, and retain clinicians
Measuring Quality?” Stroke 39(12): 3367–71, to work in underserved areas and encouraging
December 2008. individuals from underrepresented groups to
Krumholz, Harlan M., Saif S. Rathore, Jersey Chen, enter the health professions and providing
et al. “Evaluation of a Consumer-Oriented Internet the financial means for them to do so. By estab-
Health Care Report Card: The Risk of Quality lishing the infrastructure to expand access to
Ratings Based on Mortality Data,” Journal of the healthcare, HRSA works to eliminate health dis-
American Medical Association 287(10): 1277–87, parities.
March 13, 2002.
Lin, Chinho, and Chun-Mei Lin. “Using Quality Report
Cards for Reshaping Dentist Practice Patterns: A Pre- History
Play Communication Approach,” Journal of Evaluation With the passage of federal Titles V and VI of the
in Clinical Practice 14(3): 368–77, June 2008. Social Security Act in 1935, the federal govern-
Palsbo, Susan E., and Thilo Kroll. “Meeting Information ment, through the U.S. Public Health Service,
Needs to Facilitate Decision Making: Report Cards
began providing grants to the states for healthcare
for People With Disabilities,” Health Expectations
programs. By 1943, both the Bureau of Medical
10(3): 278–85, September 2007.
Services and the Bureau of State Services were cre-
Shahian, David M., and Sharon-Lise Normand.
ated within the U.S. Public Health Service, which
“Comparison of ‘Risk-Adjusted’ Hospital Outcomes,”
Circulation 117(15): 1955–63, April 15, 2008.
at the time was part of the Federal Security Agency
Spath, Patrice L., ed. Provider Report Cards: A Guide
(FSA). A decade later, the FSA became the U.S.
for Promoting Health Care Quality to the Public. Department of Health, Education, and Welfare
Chicago: American Hospital Association Press, 1999. (DHEW).
Terry, Ken. “Physician Report Cards: Help, Ho-Hum, or By 1966, the Bureau of Medical Services and
Horror?” Medical Economics 83(14): 22–24, July 21, the Bureau of State Services were transformed into
2006. the Bureau of Health Services and the Bureau of
Health Manpower, respectively. At the same time,
the Community Health Center program was insti-
Web Sites tuted, followed by the National Health Service
Corps, which began in 1970.
In 1973, the Health Services Administration
and the Health Resources Administration were
Health Grades, Inc.: http://www.healthgrades.com
established. In essence, the Bureau of Health
Leapfrog Group: http://www.leapfroggroup.org Services became the Health Services Administration,
U.S. News and World Report: http://www.usnews.com while the Bureau of Health Manpower became
the Health Resources Administration. Finally in
1982, the Health Services Administration and the
Health Resources Administration merged to
Health Resources and Services create the Health Resources and Service
Administration (HRSA). This was just 2 years
Administration (HRSA) after the U.S. Department of Health, Education,
and Welfare (DHEW) was reorganized into the
The Health Resources and Services Administration U.S. Department of Health and Human Services
(HRSA) is one of 11 agencies in the U.S. Department (HHS).
534 Health Resources and Services Administration (HRSA)
Organization funds—to grantees at the state and local levels—

that are used to fund programs such as Women,
Today, HRSA’s staff of more than 1,600 individu- Infants, and Children (WIC).
als is headquartered in the Washington, D.C., The Bureau of Clinician Recruitment and Service
suburb of Rockville, Maryland. The administrator (BCRS) supports the education of students and
of HRSA oversees 6 bureaus and 12 offices with clinicians through scholarship, loan repayment,
an estimated fiscal year (FY) 2008 budget of $5.8 and recruitment programs.
billion. The 6 bureaus are (1) the Bureau of Health
Professions (BHPr), (2) the Bureau of Primary
Health Care (BPHC), (3) the Healthcare Systems Advisory Committees
Bureau, (4) the HIV/AIDS Bureau, (5) the Maternal HRSA is also involved in several committees
and Child Health Bureau, and (6) the Bureau of that advise the HHS and the U.S. Congress on
Clinician Recruitment and Service. healthcare matters. In the area of workforce devel-
The BHPr focuses on issues related to the opment, it is part of the Council on Graduate
healthcare workforce, including the education of Medical Education, the National Advisory Council
underrepresented minorities in the health profes- on Nursing Education and Practice, and the
sions and the recruitment and retention of clini- National Advisory Committee on the National
cians to work in underserved areas. This bureau Health Service Corps. Members of HRSA also
houses the National Health Service Corps (NHSC) serve on the National Advisory Committee on
and the National Practitioner Data Bank. Rural Health and Human Services, the National
The BPHC identifies underserved areas across Advisory Council on Migrant Health, the Advisory
the country and provides those areas with increased Committee on Organ Transplantation, the Centers
access to primary care. To this end, the most for Disease Control and Prevention (CDC)/HRSA
notable program housed in the BPHC is the Advisory Committee on HIV and STD (sexually
Consolidated Health Centers Program, which transmitted disease) Prevention and Treatment, the
includes Federally Qualified Health Centers Advisory Committee on Childhood Vaccines, and
(FQHC), Migrant Health Centers, Rural Health the Advisory Committee on Heritable Disorders
Centers, and others. and Genetic Diseases in Newborns and Children.
The Healthcare Systems Bureau leads several
efforts and oversees a variety of diverse HRSA
Strategic Partnerships
programs, including the vaccine injury compensa-
tion program; organ transplantation program; HRSA also partners with other government
efforts to reduce the number of uninsured indi- agencies and organizations at the federal, state,
viduals; and support of state and local efforts at and local levels. For instance, together with the
emergency management, disaster planning, and CDC, HRSA targets preventive care for chronic
bioterrorism response. diseases in underserved communities, assists in
The HIV/AIDS Bureau houses the Ryan White emergency preparedness and bioterrorism response
Comprehensive AIDS Resources Emergency planning, and strives to find solutions to the HIV/
(CARE) Act Program, providing funding to grant- AIDS epidemic. The agency’s Office of Pharmacy
ees for HIV/AIDS outreach; AIDS Drug Assistance Affairs implements the federal 340B Drug Pricing
Programs (ADAPs); and other efforts aimed at Program to provide access to low-cost prescription
increasing access to healthcare for individuals who drugs for federally funded grantees and other
are uninsured or underinsured and living with safety net providers. HRSA also works closely with
HIV/AIDS. the Agency for Healthcare Research and Quality
The Maternal and Child Health Bureau (MCHB) (AHRQ), the Indian Health Service (IHS), and the
provides national leadership on issues relating to Substance Abuse and Mental Health Services
women’s and children’s health, including access to Administration (SAMHSA). At the state level,
healthcare, programs designed to care for children HRSA partners with public health programs such
with special healthcare needs, and other similar as those administered under the Title V Maternal
programs. This bureau administers Title V grant and Child Health Block Grant and the Ryan White
Health Resources and Services Administration (HRSA) 535
CARE Act. Locally, HRSA provides grants to Receipt of such a designation is typically a prereq-
community-based organizations such as hospitals, uisite to qualifying for most grant programs
health centers, and academic institutions. administered by the agency and is also used by
other programs outside HRSA. More than 34
federal programs rely on HRSA’s designation of
Grants and Funding Opportunities
the medically underserved in making their fund-
HRSA is primarily a grant-giving and oversight ing decisions.
agency. That is, the majority of its budget goes to There are two general classifications: Health
providing grants and other funding in support of Professional Shortage Areas (HPSAs) and Medi
external organizations that pursue the agency’s cally Underserved Areas or Populations (MUAs
mission through education, training, and research. or MUPs). HPSAs include urban or rural geo-
These grantees include community-based organi- graphic areas and populations with a shortage of
zations, colleges and universities, hospitals, local primary-care, dental, or mental health providers.
and state governments, associations, and founda- If an area or population has more than 3,500
tions. In a typical year, community-based organi- persons per provider, it is considered to be under-
zations, hospitals, and universities account for served and is classified as a HPSA. If an area has
more than three fourths of the total funding dis- a ratio of 3,000:1 and can also demonstrate
bursed by HRSA. unmet need in the population, it too is classified
The various bureaus of HRSA administer a as a HPSA.
number of scholarship and loan programs to In contrast, MUAs and MUPs rely on an Index
health professionals in training to encourage them of Medical Underservice (IMU) to determine an
to pursue a career working in an underserved area’s or a population’s status. The IMU yields a
area, as well as to increase the representation of score ranging from 0 (completely underserved) to
minority populations and the teaching of cultural 100 (least underserved). A score of 62.0 or below
competency in health profession schools. qualifies for MUA designation. The IMU itself is
Scholarships and loans are awarded to students in calculated based on the ratio of primary-care phy-
medicine, nursing, dentistry, optometry, veteri- sicians per 1,000 population, the infant mortality
nary medicine, pharmacy, podiatric medicine, rate, the percentage of the population below pov-
public health, chiropractic medicine, the allied erty, and the percentage of the population age 65
health professions, behavioral and mental health, and older.
and physician assistants who are from disadvan-
taged backgrounds. HRSA’s loan repayment pro-
National Health Service Corps
grams repay certain student loans in exchange for
fulfilling a service obligation by working in an The National Health Service Corps (NHSC)
underserved area upon graduation. The best- exists to ensure that healthcare providers are avail-
known loan repayment program is part of the able to serve in the most underserved areas of the
National Health Service Corps. country. The NHSC acknowledges that even if a
clinician is dedicated to caring for underserved
populations, it can often be unfeasible for them to
Healthcare Workforce and the
do so without additional incentives for a variety of
Designation of Underserved Areas
reasons. To recruit clinicians to serve in these
One of HRSA’s primary missions is ensuring that areas, the NHSC operates both a scholarship and
an adequate supply of clinicians exists in the a loan repayment program; both of these initia-
country to provide needed care. Currently, there tives entail a service obligation upon graduation
is both an absolute shortage of clinicians per that requires the clinician to work in an under-
capita as well as a maldistribution of clinicians served area for a length of time depending on how
across the country. To target clinician placement, much assistance he or she received while in school.
HRSA’s National Center for Health Workforce There are currently more than 4,000 active NHSC
Analysis designates geographic areas and popula- clinicians providing care to nearly 4 million U.S.
tion groups as being medically underserved. residents.
536 Health Resources and Services Administration (HRSA)
Health Disparities Collaboratives staff, characteristics of the population served, ser-

vices the program provides, and the financial perfor-
Beginning in 1998, HRSA established a national
mance of the organization. The bureau then uses
network of Health Disparities Collaboratives
these individual reports to compile aggregated data
(HDC) to gather evidence of improved health out-
at the state, regional, and national levels. HRSA also
comes among disadvantaged populations and to
uses the UDS data to monitor the performance of
use these data to implement new evidence-based
individual health centers and their compliance with
practices. Using the Chronic Care Model, the
federal laws as well as to evaluate the program as a
HDC seeks to address medical conditions that are
whole in support of the annual budget requests sub-
the most expensive for community health centers
mitted to the U.S. Congress.
to treat or for which a large number of patients are
seen at the center. These conditions included diabe-
tes, cardiovascular disease, asthma, cancer, and Further Implications
depression. More than 450 federally funded, com-
HRSA plays an essential role in increasing access
munity health centers have participated in the
to healthcare for underserved areas and popula-
HDC since the program’s inception.
tions by funding projects; expanding opportuni-
ties for health professionals; and providing health
Data Collection and Availability information and data to agencies, researchers,
clinicians, and the general public. In the future,
HRSA maintains a variety of data—related to the efforts of HRSA will continue to be important,
healthcare access, clinician workforce, and related especially with the federal goal of eliminating
sociodemographic factors—accessible through its health disparities.
geospatial data warehouse. Most notable among
these are the Area Resource File (ARF), the Brad Wright
National Practitioner Data Bank (NPDB), and the
Health Centers Uniform Data System (UDS). See also Access to Healthcare; Community Health
The ARF is a national database of county-level Centers (CHCs); Federally Qualified Health Centers
health resource information, combining data from (FQHCs); Health Professional Shortage Areas
more than 50 varied sources such as the American (HPSAs); Health Workforce; National Health Service
Medical Association’s Physician Masterfile, the Corps (NHSC); National Practitioner Data Bank
U.S. Census Bureau, and the CDC. Taken together, (NPDB); Vulnerable Populations
these data make the ARF one of the most compre-
hensive sources of county-level health resource
data and include demographic data, indicators of Further Readings
need, and provider availability.
Eden, Jill, and Rosemary Stevens, eds. Evaluating the
The NPDB is a national repository of informa-
HRSA Traumatic Brain Injury Program. Washington,
tion collected on clinicians, with a focus on those
DC: National Academies Press, 2006.
who are reported to HRSA as having acted with- Gebbie, Kristin M., Linda Rosenstock, and Lyla M.
out integrity in their profession. State medical Hernandez, eds. Who Will Keep the Public Healthy?
boards and other entities report this information to Educating Public Health Professionals for the 21st
the NPDB to identify clinicians who have behaved Century. Washington, DC: National Academies Press,
unprofessionally, paid an excessive number of mal- 2003.
practice suits, or had their license revoked and Lewin, Marion Ein, and Stuart H. Altman, eds.
have moved from one state to another. America’s Health Care Safety Net: Intact but
The UDS collects data on all the programs in the Endangered. Washington, DC: National Academies
Consolidated Health Centers Program. By law, all Press, 2000.
programs receiving federal grant funding from Smedley, Brian D., Adrienne Stith Butler, and Lonnie R.
HRSA’s BPHC are required to submit annual UDS Bristow, eds. In the Nation’s Compelling Interest:
reports. The data reported include information about Ensuring Diversity in the Health-Care Workforce.
the health center’s governing board and operating Washington, DC: National Academies Press, 2004.
Health Savings Accounts (HSAs) 537
Web Sites health divisions to insurers that planned to stay

Health Resources and Services Administration (HRSA): in the healthcare business. Aetna, Cigna, and
http://www.hrsa.gov UnitedHealth are examples of commercial insurers
HRSA Information Center: http://ask.hrsa.gov that stayed in healthcare, along with the Blue
U.S. Public Health Service (USPHS): http://www.usphs.gov Cross and Blue Shield plans.
In the late 1990s, healthcare expenditures
started to rise again when health maintenance
organizations (HMOs) and managed-care prod-
ucts fell into general disfavor. Insurance subscrib-
Health Savings ers were looking for better options than the
Accounts (HSAs) restrictions imposed by HMOs and managed care.
The HSAs, included in the MMA, seemed to meet
the need for cost controls that the insured person
Health savings accounts (HSAs) are a relatively
could manage, and it provided an alternative for
new phenomenon in the United States. HSAs
the non-Medicare population.
are tax-advantaged savings accounts for indi-
viduals who are enrolled in high-deductible
health plans. HSAs came into existence with the
passage of the Medicare Modernization Act of Provisions of HSAs
2003 (MMA). The MMA, federal legislation The Internal Revenue Service (IRS) developed
that introduced a pharmacy benefit for Medicare guidelines for HSAs in its 2004 tax year docu-
enrollees, also included provisions for private, ments. To enroll in an HSA, individuals must
fee-for-service health plans. These private health have a trustee—either a bank, employer, or the
plans are under the consumer-directed health IRS. The advantages of HSAs include (a) the
initiatives. ability to claim a tax deduction; (b) the ability to
exclude the amount put into the HSA from gross
income, if the amount is contributed by an
Overview
employer; (c) the contributions can remain in
In 1984, John Goodman—the president of the the account until the money is used; (d) the
National Center for Policy Analysis and an early interest accrued on the account is tax free; (e)
proponent of initiatives to allow individuals to the contributions are portable and can be moved,
take control of their healthcare expenditures— if there is a job change; (f) the monies can be
began advocating for consumer-directed health transferred to an heir; and (g) the funds can be
plans. He wrote numerous newspaper articles and used for nonhealthcare purposes by paying
gave speeches at national meetings on the poten- income taxes.
tial benefits of allowing private citizens to manage The prospective HSA member enrolls with an
their own healthcare rather than ceding control to IRS-designated trustee. The enrollee pays into
insurers and providers. He also went to the U.S. the plan on an annual basis. The contribution is
Congress and gained legislative support from both up to a given deductible amount not to exceed
Democrats and Republicans to examine alterna- $2,600 for an individual and $5,150 for a fam-
tives to the existing employer-sponsored health ily. The HSA member can contribute these
insurance plans. amounts each year until the close of the tax year,
In the 1990s, healthcare expenditures in the which is April 15. When the HSA member files
country appeared to be under control with the his or her taxes for the preceding year on the
introduction of managed care. During this time, Form 1040 U.S. Individual Income Tax Return,
there were numerous commercial plans that entered he or she must also file the Health Savings
the health insurance business and expanded their Account Form 8889. When enrolling in a HSA,
offerings to include managed care. Insurers soon the enrollee must designate a beneficiary in case
found that healthcare was a difficult business in of death so that the account can be transferred
which to operate, and they eventually sold off their to an heir.
538 Health Savings Accounts (HSAs)
As of January 2008, there were an estimated 6.1 high blood pressure in the population that, in
million HSA enrollees in the nation. Health insur- many cases, can be successfully managed if
ers see HSAs as an opportunity to expand their individuals begin to accept responsibility for
product lines. However, insurers are receiving maintaining their own health through wise
competition from banks, credit unions, and money decision making. With the support of employ-
management firms; they see these accounts as a ers, insurers, and some of the general public,
financial vehicle, and many have registered to HSAs may continue to expand as an alternative
become trustees. This competition from the finan- insurance option.
cial industry has caused some insurers to purchase
banks, as evidenced by UnitedHealth’s acquisition Diane M. Howard
of Exante Financial Services and the Blue Cross
Blue Shield Association’s charter of the Blue See also Blue Cross and Blue Shield; Coinsurance,
Healthcare Bank, owned by 33 Blue Cross and Copays, and Deductibles; Compensation Differentials;
Blue Shield companies. Consumer-Directed Health Plans (CDHPs); Cost of
The verdict is still out on the possible success Healthcare; Health Insurance; Health Maintenance
Organizations (HMOs); Managed Care
of HSAs. Patients have to pay out-of-pocket
costs until they reach their deductible limit.
After the deductible threshold is reached, pro- Further Readings
viders then bill the HSA. Providers need the
billing expertise to complete the transaction Feldmen, Roger, Stephen T. Parente, Jean Abraham, et al.
and patients need the education to use HSAs “Health Savings Accounts: Early Estimates of
appropriately. National Take-up,” Health Affairs 24(6): 1582–91,
Some have criticized HSAs because they tend to November–December 2005.
Goodman, John, Peter Ferrara, Gerald Musgrave, et al.
attract a more affluent and educated population
Solving the Problem of Medicare. NCPA Policy
who are more willing to take responsibility for
Report No. 109. Washington, DC: National Center
their own health. This takes a healthy population
for Policy Analysis, 1984.
away from insurance pools leaving those who are
Morrisey, Michael A. Health Insurance. Chicago: Health
less healthy and less willing to take responsibility Administration Press, 2007.
for their health, which increases the premium dol- Robinson, James C. “Health Savings Accounts: The
lars for those left in the insurance pools. While Ownership Society in Health Care,” New England
HSAs move the responsibility to the individual, Journal of Medicine 353(12): 1199–1202, September
the account does nothing to control healthcare 22, 2005.
costs. The individual takes advantage of the insur- U.S. Government Accountability Office. Health Savings
er’s negotiated rates, but this does not address the Accounts: Participation Grew, and Many HSA-
cost escalation in healthcare. The enrollee has to Eligible Plan Enrollees Did Not Open HSAs While
manage with these predetermined rates. Yet for Individuals Who Did Had Higher Incomes. GAO-08–
those HSA members who remain vigilant and 802T. Washington, DC: U.S. Government
mindful of their healthcare purchases, the HSA Accountability Office, 2008.
may work well.
Web Sites
Future Implications
National Center for Policy Analysis (NCPA),
In the future, the number of individuals enrolled A Brief History of Health Savings Accounts:
in HSAs will likely increase. Many employers http://www.ncpa.org/prs/tst/20040811_hsa_history.htm
want to limit their exposure to healthcare U.S. Department of Treasury, Health Savings Accounts:
insurance costs, and a number of healthcare http://www.ustreas.gov/offices/public-affairs/hsa
proposals are being advanced to promote the U.S. Office of Personnel Management, High Deductible
private healthcare marketplace. They are con- Health Plans with Health Savings Accounts:
cerned about the rates of obesity, diabetes, and http://www.opm.gov
Health Services Research, Definition 539
health and well-being outcomes. These character-

Health Services istics are to be examined and understood for indi-
Research, Definition viduals and for populations. The linkage of
individual and population health forms an explicit
Today, health services research (HSR) is a recog- bridge between medicine and public health and
nized and well-respected field of investigation, between health service interventions at both the
supported by numerous government agencies, foun- individual and population or community levels.
dations, health plans, and insurers. The products of These changes in the definition document the
its research are widely used by policymakers; regu- changing vision for HSR and for health services.
latory agencies; healthcare providers; health plans; In the following sections, a brief history of the
insurers; and increasingly, by the general public. In field is provided, followed by a discussion of the
2001, the Association for Health Services Research, basic concepts and tools of HSR.
the predecessor to the AcademyHealth, adopted its
currently accepted definition: History
Health services research is the multidisciplinary Looking back over the history of the field, it can
field of scientific investigation that studies how be seen how HSR has changed to reflect the grow-
social factors, financing systems, organizational ing breadth of understanding of the factors affect-
structures and processes, health technologies, ing health and the increasing scope and effectiveness
and personal behaviors affect access to health- of health services.
care, the quality and cost of healthcare, and HSR traces its beginnings back to the 1920s and
ultimately our health and well-being. Its research initiatives by philanthropic foundations to improve
domains are individuals, families, organizations, the living conditions of the poor. In the 1950s, the
institutions, communities, and populations. (Lohr first legislation was passed by the U.S. Congress to
and Steinwachs, 2002, pp. 7–9) support studies of health services. The name health
services research was initially applied in the mid-
The definition of HSR has changed and evolved 1960s to a federal grants review study section
over time reflecting the capacity of the field to awarding research funds authorized under the Hill-
address the increasingly complex array of health Burton Act. The research was to benefit hospitals
services, the role of preventive as well as curative by providing guidance to improve hospital opera-
services, and the impact of services on both indi- tions ranging from nurse-staffing models to sched-
viduals and populations. In 1979, a National uling and patient flow models. As reported by
Academy of Sciences, Institute of Medicine (IOM) Charles Flagle, a member of this study section, HSR
report titled Health Services Research: A Report of was seen as the field addressing operational prob-
a Study stated: “Health services research is inquiry lems in healthcare and specifically in hospitals.
to produce knowledge about the structure, pro- In 1967, U.S. President Lyndon B. Johnson
cesses, or effects of personal health services” ordered the creation of the National Center for
(p. 14). The early and current definitions substan- Health Services Research (NCHSR) in the federal
tially overlap. The earlier definition was under- Department of Health, Education, and Welfare
standable to researchers who produced HSR but (DHEW). The name was subsequently changed to
likely not very understandable to the wide range of the Bureau of Health Services Research and
HSR users and the public. The current definition Evaluation and then to the National Center for
should be clearer to users of HSR and is more Health Services Research and Development
encompassing, recognizing the importance of social (NCHSR&D). In 1989, the U.S. Congress passed
factors and personal behaviors on the use of health legislation replacing NCHSR&D with the Agency
services and health outcomes. The definition iden- for Health Care Policy and Research (AHCPR).
tifies specific characteristics of the health services This elevated HSR to the same organizational level
that are of particular importance, including access in the Department of Health and Human Services
to care, quality, cost, and their contribution to (HHS) as the National Institutes of Health (NIH).
540 Health Services Research, Definition
One of the congressional mandates for the AHCPR incentives inherent in payment, regulatory, and
was to undertake outcomes research to learn what quality reporting methodologies. HSR is increas-
services benefit whom and under what circum- ingly relied on to provide the methods and mea-
stances. Also, the new agency was to integrate surement tools needed to evaluate the efficiency
knowledge from health services and clinical and quality of care and to provide the knowledge
research and develop practice guidelines for pro- needed by policymakers, providers, payers, and
viders and patients. The goal was to improve qual- the general public to make better-informed health-
ity and reduce the costs associated with unnecessary care decisions.
use and ineffective services. In 1999, when the U.S.
Congress reauthorized the AHCPR, its name was
Basic Concepts and Tools
changed to the Agency for Healthcare Research
and Quality (AHRQ). At the same time, the U.S. HSR is a field of study that draws on the theories
Congress removed the mandate for AHRQ to and methods of the social and behavioral sciences,
develop and disseminate practice guidelines and economics, medicine, public health, engineering,
removed the word policy from its name. Controversy and mathematical disciplines. As a result, the
had surrounded the AHCPR’s roles in health pol- tools used in HSR are not unique to the field.
icy reform and in disseminating practice guidelines What has emerged as unique, however, is their
that defined preferred treatments. These changes adaptation to the understanding of health services
modified the scope of its mission. and patient outcomes. Three research themes
In seeking to understand which health services have dominated the HSR field: (1) controlling ris-
work best, for whom, and under what circum- ing healthcare costs and improving efficiency,
stances, the AHRQ is expected to provide infor- (2) improving the quality of healthcare services
mation that ultimately affects the practice of to ensure the best outcomes for patients, and
medicine. In the Medicare Modernization Act of (3) improving access to healthcare for disadvan-
2003, the U.S. Congress gave the mandate to taged and uninsured populations. Health services
AHRQ to undertake comparative-effectiveness outcomes are defined broadly and include mortal-
research. The goal of comparative-effectiveness ity, morbidity, health-related quality of life, satis-
research is to provide information not currently faction, and healthcare costs.
available on which alternative treatments for spe-
cific health problems are best and for whom. The
Healthcare Costs
findings from comparative-effectiveness studies
are expected to influence medical-care choices Rising and difficult to control, healthcare costs
made by providers and by healthcare consumers, have been a persistent public policy issue since the
and may influence coverage choices made by pay- passage of the Medicare and Medicaid programs in
ers and health plans. To the extent the compara- 1965. Health economists have contributed to the
tive evidence leads to winners and losers in the understanding of the complexity of forces driving
medical marketplace, the interpretation and healthcare costs, including the lack of cost competi-
robustness of the HSR data will likely be chal- tion among providers, the design of health insur-
lenged. Although this may be uncomfortable for ance plans in a way that protects individuals from
the field at times, it will signify the maturity of having to make economic choices (moral hazard),
HSR and its growing capacity to provide timely and failures to provide consumers with informa-
and relevant information that can improve the tion on cost and quality trade-offs. The classic
quality of healthcare. RAND Health Insurance Experiment (HIE) of the
HSR has provided the tools used by healthcare 1970s demonstrated that increasing the level of
policymakers to modify payment methodolo- out-of-pocket payments (coinsurance and deduct-
gies (e.g., case-mix adjustment and pay-for- ibles) for healthcare reduces the average use of
performance), measure performance (i.e., quality) health services and costs. An analysis of episodes
of providers, and regulate the healthcare industry. of care by Keeler and Rolph showed that the level
Advances in measurement methodologies have of out-of-pocket payments was a primary influence
made it possible to restructure and refine the on the decision whether or not to seek healthcare.
Once the decision to seek healthcare was made, In the 1990s, there was rapid growth of man-
coinsurance and deductibles had little effect on the aged-care plans that used administrative processes
cost of the episode of treatment. One interpretation to manage utilization during episodes of treatment
of this finding was that once the patient was receiv- to control the costs of care (e.g., prior authoriza-
ing healthcare, the physician and not the patient tion, utilization review, and limits on the number
largely determined the extent of utilization. of services). These plans generally did not impose
Recognition that incentives for efficiency needed deductibles and charged modest copayments to
to be present for both providers (supply side) and avoid discouraging ambulatory care utilization.
patients (demand side) led to policy innovations Overall, utilization controls were principally sup-
using HSR tools. When the Medicare program was ply side, where it was perceived that the greatest
started, it made cost-based payments to hospitals impact could be achieved. Public reaction to health
and usual, customary, and reasonable payments to plans controlling utilization and limiting access to
physicians. As a result, healthcare costs rose rap- some specialists and/or tests and treatments was
idly as hospitals and physicians learned how to very negative. One result was that health plans
maximize their income. In 1983, Medicare imple- began offering insurance plan options to enrollees
mented a prospective payment system (PPS), pay- that allowed them to retain greater choice by pay-
ing hospitals a prospectively set rate for each ing higher premiums. The public concerns also
admission based on the discharge diagnosis and contributed to laws in many states that required
procedures. The classification system used in this timely appeal processes, using third parties, when
payment system, diagnostically related groups services were denied.
(DRG), was a product of 1970s HSR. In that the Another concern was that HMOs and managed-
DRG payment for inpatient episodes was indepen- care plans were responding to the capitation pay-
dent of the patient’s length of hospital stay, it pro- ment method by seeking to enroll healthier people
vided strong financial incentives for shorter hospital and avoiding very sick people in the community.
stays. The payment system also created a financial This was a result of having capitation rates based
incentive to increase the number of admissions on age and not explicitly taking into account
(episodes), to fill the beds emptied due to reduc- health characteristics. HSR investigators developed
tions in the average length of patient stays. To and validated methods for risk adjustment. Today,
avoid paying for unnecessary admissions, Medicare these methods are being applied to adjust capita-
instituted reviews of hospital admissions to ensure tion rates based on the health characteristics of
appropriateness. The review of admissions applied enrolled populations, better matching the capita-
criteria from the Appropriateness Evaluation tion rate to the healthcare needs of the enrollees.
Protocol (AEP), a product of HSR studies.
Health maintenance organizations (HMOs) date
Healthcare Quality
back to the Kaiser Permanente clinics for employ-
ees in the 1930s. In 1983, the U.S. Congress passed The accepted paradigm for examining the qual-
the HMO Act, which defined the HMO in federal ity of healthcare is drawn from the seminal work
law. HMOs receive a fixed capitation payment for of Avedis Donabedian. Quality of care is influ-
each enrollee (per person, per year) instead of enced by the structure of the healthcare system and
being paid on a fee-for-service basis. The incentives its resources and by the processes of diagnosis,
associated with capitation payment are, clearly, to treatment, and management. These come together
live within a budget equaling the total enrollment to influence the health outcomes experienced by
times the capitation rate. To balance their budgets, patients. The measurement of quality of care
some consumers challenged that HMOs were sac- involves the measurement of structural and pro-
rificing quality of care to save costs. HSR in the cess of care characteristics and their influence on
1970s and 1980s examined the quality of care of patient outcomes. With advances in HSR and
HMOs compared with the fee-for-service care pro- clinical research, knowledge is growing and clari-
vided in the same communities. The findings con- fying the contribution of specific treatments (pro-
sistently showed that HMO quality of care was cesses) to the likelihood of alternative health
equal to or better than fee-for-service care. outcomes.
542 Health Services Research, Definition
Provider licensure and facility accreditation is activities valued by the patient). The relationship
required by states and payers and, for a long time, of treatment choice to trade-offs in outcomes may
was accepted by the public as sufficient to protect be most often discussed as a consideration for end-
their quality of healthcare. Accrediting organiza- of-life care, when treatments that may extend life
tions for hospitals and health plans (e.g., the Joint may also significantly diminish quality of life for
Commission and the National Committee for the time that remains. In routine healthcare, treat-
Quality Assurance [NCQA]) require healthcare ments prescribed that interfere with a patient’s
organizations to meet structural standards and ability to work or carry out other usual activities
conduct studies to measure care processes and may be less desired.
patient outcomes. The findings from these studies Starting in 1999, the IOM produced a series of
are expected to feedback into the care processes to reports that informed the general public and poli-
improve patient outcomes. Quality of care, how- cymakers that America’s healthcare was facing
ever, became a prominent public policy issue dur- serious quality problems. Tens of thousands of
ing the late 1990s. One source of concern were Americans were dying each year due to medical
decisions made by managed-care plans that spe- errors and the failure to provide consistent, high-
cific tests or procedures ordered by the patient’s quality care. In a 2001 report titled Crossing the
physician were “not deemed medically necessary” Quality Chasm: A New Health System for the
and would not be covered by the managed-care 21st Century, the IOM found that the American
insurer. Disagreements about medical necessity healthcare system was fundamentally flawed.
between physicians and managed-care plans put Systems of care were largely dysfunctional; not
the patient in the difficult position of having to meeting the growing needs of chronically ill popu-
decide who to believe and tested the patient’s will- lations; and failing to provide continuing, coordi-
ingness to pay out-of-pocket costs for the physi- nated, and integrated healthcare. The report
cian-ordered tests or treatments not covered by concluded that to create a functioning healthcare
their plan. Other sources of concerns came from system, it would require a fundamental transfor-
HSR studies showing that only half of the time did mation of the current system. The report also
patients receive care meeting the quality standards stated six specific goals for quality of care for the
for their chronic health problems. And other HSR future. Specifically, patients should receive care
studies reported high rates of medical errors in that is safe, effective, timely, patient centered, effi-
hospitals, contributing to morbidity and mortality. cient, and equitable. And increasingly, the report-
The mounting evidence of these problems turned ing of the quality of healthcare findings is
the nation’s attention to the great need for more organized into these six categories. The National
research and policy initiatives to improve the qual- Healthcare Quality Report, mandated by the U.S.
ity of healthcare. Congress, uses this framework to compare quality
In Medicare: A Strategy for Quality Assurance, of care over time and across populations and
the IOM defined quality of care as “the degree to diagnoses.
which health services for individuals and popula-
tions increase the likelihood of desired health out-
Access to Care
comes and are consistent with current professional
knowledge” (p. 21). The emphasis is on providing The American healthcare system differs sub-
care that can be expected to lead to the best out- stantially from systems in other developed nations
comes. However, for many this is not sufficient: (e.g., Canada, Germany, and the United Kingdom)
Instead, the care provided should increase the like- by failing to provide health insurance coverage to
lihood of the outcomes desired by the patient. And all its citizens. The public commitment to health
the patient’s desired outcomes may differ from the insurance coverage is limited. The Medicare and
usual medical treatment goals, which would be Medicaid programs cover the elderly, the disabled,
expected to be to reduce mortality and morbidity and many, but not all, of the poor. The Veterans
risks. Patients, however, may be willing to incur Administration covers those who have served in
increased mortality and morbidity risks to improve the military, with priority given to service-
quality of life outcomes (e.g., to be able to do those connected disabilities. The number of uninsured
Americans has been growing and was estimated Disparities in Healthcare

by the Kaiser Commission on Medicaid and the
Among the most vexing problems in American
Uninsured to be approximately 46.4 million in
healthcare are the extensively documented dis-
2006. The HSR field has systematically docu-
parities in the health services received by racial
mented the adverse health effects of being unin-
and ethnic minorities as compared with the major-
sured. Lack of health insurance is associated with
ity population. One contributor is poorer access
fewer preventive services and contributes to sig-
to care among minorities. However, disparities
nificant delays in the receipt of necessary acute and
persist even after people have entered treatment.
chronic care.
In a groundbreaking national report Unequal
In its report Access to Health Care in America, Treatment: Confronting Racial and Ethnic
the IOM has defined access to healthcare as being Disparities in Healthcare, the IOM found that
the “timely use of personal health services to pro- significant disparities in treatment occurred in
duce the best outcome” (p. 33). As a reminder of physician’s offices and resulted in the generally
HSR measurement challenges that persist, the lower quality of care for racial and ethnic minori-
measurement of timeliness is not well developed. ties. The report described the multiple dimensions
Early efforts to measure timeliness in ambulatory of this problem, including the extent to which
care showed that patients and physicians fre- disparities are associated with cultural differences,
quently disagreed about the timeliness of the visit. language and communication differences,
Criteria by which to judge timeliness of care do increased uncertainty about best treatment, or
not exist for most medical conditions. Few quality stereotypes and biases toward ethnic and racial
standards specifically assess timeliness of care and minorities. The evidence is convincing that dis-
little is known about the timeliness of most parities exist and are harmful. The future chal-
healthcare. lenge for HSR is to identify ways to intervene
Improving access to care has proved to be more effectively to prevent disparities in quality of care
complex than merely extending insurance cover- from occurring. The goal is to strengthen the
age to all Americans, although this is a prerequisite capacity of the nation’s healthcare system to pro-
for access. Other barriers to access exist, including vide equal quality care for all.
the lack of local availability of healthcare services,
delays in being able to obtain visits with local
healthcare providers, and limited understanding
Future Implications
among consumers about how to use healthcare The definition of HSR and associated definitions
services most appropriately. Early researchers of quality of care and access to care are shaped by
examined healthcare-seeking behaviors to under- our understanding of the contributions of health
stand individual decision making. The concepts of services to disease and the health outcomes of indi-
perceived health risks, the expected benefits, and viduals and populations. As a result, these defini-
overcoming the barriers to the receipt of care were tions can be expected to change as we learn more.
conceptualized and measured. It was recognized In the future, the definition of HSR may more spe-
that the failure to receive timely care may be the cifically address the importance of environmental
result of complex interactions of patient decision factors and their effects on health and the need for
making, insurance coverage, availability of appoint- services. Changes in technology may also lead to
ments with providers, delays in receiving tests and changes in the definition. For example, as new
results, and competing demands in the patient’s technology makes it possible for individuals to
life. Today, it is widely acknowledged that con- self-diagnosis and the potential for self-manage-
sumers must be educated to be able to achieve the ment or treatment becomes greater, the distinction
maximum benefits from the health services avail- between patient and provider may blur. Even
able. Also, many believe that to have a responsive today, we recognize that successful chronic-disease
American healthcare system, all citizens need to management is highly reliant on the patient and
have adequate health insurance coverage. The the family to manage day-to-day care. Successful
means for achieving these goals are a current prior- chronic-disease management requires patients to
ity for HSR. be able to identify and appropriately respond to
544 Health Services Research, Origins
acute exacerbations. Although the defining charac- Field,” Health Services Research 37(1): 15–17,
teristics of HSR may change in the future, the February 2002.
desired outcomes are likely to remain the same: Luft, Harold S. “How Do Health Maintenance
protecting and improving individual and popula- Organizations Achieve Their Savings?” New England
tion health and well-being. Journal of Medicine 298(24): 1336–43, June 15, 1978.
Donald M. Steinwachs
Web Sites
See also AcademyHealth; Agency for Healthcare
Research and Quality (AHRQ); Health Economics; AcademyHealth: http://www.academyhealth.org
Health Services Research, Origins; Institute of Agency for Healthcare Research and Quality (AHRQ):
Medicine (IOM); Medical Sociology; Public Health http://www.ahrq.gov
Canadian Association for Health Services and Policy
Research (CAHSPR): http://www.cahspr.ca
Further Readings Canadian Health Services Research Foundation
(CHSRF): http://www.chsrf.ca
Agency for Healthcare Research and Quality. National
Health Research and Educational Trust (HRET):
Health Care Quality Report. Washington, DC:
http://www.hret.org
Department of Health and Human Services, 2006.
Health Resources and Services Administration (HRSA):
Donabedian, Avedis. “Evaluating the Quality of Medical
http://www.hrsa.gov
Care,” Milbank Memorial Fund Quarterly 44: 166–
National Academy of Sciences, Institute of Medicine
203, 1966.
(IOM): http://www.iom.edu
Institute of Medicine. Health Services Research: A
Report of a Study. Washington, DC: National
Academies Press, 1979.
http://www.nlm.nih.gov/hmd/nichsr/home.html
Institute of Medicine. Controlling Costs and Changing
Robert Wood Johnson Foundation (RWJF):
Patient Care? The Role of Utilization Management.
http://www.rwjf.org
Institute of Medicine. Medicare: A Strategy for Quality
Assurance, vol. 1. Washington, DC: National
Academies Press, 1990. Health Services
Institute of Medicine. Access to Health Care in America. Research, Origins
Institute of Medicine. To Err Is Human: Building a Safer Healthcare providers, public health officials, and
Health System. Washington, DC: National Academies
others were examining access, cost, quality, and
Press, 2000.
the outcomes of healthcare long before the term
Institute of Medicine. Crossing the Quality Chasm: A
heath services research (HSR) was coined. While
New Health System for the 21st Century.
many countries and cultures have been grappling
with issues concerning the efficacy and efficiency
Institute of Medicine. Unequal Treatment: Confronting
Racial and Ethnic Disparities in Healthcare.
of healthcare delivery and medical outcomes for
Washington, DC: National Academies Press, 2003. centuries, the United States has a particularly rich
Kaiser Commission on Medicaid and the Uninsured. The history in this subject.
Uninsured: A Primer: Key Facts About Americans The field of HSR has codified diverse concepts
Without Health Insurance. Washington, DC: Kaiser and methods under a broad rubric within the past
Commission on Medicaid and the Uninsured, October century. In contrast to the rapidly evolving arena of
2007. biomedical research, there was no defined field of
Keeler, Emmett B., and John E. Rolph. “The Demand scientific investigation that encompassed the many
for Episodes of Treatment in the Health Insurance disciplines, methods, and problems being addressed.
Experiment,” Journal of Health Economics 7(4): Instead, the field of HSR included the questions
337–67, 1988. being asked about the disparate facilities, person-
Lohr, Kathleen N., and Donald M. Steinwachs. “Health nel, management, use, benefits, risks, costs, social
Services Research: An Evolving Definition of the and behavioral influences, and outcomes brought
Health Services Research, Origins 545
to bear on the full spectrum of human health and National Institutes of Health (NIH) were founded
disease. Early efforts to expand and formalize the during this time, and the first issues of the Journal
study of HSR laid a strong foundation for the care- of American Medicine and the precursor of the
ful examination of the nation’s healthcare system New England Journal of Medicine also appeared
and the ongoing efforts to improve it. in the 19th century.
The National Information Center on Health
Services Research and Health Care Technology
Early 20th Century
(NICHSR) has compiled a comprehensive history
of the field, highlighting important milestones and Research on health services continued into the
events that helped define the area of study. This turn of the 20th century, with many studies address-
entry examines this history and the origins of ing the role of health professionals and institutions
HSR. and examining the impact of disease and disability in
the United States. For example, Hull House and the
History Chicago Medical Society conducted a birth record
study in 1908 to document the role of midwives dur-
Early History
ing childbirth; the Flexner report, published in 1910,
Many early achievements in the field of health investigated the quality of 130 medical schools in
services can be credited to England. In the 17th North America and recommended the closure of
century, Sir William Petty (1623–1687), a physi- 100 schools. Other efforts included the Report on
cian and an economist, used quantitative reason- National Vitality in 1909, surveys carried out by
ing when looking at physician practice and hospital insurance companies, and several studies looking at
care. William Farr (1807–1883) relied on statisti- social and health insurance.
cal data on morbidity and mortality to evaluate the The American Medical Association (AMA) sur-
effectiveness of the healthcare system in the 19th veyed the characteristics and the geographic distri-
century. Florence Nightingale (1820–1910), con- bution of hospitals in the nation in 1919. Ernest
sidered the founder of modern nursing, worked Codman (1869–1940) developed a system to
with Farr to develop uniform reporting procedures monitor surgical outcomes; he was also a founding
for British hospitals; she also was one of the first member of the American College of Surgeons
researchers to use graphics to explain and promote (ACS) and its Hospital Standardization Program.
good hygiene practices. The Committee on the Costs of Medical Care
The Industrial Revolution in the United States (CCMC) was created in 1927, and it conducted 27
spurred the creation of many public health entities different studies in the late 1920s and early 1930s
designed to promote hygiene, nutrition, and safety. before publishing its final report, Medical Care for
These early agencies focused on assessing the the American People.
health needs for many populations, as well as
evaluating the success of health interventions; they
The Great Depression
relied on health services approaches to measure the
outcomes of their programs. The U.S. Public The social and political conditions of the Great
Health Service (USPHS), which was established in Depression, which started in 1929 and lasted until
1798 to provide medical care to merchant seaman, the beginning of World War II, prompted several
expanded its role to partner with local public policy changes and further examination of the
health departments in keeping military training insurance and healthcare systems. During this
bases free of disease during World War I. The time, the Social Security Act was passed by the U.S.
American Public Health Association (APHA), Congress; the Blue Cross and Blue Shield plans
which was established in 1872, examined the coor- developed to insure patients for physician care and
dination of local public health departments in hospital care; and important studies—such as the
providing coverage to the whole country following National Health Survey and the Department of
the passage of the federal Social Security Act in Labor, Division of Cost of Living surveys—
1935. The predecessors to the Association of examined health disparities, the impact of income
American Medical Colleges (AAMC) and the on health status, and access to quality healthcare.
Laws passed as part of the New Deal increased Medical Facilities, and U.S. Congressman John E.
the federal government’s role in social programs Fogarty to increase that year’s Hill-Burton appro-
and funding. However, private, charitable organi- priation for what Block construed as medical-care
zations still played an important role in advancing research. These efforts resulted in a $1.2 million
HSR. The Milbank Memorial Fund, the Common increase in the available funds supporting research
wealth Fund, and the Kellogg Foundation all and initiatives in hospitals and other related health
focused on improving healthcare in the country, fields to gather information and develop new
and they helped fund the publication and dissemi- methods. They also advanced the field of HSR.
nation of books and reports. In 1936, the Robert Funding for this legislation ended in 1975.
Wood Johnson Foundation (RWJF) was estab- Beyond the Hill-Burton legislation, the U.S.
lished; it would eventually become one of the larg- Congress passed several federal laws to expand
est healthcare foundations in the county. While public health and HSR. The Health Research Act
these philanthropic entities provided essential sup- of 1956 authorized increased funding for research
port during the Great Depression, all of them con- into major diseases. In addition, the National
tinue with their expanded efforts today. Health Survey Act was also passed that year and
provided for data collection, research, and statisti-
cal analysis on health needs, including special sick-
Federal Legislation
ness and disability studies, by the USPHS.
Following the findings of the special Committee The changing social climate in the United States,
on Medicine and the Changing Order, which was especially the Civil Rights movement, highlighted
established by the New York Academy of Medicine the issue of poverty for many Americans. The Civil
and the American Hospital Association’s Com Rights Act, the Economic Opportunity Act, the
mission on Hospital Care, the U.S. Congress Comprehensive Health Planning and Services Act,
passed the Hospital Survey and Construction Act and the passage of the Medicare and Medicaid pro-
of 1946. Better known as the Hill-Burton Act, this grams allowed researchers to further examine issues
federal legislation allowed for funding and condi- of the medically underserved, access to services,
tions that expanded hospital construction through- advances in health technology, health economics,
out the country, especially in rural areas. The and the role of the healthcare professional. This
funding encouraged states to plan and build hos- expansion of federal policy set the stage for new
pitals, which greatly increased the number of laws and amendments to come in the 1970s and
facilities and hospital beds. That same year, the 1980s, much of it helping advance the role of HSR.
U.S. Congress also passed the National Mental
Health Act—which promoted research, training,
The Role of the National Institutes of Health
and treatment centers in mental health—and the
National Health Service Act, which organized Because of the expansion of the Hill-Burton Act to
local health centers to provide health services. include research, the NIH’s Division of Research
In 1949, the U.S. Congress recognized the need Grants (DRGs) was assigned the responsibility for
for research activities directed toward understand- reviewing new grant applications in 1955. Several
ing and improving hospital facilities. In 1954, NIH Study Sections existed at that time, including
amendments to the Hill-Burton Act allowed for ones for Sanitation, Environmental Health, Public
funding to support chronic-care facilities. One Health, and Public Health Methods. The Nursing
year later, policy was expanded to provide addi- Research Study Section was established to exam-
tional funds for research in hospital operation and ine patient care. Shortly after this time, the NIH
administration in response to the identified need. proposed the creation of the Hospital Facilities
Louis Block, a former hospital consultant, served Research Study Section. These study sections were
as chief of the Research Grants Branch of the then designated the Health Services Group.
U.S. Department of Health, Education, and Welfare After much internal debate as to the mission of
(DHEW). In 1955, Block worked with John the study sections and the gaps in research needs
Cronin, chief of the Division of Hospital and not being addressed by any one group, members of
Health Services Research, Origins 547
the sections recommended expanding the role of shaping and expanding the field, several other
the Hospital Facilities Research Study Section federal government agencies also had an impor-
beyond the narrow scope of hospitals to include tant impact. The national Institute of Medicine
research on patient care and healthcare systems. In (IOM) was established in 1970 to study policy
1960, the NIH established the Health Services issues that affect the health of Americans. Its work
Research Study Section. It was primarily responsi- deals with quality of care, access to services, and
ble for operational research in a community setting healthcare financing and coverage systems.
such as a health department; it was charged with The National Center for Health Services
the review of research grant applications in the area Research and Development (NCHSR&D), estab-
of community health, including needs, resources, lished by Executive Order in 1968, was created to
planning, and practices of professionals, organiza- support research, development, demonstrations,
tions, and institutions. The section was also respon- and related training directed to the improvement
sible for reviewing applications for public welfare of the organization, staffing, delivery, and financ-
programs as they related to community health. ing of health services, including the design and
The Health Services Research Study Section, operation of health facilities. By 1974, that entity
however, soon became focused on defining and became the National Center for Health Services
developing its field, stimulating needed research, Research (NCHSR). The Veteran’s Administration
and improving research quality and credibility. also started a Health Services Research and
Program development became just as important as Development Office, and the U.S. Congress cre-
reviewing grant applications. Kerr L. White, who ated the National Center for Health Statistics
gained a reputation as a health services researcher (NCHS) in 1974 to compile statistical information
at the University of North Carolina, served as to guide policy to improve health. The Health Care
chairman of the study section from 1963 to 1965. Financing Administration (HCFA) was established
One of his major initiatives at this time was to in 1977 to oversee the Medicare and Medicaid
commission a set of articles that defined the scope, programs; now known as the Centers for Medicare
methods, standards, and applications of HSR. and Medicaid Services (CMS), this entity helped
White organized a special symposium on medical develop and establish the prospective payment sys-
care research in 1964. The Milbank Memorial tem for Medicare recipients.
Fund Quarterly published these articles in a special In the late 1980s, the U.S. Congress established
issue on HSR in 1967. the Agency for Health Care Policy and Research
The leadership of the Health Services Research (AHCPR) from the National Center on Health
Study Section envisioned this new field as an amal- Services Research (NCHSR). It was focused on
gam of the perspectives of public health and clinical patient outcomes and responsible for developing and
medicine, including methodology from economics, sharing clinical practice guidelines, quality stan-
social survey research, epidemiology, biostatistics, dards, medical review criteria, and performance
and systems analysis. Another initiative of the measures. The AHCPR initiated Patient Outcomes
group was to launch the new journal Health Research Teams (PORTs), large multidisciplinary,
Services Research, first published in 1966. The first multi-institutional projects that examined patient
issue covered four topics: length of stay, statistical outcomes, treatment standards, and practice effec-
methods, health services utilization, and informat- tiveness for common chronic and acute conditions.
ics. Other journals followed, such as Medical Care Similarly, the AHCPR also sponsored the use of
Review and Social Science and Medicine, offering evidence-based clinical practice guidelines; through a
health services researchers the opportunity to pub- partnership with the AMA, it set up the Web-based
lish their studies and share their findings. National Guideline Clearinghouse. In 2000, the U.S.
Congress established the Agency for Healthcare
Research and Quality (AHRQ) from the AHCRP.
Other HSR Agencies
Other federal agencies key to the promotion
Although the inclusion of the Health Services and growth of HSR include the Health Resources
Research Study Section at the NIH was key to and Services Agency (HRSA), the Substance Abuse
and Mental Health Services Administration rely on HSR to provide accurate data and strong
(SAMHSA), and the National Information Center recommendations for measures aimed at improving
on Health Services Research and Health Care the nation’s healthcare system. As this entry docu-
Technology (NICHSR) ments, the field made an impact on several social
Private and professional organizations also play and heath reforms in the past century. From help-
an important role in the ongoing efforts of HSR. ing control Medicaid costs to increasing access to
Universities and private research centers—including care through the Medicaid and State Children’s
the RAND Corporation, which conducted its semi- Health Insurance Programs (SCHIP), researchers
nal Health Insurance Experiment from 1974 to have focused on assessing needs and evaluating
1982—enable the field to make notable advances. programs. The field of HSR continues to evolve
The Joint Commission, a nonprofit organization and expand to meet the changing needs of the
originally founded in 1951, has expanded its mis- nation.
sion to improve the safety and quality of care to the Moving forward, health services researchers
general public through rigorous accreditation of will be at the forefront of developing and imple-
healthcare organizations and facilities. The menting new healthcare reforms. As the nation
International Society of Technology Assessment in continues to debate such issues as a national health
Health Care (ISTAHC) was organized in 1985 to insurance system, the escalating costs of health-
encourage research, education, cooperation, and care, outreach efforts for chronic disease, and
the exchange of information. It became the Health increased education for health promotion, its lead-
Technology Assessment International (HTAi) in ers will increasingly turn to the field of HSR for
2003. information and solutions.
The Association of Health Services Research
(AHSR), founded in 1981, was a prominent group Kathryn Langley
that strove to educate the public and politicians See also AcademyHealth; Anderson, Odin W.; Codman,
about the importance of HSR. Through a merger of Ernest Amory; Committee on the Costs of Medical
the AHSR and the Alpha Center in 2000, the group Care (CCMC); Health Services Research, Definition;
is now known as AcademyHealth. Its mission is to Public Health; Public Policy; White, Kerr L.
promote interaction across the health research and
policy arenas by gathering perspectives from many
disciplines and professions and fostering working Further Readings
relationships between scientists, advocates, and
policy makers. AcademyHealth partners with gov- Anderson, Odin W. The Evolution of Health Services
ernment offices, philanthropic foundations, and Research: Personal Reflections on Applied Social
Science. San Francisco: Jossey-Bass, 1991.
universities on a broad array of projects.
Codman, Ernest A. A Study in Hospital Efficiency: The
First Five Years. Boston: Thomas Todd Company, 1916.
Future Implications Committee on the Costs of Medical Care. Medical Care
for the American People: The Final Report of the
The middle of the 20th century proved to be a Committee on the Costs of Medical Care. Chicago:
defining time for the field of HSR in the United University of Chicago Press, 1932.
States. Now, several subspecialties of the field Flexner, Abraham. Medical Education in the United
have emerged, including clinical epidemiology, States and Canada: A Report to the Carnegie
evaluative health sciences, evidenced-based medi- Foundation. New York: Carnegie Foundation, 1910.
cine, health economics, health policy research, Flook, E. Evelyn, and Paul J. Sanazaro, eds. Health
healthcare research, medical-care research, out- Services Research and R&D in Perspective. Ann
comes research, patient care research, and popula- Arbor, MI: Health Administration Press, 1973.
tion health research. These areas are all concerned Ginzberg, Eli, ed. Health Services Research: Key to
with improving access, cost, quality and the out- Health Policy. Cambridge, MA: Harvard University
comes of healthcare. Press, 1991.
Policymakers have taken an evidence-based Mainland, Donald, ed. Health Services Research, vols.
approach to new legislation and regulations; they 1–2. New York: Milbank Memorial Fund, 1967.
Heath Services Research at the Veterans Health Administration (VHA) 549
McCarthy, Thomas, and Kerr L. White. “Origins of outpatient services. The VHA operates more
Health Services Research,” Health Services Research than 1,400 sites of care, including 872 ambula-
35(2): 375–87, June 2000. tory-care and community-based outpatient
Thompson, John D. Applied Health Services Research. clinics, 135 nursing homes, 45 residential reha-
Lexington, MA: Lexington Books, 1977. bilitation treatment programs, 209 Veterans
White, Kerr L., Julio Frenk, Cosme Orgonez, et al., eds. Centers, and 108 comprehensive home care pro-
Health Services Research: An Anthology. Washington, grams. The total staff of the VHA was 182,946
DC: Pan American Health Organization, 1992. full-time equivalents, including 11,343 physi-
cians, more than 50,000 nurses, and other clini-
cal and support staff. These professionals provided
Web Sites
care for a total of 7.9 million enrolled veterans,
AcademyHealth: http://www.academyhealth.org including 567,852 receiving acute-care inpatient
Kerr White Health Care Collection, University of services and an additional 300,000 receiving
Virginia: http://historical.hsl.virginia.edu/kerr/hsr.cfm inpatient psychiatric care, nursing home, or
National Information Center for Health Services other types of inpatient care. Enrolled veterans
Research and Health Care Technology (NICHSR): generated a total of 60 million outpatient visits.
http://www.nlm.nih.gov/nichsr The VHA’s total annual budget for FY2006
exceeded $31 billion.
Heath Services Research Education
at the Veterans Health The educational role of the VHA was initiated
in 1948 with the now famous “Memorandum 2”
Administration (VHA) signed by Omar Bradley, the director of the
Veterans Administration, the precursor of the
The Veterans Health Administration (VHA) is the VA. This memorandum directed the VHA to
federal government’s lead agency serving the develop affiliations with the nation’s medical
healthcare needs of the veterans of the U.S. military schools and other health-affiliated schools to
services, and the largest healthcare delivery system develop a constant source of physicians and other
in the United States. The VHA is part of the U.S. healthcare workers for the VHA’s healthcare mis-
Department of Veterans Affairs (VA), a cabinet- sion. The VHA is currently affiliated with 107
level department of the federal government. The medical schools, 55 dental schools, and more
VA is composed of the VHA, the Veterans Benefit than 1,200 other schools across the nation. Each
Administration, and the Cemetery Administration. year, about 90,000 health professionals are
The Veterans Benefit Administration administers trained in VA medical centers. More than half of
many programs, including the GI Bill, mortgages, the physicians practicing in the nation receive
and compensations and pensions, while the some of their professional training in the VA
Cemetery Administration administers 1,000 ceme- healthcare system.
teries across the nation for veterans.
Backup to the U.S. Department of Defense
Overview of the VHA The VHA’s medical system serves as a backup to
The VHA’s mission includes healthcare, educa- the U.S. Department of Defense during national
tion, backup for the U.S. Department of Defense, emergencies and as a federal support organization
and research. during major disasters.
Healthcare Research
In fiscal year (FY) 2007, the VHA comprised One of the major strengths of the VHA is
155 medical centers providing inpatient and that it is a healthcare delivery system as well as
550 Heath Services Research at the Veterans Health Administration (VHA)
a research-granting agency. In FY2006, the Mission

U.S. Congress appropriated $412 million for
The mission of HSR&D is to advance knowl-
the Office of Research and Development (ORD)
edge and promote innovations that improve the
of the VHA. Because research is one of the
health and care of veterans and the nation. Many
main missions of the VHA, each medical facil-
of the studies conducted by this service have been
ity contributes the cost of their investigators’
used within and outside the VA to assess new tech-
salaries and infrastructure support for these
nologies, explore strategies for improving health
grants, thus greatly enhancing the amount allo-
outcomes, and evaluate the cost-effectiveness of
cated by Congress. In 2006, this was an addi-
services and therapies. The need for high-quality
tional $357 million from the medical-care
health services research (HSR) continues to grow
account. Non-VA sources, such as the National
to keep pace with and respond to the rapid changes
Institutes of Health (NIH), other government
under way within the VHA and in the healthcare
agencies, and pharmaceutical companies, pro-
community as a whole. The HSR&D carries out
vided an additional $882 million in funding for
this mission through its various programs, includ-
VA research.
ing peer-reviewed research, career development,
VA research focuses on areas of concern to
and research and resource centers.
veterans. It has earned an international reputa-
tion for excellence in areas such as aging,
chronic disease, prosthetics, and mental health. Health Services Research
Studies conducted within the VA help improve
medical care not only for the veterans enrolled HSR in the VA examines the organization,
in the VA’s healthcare system but also for delivery, and financing of healthcare from the per-
the nation at large. Because 7 out of 10 VA spectives of patients, caregivers, providers, and
researchers are also clinicians, the VA is managers to improve the quality and economy of
uniquely positioned to translate research results care. Specifically, the HSR&D is interested in
into improved patient care. VA scientists and evaluation of the structure, processes, and out-
clinicians collaborate across many disciplines, comes of care, including issues of patient safety
resulting in a synergistic flow of inquiry, dis- and equity. The HSR&D is also concerned with
covery, and innovation between the laboratory system-level outcomes such as assessments of cost
and clinical settings. and access, as well as effective ways to translate
The ORD of the VHA is divided into four ser- clinical knowledge into practice. The underlying
vices: Basic Research Service; Clinical Research objectives of HSR in the VA are to understand and
(including Cooperative Trials) Service; Reha improve clinical decision making and care, inform
bilitation Research and Development Service; and patients, evaluate changes in the healthcare sys-
Health Services Research and Development tem, and inform VA policymakers.
Service. Each of these services solicits requests for HSR&D’s projects are often multidisciplinary
proposals in their designated areas. And each ser- activities. They involve expertise in a combination
vice has several study sections to review grant of clinical fields (medicine and all its specialties,
proposals. nursing, and other healthcare professions), social
sciences (especially psychology, sociology, econom-
ics, and organization theory), and multiple research
Health Services Research approaches and methods (experimental and quasi-
and Development Service experimental studies, survey research, database
The Health Services Research and Development analyses, biostatistics, psychometrics, economet-
Service (HSR&D) was initiated in 1976 with a rics, and modeling techniques).
budget of $3.6 million. In FY2007, its budget
was $68 million. An additional $14 million was
HSR&D’s Components
allocated to HSR&D by Patient Care Services
to administer the Quality Enhancement Research The HSR&D has six components: (1) investigator-
Initiative (QUERI) program. initiated research (IIR), (2) service-directed research,
Heath Services Research at the Veterans Health Administration (VHA) 551
(3) career development for clinicians and nonclini- posal is requested from the investigator. Proposals
cians, (4) research centers, (5) resource centers, are peer reviewed by an expert panel of reviewers,
and (6) QUERI. and if approved, are considered for funding.
Investigator-Initiated Research Career Development for

Clinicians and Nonclinicians
The largest component of HSR&D’s budget is
allocated to the IIR program. The HSR&D Service The Career Development Program is intended
has active solicitations in 11 priority areas: (1) to attract, develop, and retain talented researchers
access and rural health; (2) complex, chronic con- working in areas of particular importance to
dition care; (3) equity and health disparities; (4) improving the health and care of veterans. The
health services genomics; (5) health informatics; program is open to clinicians and nonclinicians.
(6) implementation and management research; (7) Specifically, it includes the career development
long-term care and care giving; (8) mental health; award one (CDA-1), career development award
(9) postdeployment health; (10) research method- two (CDA-2), career development transition award
ology; and (11) women’s health. (CDTA), and career development enhancement
Research proposals in these areas may request award (CDEA).
up to 4 years of funding and up to $900,000; how- The CDA-1 is an entry-level career development
ever, projects that can produce useful findings, program open to both clinicians and nonclinicians.
either intermediate or final, in a shorter time frame It emphasizes mentorship and career development
are encouraged. The research designs used in the planning with full salary support for up to 2 years.
research studies are expected to be appropriate The CDA-2 is a midlevel program open to both
and efficient, with all budget categories well justi- clinicians and nonclinicians who must outline a
fied. All proposals are reviewed by a scientific- 3- to 5-year agenda of career development and
merit review board made up of experts in the area research activities. It includes full salary support
from within and outside the VA. Proposals must for 3 to 5 years.
receive a high priority score to be considered for The CDTA is only open to clinicians who have
funding. submitted a merit review proposal that has been
approved. This award provides up to 3 years of
transition funding to ensure that their research
Service-Directed Research
career is well established.
The emphasis in service-directed research is on Last, the CDEA supports established clinical
applied, action-oriented research that uses estab- and nonclinical scientists by providing the oppor-
lished evidence to create and document real change tunity for a research sabbatical of up to 6 months
within an organizational unit. Projects respond to learn new research skills. To be considered for
rapidly to organizational needs, favor active facili- this award, an individual must have been an inde-
tation over passive observation, modify approaches pendent investigator in the VA for a minimum of 6
in midstream through formative evaluations, and years. During the award period, the individual
share resources from VHA operational entities. must devote 100% of his or her time to research.
Service-directed projects adopt the implementation
framework used by the VA’s QUERI. Principal
Research Centers
investigators are encouraged to integrate their
work with the QUERI program and to address There are 13 HSR&D Centers of Excellence
conditions of high priority to the VHA because of located throughout the nation. In addition,
prevalence, burden, urgency, or special emphasis HSR&D’s Research Enhancement Award Program
populations. (REAP) supports nine other research centers.
Project proposals are solicited through announce- HSR&D provides core funding for its Centers
ments to VA’s QUERI Centers, HSR&D’s Centers of Excellence. Each center develops its own research
of Excellence, or announcements to all the VA. On agenda, is affiliated with a VA medical center, and
approval of a concept paper, a full project pro- collaborates with local schools of public health
552 Heath Services Research at the Veterans Health Administration (VHA)
and universities to carry out its mission. The Colorado; Center for Healthcare Knowledge
research at each center serves to energize the facil- Management in East Orange, New Jersey;
ity and network with which they are affiliated and Rehabilitation Outcomes Research Center for
provides a constant source of innovation, creativ- Veterans with Neurological Impairment in
ity, and support. Centers of Excellence are com- Gainesville, Florida; Center for Mental Healthcare
petitively awarded and must compete for renewal and Outcomes Research (CeMHOR) in Little
every 5 years. Rock, Arkansas; Columbia Center for the Study of
Current Centers of Excellence include the fol- Chronic Comorbid Mental and Physical Disorders
lowing: Center for Clinical Management Research, in Portland, Oregon; Veterans Evidence-Based
located in Ann Arbor, Michigan; Center for Health Research Dissemination and Implementation Center
Quality, Outcomes and Economic Research in San Antonio, Texas; Program to Improve Care
(CHQOER) in Bedford, Massachusetts; Center for Veterans with Complex Comorbid Conditions
for Organization, Leadership, and Management in San Francisco, California; and the VA Outcomes
Research (COLMR) in Boston, Massachusetts; Group in White River Junction, Vermont.
Center for Health Services Research in Primary
Care in Durham, North Carolina; Center for
Resource Centers
Management of Complex Chronic Care in Hines,
Illinois; Houston Center for Quality of Care and HSR&D provides core funding to three resource
Utilization Studies (HCQCUS) in Houston, Texas; centers that support its management and investiga-
Center for Excellence on Implementing Evidence- tors by providing data, consultation, and focused
Based Practice in Indianapolis, Indiana; Center research on management issues, health economics,
for Research in the Implementation of Innovative and informatics systems. The three centers are
Strategies and Practice (CRIISP) in Iowa City, the Health Economics Resource Center (HERC),
Iowa; Center for Chronic Disease Outcomes VA Information Resource Center (VIREC), and
Research (CCDOR) in Minneapolis, Minnesota; the Center for Information Dissemination and
Center for Health Care Evaluation (CHCE) in Palo Education Resources (CIDER).
Alto, California; Center for Health Equity Research The HERC, located in Menlo Park, California,
and Promotion (CHERP) in Pittsburgh and assists VA researchers in assessing the cost-
Philadelphia, Pennsylvania; Northwest Center for effectiveness of medical care, evaluating the effi-
Outcomes Research in Older Adults in Seattle, ciency of VA programs, and providing and
Washington; and Center for the Study of Healthcare conducting high-quality economics research.
Provider Behavior in Sepulveda, California. The VIREC, in Hines, Illinois, supports VA
The HSR&D also provides core support for researchers using databases and information by
nine REAPs, located at VA medical centers and not creating a knowledge base of factual and evaluative
affiliated with a Center of Excellence but which information about the VA and select non-VA data.
already have a history of HSR&D research and It disseminates information via a help desk, publi-
a minimum number of funded investigators. They cations, a Web site, research user guides to select
are to develop a core program of investigators, data sources, and a HSRData Listserv. The center
statisticians, and other social scientists to support also represents the interests of VA researchers using
and facilitate the development of HSR&D research databases and information systems through formal
projects and the training and mentoring of new and informal liaisons within the VA and with other
HSR&D investigators. REAP sites are smaller than healthcare agencies and organizations.
Centers of Excellence but may compete to become The CIDER, in Boston, Massachusetts, man-
a Center of Excellence when appropriate. REAP ages the HSR&D’s national dissemination efforts.
sites are competitively awarded and must compete Specifically, the center manages the national
for renewal every 5 years. HSR&D and QUERI Web sites. It coordinates
The current REAP sites include the following: HSR&D’s cyber seminars, and it develops and
Deep South Center on Effectiveness, located in contributes to HSR&D’s research and develop-
Birmingham, Alabama; Colorado REAP to Improve ment publications and other VA and non-VA pub-
Care Coordination for Veterans (CRICC) in Denver, lications and products.
Health Services Research in Australia 553
Quality Enhancement Research Initiative Providers,” Journal of the American Medical

Women’s Association 59(3): 192–97, Summer 2004.
The HSR&D’s QUERI is a multidisciplinary, Fine, Michael J., and John G. Demakis. “The Veterans
data-driven, quality improvement program Health Administration’s Promotion of Health Equity
designed to ensure excellence in all places where for Racial and Ethnic Minorities,” American Journal
the VHA provides healthcare services, including of Public Health 93(10): 1622–24, October 2003.
inpatient, outpatient, and long-term care settings. Joseph, Anne M., Nancy J. Arikian, Larry C. An, et al.
QUERI is designed to translate research discoveries “Results of a Randomized Controlled Trial of
and innovations into better patient care and sys- Intervention to Implement Smoking Guidelines in
tems improvements. It focuses on nine high-risk or Veterans Affairs Medical Centers: Increased Use of
highly prevalent diseases or conditions among Medications Without Cessation Benefit,” Medical
veterans: chronic heart failure, diabetes, HIV/ Care 42(11): 1100–1110, November 2004.
hepatitis, ischemic heart disease, mental health, Longman, Phillip. Best Care Anywhere: Why VA Health
polytrauma, spinal cord injury, stroke, and sub- Care Is Better Than Yours. Sausalito, CA: Polipoint
stance use disorders. QUERI aims to identify best Press, 2007.
practices, systematize their use, and provide the McQueen, Lynn, Brian S. Mittman, and John G.
ongoing feedback necessary to maintain ongoing Demakis. “Overview of the Veterans Health
improvement. Administration (VHA) Quality Enhancement
Research Initiative (QUERI),” Journal of the
American Medical Informatics Association 11(5):
Today and the Future 339–43, September–October 2004.
The VHA, through the active involvement and Oliver, Adam. “The Veterans Health Administration: An
support of all its services, including HSR&D, American Success Story?” Milbank Quarterly 85(1):
leads the nation in healthcare quality indicators, 5–35, January 2007.
such as the administration of beta-blockers to Stroupe, Kevin T., Denise M. Hynes, Anita Giobbie-
Hurder, et al. “Patient Satisfaction and Use of
heart attack patients, breast and cervical cancer
Veterans Affairs Versus Non–Veterans Affairs
screening, immunizations, and diabetic care. It
Healthcare Services by Veterans,” Medical Care
exceeds the national average in quality scores
43(5): 453–60, May 2005.
from the Joint Commission. It has set the bench-
mark in patient satisfaction for hospital services in
the American Customer Satisfaction Index, an
indicator developed by the University of Michigan Web Sites
Business School. And the VHA is widely recog- Congressional Budget Office (CBO): http://www.cbo.gov
nized as an industry leader for patient safety. Health Services Research and Development Service
Other healthcare systems in the United States, as (HSR&D): http://www.hsrd.research.va.gov
well as foreign nations, are studying the VHA’s U.S. Department of Veterans Affairs (DVA):
success and are trying to duplicate it. http://www.va.gov
U.S. Government Accountability Office (GAO):
John G. Demakis http://www.gao.gov
See also Computers; Continuum of Care; Electronic
Clinical Records; Multihospital Healthcare Systems;
Quality Enhancement Research Initiative (QUERI) of
the Veterans Health Administration (VHA); Quality of Health Services Research
in Australia
Healthcare; TRICARE, Military Health System; U.S.
Department of Veterans Affairs (VA)
Australian healthcare appears to operate effec-

Further Readings tively, compared with other countries. Australians
Bean-Mayberry, Bevanne, Chung-Chou Chang, Melissa live longer than their counterparts in New Zealand,
McNeil, et al. “Comprehensive Care for Women Canada, the United Kingdom, and the United
Veterans: Indicators of Dual Use of VA and Non-VA States. Healthcare in Australia accounts for close
554 Health Services Research in Australia
to 10% of the nation’s gross domestic product of health technology assessment approaches to pro-
(GDP). While this percentage is lesser than for posals for new government funding, particularly
Canada, France, Germany, and the United States, public health programs, has been evident over a lon-
it is higher than for the United Kingdom or New ger period. Australian researchers have made signifi-
Zealand. Australia’s healthcare system ensures cant contributions to the development of case-mix
universal coverage for medical services, hospital classification. HSR has also been used to develop
care, and pharmaceuticals. and assess new methods of funding, though this has
Nonetheless, Australia faces challenges, with not been applied consistently, and many new fund-
rapidly increasing health service costs, lack of coor- ing schemes have been established with little or no
dinated care particularly for chronic and continu- independent research. In the important area of
ing health problems, failures in safety and quality, health workforce, there has been little independent
and poor health outcomes for some population or investigator-initiated research, although govern-
groups, most particularly indigenous Australians. ment inquiries and planning agencies have generated
In the future, advances in medical technology, a substantial activity. There is continued interest in the
growing proportion of elderly, and population development of research that will ensure a suitable
health changes such as the rise in obesity may con- evidence base for policy development.
tinue to stretch health service delivery and the In addition, the Health Services Research
nation’s capacity to finance the growing demands Association of Australia and New Zealand
on the healthcare sector. Health services research (HSRAANZ) holds its major scientific meeting every
(HSR) helps assess these issues, develop interven- 2 years. This active group represents the significant
tions, and inform policy change. history and promising advances in this field.
Background Pharmacoeconomics
Australia has a federal system of government in The Pharmaceutical Benefits Scheme (PBS) pro-
which both the national government and the vides universal access to prescription medicines
States and Territories hold responsibility for outside public hospitals and funds around 90% of
healthcare. In addition, the system is a complex prescriptions. Patients are charged a set copay-
set of interactions between the public and pri- ment. Pharmaceutical manufacturers apply for a
vate sectors in both healthcare finance and product listing on the PBS for specified indications.
delivery. Most Australians live in urban centers The submission is required to provide evidence of
along the southeastern coastline. Service deliv- the drug’s safety, effectiveness, and, since 1993,
ery to the rural populations has to contend with cost-effectiveness according to detailed guidelines.
large distances, remote centers, extremes of cli- The evidence is reviewed and may be reworked by
mate, shortages of healthcare workers, limited an independent advisory committee assisted by a
access to specialist and referral services, as well team of independent evaluators. This requirement
the social and economic problems of remote has generated a great deal of interest and work in
communities. pharmacoeconomics, though much of it occurs in
The importance of Australian HSR has been rec- the private sector and under commercial, in-confi-
ognized by many national reviews of health and dence provisions. As a result, relatively little of it
medical research funding, acknowledging that appears in the public domain.
reforms in health funding, financing, and the deliv- Pharmaceuticals currently account for around
ery of healthcare require solutions that are tailored 15% of Australia’s total healthcare spending, but
to the Australian culture, history, and organization. this has been the fastest growing component of the
There are several areas in which Australian research health budget for several years. The rationale for
has made significant contributions. Australia was this approach is delivering value for money in new
the first country in the world to introduce the drug treatments rather than a focus on cost sav-
requirement that the cost-effectiveness of new drug ings. Drug costs have continued to rise since 1993
therapies be considered explicitly before new phar- and various cost-saving strategies, such as encour-
maceuticals are added to the subsidized list. The use aging the use of generic drugs, have been adopted.
Economic evaluations submitted to the expensive or likely to be widely used and are less
Pharmaceutical Benefits Advisory Committee prescriptive than PBAC about the type of analysis
(PBAC) use consistent methods, and a schedule of performed. The analyses are published as a series
standardized costs is provided as a part of the sub- of MSAC reports.
mission guidelines. Although the committee favors In addition to the scientific evidence on safety,
the use of patient-relevant final outcomes, such as clinical effectiveness, and cost-effectiveness, the
quality-adjusted life years (QALYs), a wide range MSAC can also take into consideration access and
of outcome measures are used. Although interna- equity; the prevalence and burden of the disease;
tional clinical trials are considered rigorous the availability of alternative treatments; and the
evidence of safety and effectiveness, economic evalu financial impact on the MBS, the public and pri-
ation of Australian service delivery patterns and vate healthcare sectors, and society as a whole.
costs is also required so as to be relevant to the Over time, these analyses have become increas-
nation’s context. The committee has largely made ingly sophisticated.
decisions that are consistent with the incremental Nonpharmaceutical health technology assess-
cost-effectiveness result. The rigor of the evidence, ment, however, preceded the development of the
the extent of uncertainty inherent in the evidence, MSAC. Policymakers often commission substan-
the severity of the condition being treated and the tial evaluations of new procedures as part of the
availability of alternative treatments, equity, and consideration of new funding proposals. Although
the financial impact all depend on the scheme, and these efforts were in part under the auspices of
government health service funding more broadly some national technology assessment committee,
can be considered. the methodological approach adopted was not
standardized across projects. Similarly, major pub-
lic health programs, such as breast, cervical, and
Health Technology Assessment
bowel cancer screening, have generally been
A similar approach to health technology assess- required to demonstrate feasibility through pilot
ment is applied more broadly than to pharmaceu- programs, which are evaluated for acceptability,
ticals. Medical services provided elsewhere than in effectiveness, and costs.
public hospitals, either in private hospitals or out- Many investigator-initiated projects work to
patient settings, are funded by a government rebate evaluate a range of healthcare interventions, includ-
plus variable patient copayments, according to a ing public health programs, new methods of service
schedule of specified services known as the Medical delivery, and new procedures and diagnostic tech-
Benefits Schedule (MBS). The MBS covers primary nologies. These studies can be funded from multiple
care, surgical procedures, anesthesiology, pathol- sources, with variable impact on healthcare policy
ogy, and radiology. Since 1998, to be included on and practice, and where the objective may be more
the MBS and to be recommended for public fund- about knowledge creation or development of meth-
ing, new technologies and procedures must have ods rather than immediate policy impact.
evidence of safety, clinical effectiveness, and cost-
effectiveness. Applications may be made by the
Case-Mix Classification
manufacturers of devices or equipment, by pro-
vider groups, or by any interested party and should Interest in case-mix classification emerged in the
conform to the submission guidelines. The evalua- 1980s, primarily from academic involvement in the
tions are conducted by teams working under the development of a measurement tool, which could
guidance of a specialist panel established by the explain variations in lengths of stay and costs. The
Medical Services Advisory Committee (MSAC). initial work was based on the Diagnostic Related
These may extend or revise the original submis- Groups (DRGs) system developed at Yale University,
sion, both to ensure an adequate comparator for but concerns about the relevance of this coding to
the incremental analysis and to incorporate Australian clinical practice provided the impetus
Australian costs and other contextual factors. At for the development of a specific Australian clas-
this stage, MSAC guidelines only require a full sification system. Features of the Australian
economic evaluation if the proposed service is approach are the adoption of a national strategy,
556 Health Services Research in Australia
involving both the federal and state health author- employment is provided, or heavily subsidized, by
ities with the commitment of substantial funding the public purse. Australian governments—both
and other support, under the guidance of a com- the federal, as the major funder of healthcare deliv-
mittee of clinical experts, which has comprised ery, and the states, as providers of public hospital
medical, nursing, and allied health professionals. services—have a long-standing interest in ensuring
This undertaking produced a revised classification the adequacy of the future healthcare workforce. A
known as the Australian National Diagnosis national structure to undertake healthcare work-
Related Groups (AN-DRGs). The AN-DRGs were force planning has been in place since 1995, ini-
reviewed yearly and updated through three ver- tially covering the medical workforce. These efforts
sions, increasingly encompassing a wider range of have since been extended to nursing and allied
clinical factors such as age, malignancy, complica- health professions. Under the auspices of these
tions, and comorbidities as indicators of severity. various committees, a number of reviews and
A complete review of the classification structure reports have been completed and published. Further
was undertaken, prompted by the change to the work has been commissioned by various inquiries,
International Statistical Classification of Diseases also initiated by the government or parliament.
and Related Health Problems, 10th Revision The workforce-planning approach relies on a
(IDC-10). The result was the development of an projection of future demand—based on popula-
Australian clinical modification of ICD-10, the tion growth, changes in age-sex composition, and
ICD-10-AM, which is now in its fifth edition, and current patterns of use—with adjustment for the
the Australian Classification of Health Interventions. extent to which the current workforce is meeting
The DRG system was renamed the Australian current demand, and the projections of supply—
Refined Diagnostic Related Groups (AR-DRGs, looking at current training and entry, as well as
Version 4.0). The Australian case-mix classifica- expected retirements. The success of this approach
tion has been adopted by many other countries, in ensuring an adequate workforce is far from
including New Zealand, Ireland, and Germany. assured; Australia, like many other countries, is
The development of the Australian disease and facing severe shortages of trained nurses, physi-
intervention classifications and AR-DRGs repre- cians in primary care and some medical specialties,
sents a great deal of clinical and health services and allied health professions. The planning strat-
research. The research was given great impetus by egy does not take into account changes in produc-
the adoption of case-mix funding of public hospi- tivity, alterations in work patterns, or shifts in
tals in the state of Victoria in 1993 and, subse- workforce participation. For example, although
quently, followed by most of the other states. the number of medical graduates has increased
Ongoing developments are managed by the Federal more rapidly than the population growth, physi-
Department of Health and Ageing. This involves a cians have been working shorter hours, thus result-
2-year cycle of clinical input, HSR, and widespread ing, effectively, in an undersupply.
consultation around revisions to the classification Development of an adequate workforce is likely
system, as well as the preparation of cost weights to involve increasing productivity, more flexible
from morbidity and cost data supplied by all pub- approaches to professional roles and the delinea-
lic and private Australian hospitals. In addition to tion of responsibilities, varied approaches to edu-
providing an indicator of hospital efficiency, these cation and training, and reform of payment
data form a schedule of standard costs which are mechanisms. This view is not readily encompassed
used in pharmacoeconomics, health technology by traditional workforce planning methods nor by
assessments, and other evaluations. government-led planning mechanisms. However,
there has been little research activity beyond the
government-sponsored process.
Healthcare Workforce
The training of the healthcare workforce is pri-
Funding Reforms
marily determined by the government provision of
funding for training and education and by the regu- Australia has, alongside universal public health
latory requirements for safety and quality; their insurance, a substantial private health insurance
sector. Private health insurance covers private government, and it works closely with state and
treatment in hospitals, alongside universal cover- territory health agencies. Although it does not
age for free public hospital treatment. It also cov- directly collect health data, it serves as a reposi-
ers a range of ancillary services such as dental care, tory, playing a major role in ensuring standard
physiotherapy, and other allied health services that definitions and consistent approaches and in
are not provided in the public system. Since 1996, making data readily available. National data
the government has introduced a number of insur- standards have been developed by the AIHW in
ance incentives, including a 30% subsidy on health conjunction with all government health agencies
insurance premiums, which is not means tested. and the Australian Bureau of Statistics. A com-
This strategy has resulted in the rapid growth of prehensive electronic repository of national data
health insurance to cover around 45% of standards, known as METeOR, is accessible
the population, an increase of 15%. Researchers through the AIHW Web site.
investigating the effectiveness of several incentives The Australian Bureau of Statistics is responsi-
have found that the results of reform on the private ble for a number of regular as well as occasional
sector reduced the pressure on public hospitals, population surveys. There are also many adminis-
and to a lesser extent, improved the comparative trative databases, including data on the Medicare
efficiency of public and private facilities. services and the operation of private health insur-
Prior to the private health insurance incentives, ance funds. Data sets are also kept by other agen-
the major change in financing was the move from cies for specific purposes such as for medical
voluntary but government-subsidized private insur- audits. However, access to such data is often at the
ance to universal, tax-financed, insurance covering discretion of the data custodians, and the proto-
both hospital treatment and out-of-hospital medi- cols for release of data vary widely.
cal services. The first, universal, public scheme was Australia has been slow to develop ongoing
introduced in 1976 as Medibank, dismantled by a population panels—in which a representative pop-
subsequent government then reestablished in 1984 ulation sample is followed over time—but a few
as Medicare. The scheme’s architecture was devel- have been initiated in recent years and are starting
oped from the independent research of two univer- to provide data. There is also increasing interest in
sity economists, John Deeble and Richard Scotton. the ability to link individuals across data sets.
Notions of managed competition and the sepa- Arrangements in Western Australia have allowed
ration of purchasers, providers, and funders did data linkage for many years and have demon-
not gain traction with Australian policymakers strated the role of this linkage in supporting high-
nor, for that matter, with health services research- quality HSR.
ers. The split in funding responsibilities across
levels of government has long attracted critical
Research and Policy Links
comment, and not surprisingly, pooling these sepa-
rate entitlements into a common budget seemed As evidence-based medicine has become influen-
to offer an opportunity for improvement. This tial in clinical decision making, so there have been
approach was tested through a series of demon- calls for an evidence base for policy. The health
stration projects known as the Coordinated Care services development program was established in
Trials in the mid-1990s. Evaluation results were the 1970s to develop further reforms following the
equivocal, both in terms of health outcomes and introduction of national, public, health insurance.
costs, with some trial programs facing national Alongside a major HSR program, it was estab-
bankruptcy. lished but was subsequently allowed to decline.
Although other developed countries have invested
in building such programs over the past 20 years,
Data Sources
Australia has failed to make such investments.
The Australian Institute of Health and Welfare Public health departments and other agencies
(AIHW) is the national agency for health regularly commission research: generally through a
and welfare statistics and information. It is a competitive tendering process, with very specific
statutory authority responsible to the federal outputs required and often within short time frames.
558 Health Services Research in Canada
The major, national, health research funding agency, Duckett, Stephen J. The Australian Health Care System.
the National Health and Medical Research Council 3d ed. New York: Oxford University Press, 2007.
(NHMRC), has attempted to develop ways of Evans, Frank, Gil-Soo Han, and Jeanne Madison.
encouraging research in areas identified as priority Healthcare Reform and Interest Groups: The Case of
health problems that would meet rigorous research Rural Australia. Lanham, MD: University Press of
standards and policymakers’ needs. Many of these America, 2006.
efforts have met with limited success as funds have Haas, Marion. “Health Services Research in Australia:
been spread thinly and research priorities have been An Investigation of Its Current Status,” Journal of
Health Services Research and Policy 9(Suppl. 2): 3–9,
developed with little consideration given to research
October 2004.
feasibility. Overall, researchers have been subject to
Hall, Jane P., and Rosalie C. Viney. “National Health
many short-lived funding programs.
Reform Needs Strategic Investment in Health Services
More recently, the NHMRC has established a
Research,” Medical Journal of Australia 188(1):
Health Services Research Funding Program that 33–35, January 7, 2008.
provides more substantial and longer-term fund- Nutbeam, Don, and Anne-Marie Boxall. “What
ing. Development of this initiative was strongly Influences the Transfer of Research into Health Policy
influenced by policymakers. Initially, this program and Practice? Observations From England and
identified the priority topic of healthcare financ- Australia,” Public Health 122(8): 747–53,
ing, then priority approaches or disciplines such as August 2008.
the social sciences. Subsequently, it became less Pirkis, Jane, Sharon Goldfeld, Stuart Peacock, et al.
clearly targeted. “Assessing the Capacity of the Health Services
Research Community in Australia and New
Zealand,” Australia and New Zealand Health Policy
Future Implications 2(1): 4, March 8, 2005.
Stanton, Pauline, Eileen Willis, and Suzanne Young, eds.
The future, though less clear at the moment, is Workplace Reform in the Healthcare Industry: The
promising. The Australian NHMR is now commit- Australian Experience. New York: Palgrave
ted to implementing many of the recommendations Macmillan, 2005.
of the most recent review of research funding and Taylor, Sandra, Michelle Foster, and Jennifer Fleming,
has been given substantial additional funding to sup- eds. Health Care Practice in Australia: Policy,
port these efforts. The new strategy should encom- Context, and Innovations. New York: Oxford
pass additional funding for IIR; new approaches to University Press, 2008.
developing interactions between policymakers and
researchers in defining priority topics; and the devel-
opment of centers of excellence that ensure innova- Web Sites
tion in methodological approaches, continued Australian Government National Health and Medical
development of skilled researchers, critical mass, and Research Council (NHMRC): http://www.nhmrc.gov.au
research infrastructure. Australian Institute of Health and Welfare (AIHW):
http://www.aihw.gov.au
Jane P. Hall
Health Services Research Association of Australia and
New Zealand (HSRAANZ):
See also Comparing Health Systems; Health Economics; http://www.chere.uts.edu.au/hsraanz
International Health Systems; National Health
Insurance; Pharmacoeconomics; Public Policy; Rural
Health; Technology Assessment

Further Readings in Canada
Australian Institute of Health and Welfare. Australia’s
Health 2008. Canberra, Australia: Australian Institute Health services researchers and policymakers in
of Health and Welfare, 2008. the United States and Canada often contrast and
Health Services Research in Canada 559
compare the two nation’s healthcare systems. In the Canada Health Act through fiscal transfers to
the United States, those advocating a national the provinces. Portions of these tax-based transfer
health insurance system point to Canada as evi- payments may be withheld, or financial penalties
dence that such a system works better than our imposed, if any of the criteria in Canada’s Health
own. In Canada, there is much discussion about the Act are violated. Provided they meet the criteria,
future of its healthcare system, and the U.S. system provincial and territorial governments have exclu-
is often cited either in support of or as evidence sive powers over virtually all aspects of health
against the privatization of care. This entry pres- delivery and organization, including, for example,
ents a brief overview of Canada’s national health control of hospitals, establishment of quarantine,
insurance system, and it discusses the structure and organization of health services, regulation of the
activities of health services research in Canada. practice of medicine, formation of health profes-
sionals, creation of health insurance programs,
regulation of the production and marketing of
Canada’s Healthcare System
nutritional products, adoption of health and safety
Canada’s national health insurance system has standards with respect to work and companies
evolved over the past six decades. Saskatchewan under provincial/territorial jurisdiction, and the
was the first province to establish universal, pub- system of indemnities for work-related injuries.
lic hospital insurance in 1947. By 1961, all the
country’s provinces and territories had established
A Focus on Population Health
public insurance plans that provided universal
access without user fees for hospital services. By Since 1974, when the Lalonde Report—a new
1972, the plans were extended to include physi- perspective for improving the health of Canadians—
cian services. Over the years, various laws were was presented in the House of Commons, Canadian
passed, including the Canada Health Act in health planners have adopted a broad, population-
1985. based view of health and illness, which emphasizes
The most basic objective of Canada’s healthcare the social determinants of health. An important
system has been to provide universal coverage for impetus for this perspective came from the realiza-
necessary medical care to all Canadians, without tion that significant socioeconomic gradients in
imposing financial barriers such as out-of-pocket health status persisted even after the development
expenses, deductibles, or administrative costs. of universal access to medical care. Further improve-
Canada’s provinces and territories provide 13 ments in the health of Canadians would require a
interlocking, publicly funded health systems that perspective that went beyond the healthcare system
meet the common criteria of Canada’s Health Act. to the prevention of environmental and behavioral
The first criterion is that of public administration. risks and the promotion of health. It gave rise to
This establishes a single-payer insurance system the “health field concept,” which considered health
administered by each provincial or territorial determinants from four perspectives: (1) human
Ministry of Health for all services covered under biology, (2) environment, (3) lifestyle, and (4)
the act. The second criterion is universality, requir- healthcare organizations. This framework gave
ing that all Canadian residents be eligible for impetus to national and international initiatives in
insured health services. The third is accessibility, health promotion and health protection.
which ensures that there are no financial barriers, In 1990, two Canadian researchers, Robert
such as user fees. The fourth is portability, which Evans and Greg Stoddart, published a highly influ-
allows health coverage for hospital and physician ential article that placed emphasis on the determi-
services for Canadian residents who are traveling nants of health and illness, including the social
in other provinces or countries. Finally, compre- environment. The healthcare system was identified
hensiveness refers to coverage for all hospital and as one component in a network of interrelated fac-
physician services. tors affecting population health. By the mid-1990s,
Seventy-one percent of the total funding for federal, provincial, and territorial Ministers of
Canada’s healthcare system comes from taxation. Health had all endorsed a population approach
The federal government imposes the principles of to healthcare. A decade later, a survey of senior
federal and provincial civil servants revealed that Primary-healthcare teams are to include prevention
virtually all (94%) were quite familiar with popu- and treatment services, basic emergency care, refer-
lation-based determinants of health. Population rals to specialists, and coordination of care that may
health ideas have similarly percolated through be required at other levels in the health system (such
policy and planning documents at the level of local as hospital, palliative, or rehabilitation services). As
health delivery systems. well as improvements in the management of health
and illness, primary-healthcare teams are to build
capacity to undertake evaluations, so that system
Decentralization and
performance may be monitored. Information tech-
Regionalization of Healthcare Delivery
nology, such as electronic clinical records, will play
Perhaps the most revolutionary change to occur an important role in supporting the development of
in the Canadian healthcare system since its incep- a culture of accountability and performance mea-
tion has been the move to population-focused surement.
regional systems of care. Currently, there are 108
geographically defined health regions across
Canada. The boundaries and specific responsibili- Health Information
ties of regions have been established by their respec- In Canada, the provision of population-based
tive provincial Ministries of Health. Each health statistical information is a responsibility of the fed-
region is administratively responsible to its respec- eral government. Statistics Canada is the federal
tive provincial or territorial government for the agency responsible for this function. Statistics
provision of defined, publicly funded health ser- Canada collects data on Canada’s population, its
vices to residents of their respective geographic economy, society, culture, and health through popu-
area. In recognition that the needs and demands of lation censuses, cross-sectional surveys, and longi-
regional populations will differ, health regions tudinal (panel) data. Microdata files are made
typically have the responsibility to assess, prioritize, available to researchers through university-linked
plan, and offer the suite of services that best meets research data centers, which are located throughout
the health needs of their respective populations. the country. The centers are staffed by Statistics
Canada employees and operated under Canada’s
Statistics Act.
Primary Care and Health System Renewal
The Canadian Institute for Health Information
Between 1975 and 1991, healthcare spending in (CIHI) is an independent, not-for-profit organiza-
Canada grew at an average annual rate of 3.8%. In tion that captures health system information from
September 2000, after a decade of fiscal restraint, hospitals, regional health authorities, medical prac-
deep cost cutting, and considerable loss of public titioners, and government (through billing infor-
confidence, the Ministers of Health of Canada’s mation). The institute publishes analytical
provinces agreed on an action plan for health sys- documents and special studies on a wide range of
tem renewal. They agreed that primary care should topics, including healthcare services, healthcare
be the cornerstone for health system renewal. spending, human resources, and population health.
Primary healthcare builds on the broad principles It also develops and promotes health indicators
underlying the population health approach. (such as life expectancy and per capita health
Foremost, it is an approach to health, rather than spending) to compare health status and health sys-
healthcare, that goes beyond the provision of treat- tem performance across provincial and territorial
ment-oriented services to include the full spectrum health systems and regional health authorities.
of prevention and health promotion. Primary- Microdata are made available to researchers under
healthcare services will be the first point of contact strict privacy and data protection policies.
with the health system. A key feature will be a shift
away from general practitioners, who have typically
Health Services Research in Canada
worked in solo practices, to multidisciplinary teams
of providers who are to be held accountable for In Canada, academic researchers occupy salaried
providing services to a defined client population. positions in universities (paid from university
Health Services Research in Canada 561
operating budgets), where they compete in national within and across institutes and to promote a
and other peer-reviewed funding competitions for multidiscipline approach. Under this new struc-
the funds required for conducting their research. ture, funding for health services research grew
Competition for operating funds is stiff. In a 2007 20-fold between 1999 and 2005. Typically, 30%
open grants competition from the Canadian of funding is reserved for strategic initiatives orga-
Institutes of Health Research (CIHR), for exam- nized through the institutes, and the remaining
ple, more than 2,000 operating grant applications 70% is reserved for open grants competitions.
were received, and less than 1 in 5 were funded. Currently, the CIHR funds more than 10,000 aca-
Significant health system reform, including an demic researchers and trainees across Canada with
increased emphasis on evidence-based care, health expenditures that total more than $800 million.
system accountability, and performance measure- Finally, in 2000, to build research capacity, the
ment, created a demand for health services research Canadian government created a national program
that quickly outstripped Canada’s research capac- to provide salary and infrastructure support to
ity. New funding structures were required to sup- universities to attract and retain researchers—the
port the clinical, population, and health services Canada Research Chairs Program. Under the pro-
research needed to support health system restruc- gram, researchers receive salaried positions from
turing and reform. the government in contrast to regularly awarded
In 1996, the federal budget announced funding operating grants in which researchers do not
to establish what would become the Canadian receive salary support. Universities are each allo-
Health Services Research Foundation (CHSRF) to cated a number of Chair positions and nominate
facilitate evidence-based decision making in health. researchers whose work complements their respec-
From the beginning, the foundation identified tive strategic plans. Some $300 million per year is
managers and decision makers as the primary audi- spent on all Chair positions with 26 Health Services
ences for its work and adopted an overall strategy Research Chairs having been funded to date.
that promoted linkage and exchange between With stable sources of salary funding, and
research and decision maker communities, includ- increased spending on operating grants, the field of
ing incorporating decision makers (making up health services research in Canada has begun to
50% of each committee) into the review process blossom, evidenced by the development of the
for operating grants. Since 2000, the foundation Canadian Association of Health Services and
has de-emphasized open grants competitions (trans- Policy Research (CAHSPR); a peer-reviewed aca-
ferring this portion of their budget to be adminis- demic journal entirely devoted to the topic,
tered by another federal research funding agency) Healthcare Policy (launched in 2005); and 13
so as to consolidate its activities around capacity university-based centers across the country devoted
development and knowledge transfer. to health services and policy research.
In further recognition of the need for a broad- However, despite a growing and vibrant field,
ened health research mandate in Canada, a new the 13 university-based health policy research cen-
federal health research agency was created: the ters in Canada face a number of important chal-
CIHR. This new structure includes 13 theme-based lenges, which attest to their still precarious position.
institutes, including an institute devoted to health The most important of these is how to maintain
services and policy research. The CIHR replaced stable core funding for infrastructure. Most are
the Medical Research Council as Canada’s main funded through their respective provincial minis-
health-research-funding agency. In addition to tries of health, making funding unpredictable and
incorporating the biomedical mandate of the subject to periodic renegotiation. For more than a
Medical Research Council, the CIHR was given a decade, Canadian universities have operated under
broadened mandate to foster clinical research, serious funding shortages, making them an unlikely
health system and services research, and popula- source of stable funding for these centers. A second
tion health research. By incorporating these four challenge is to maintain a balance between research
pillars of research under a single umbrella funder, that is of interest to Ministry funders (which may
the goal was not only to increase research in each not translate into an academic product) and research
of these areas but also to foster cross-pillar research that results in suitable academic publications.
Although the culture is beginning to change, Further Readings

Canadian universities still diminish the worth of Armstrong, Pat, and Hugh Armstrong. Health Care:
applied research that does not result in academic About Canada. Halifax, Nova Scotia, Canada:
publications. Certainly there is mounting pressure Fernwood, 2008.
on university academics to produce research that is Coburn, David, Keith Denny, Eric Mykhalovskly, et al.
relevant and timely. While there is still a long way “Population Health in Canada: A Brief Critique,”
to go, universities are beginning to respond by rec- American Journal of Public Health 93(3): 392–96,
ognizing the academic role of applied research and March 2003.
the importance of building capacity in this field so Evans, Robert G., and Greg L. Stoddart. “Producing
that it can be used in policy making. Health, Consuming Health Care,” Social Science and
Medicine 31(12): 1347–63, 1990.
Evans, Robert G., and Greg L. Stoddart. “Consuming
Cross-National Health Services Research
Research, Producing Policy?” American Journal of
In the context of health reform, much has been Public Health 93(3): 371–79, March 2003.
written about the Canadian versus the American Health Canada. Canada Health Act, Annual Report,
healthcare system. While not all of it has been flat- 2006–2007. Ottawa, Ontario, Canada: Health
tering or even correct, the ensuing debates have Canada, 2007.
fostered considerable cross-national research Lasser, Karen E., David U. Himmelstein, and Steffe
examining patterns of healthcare utilization and Woolhander. “Access to Care, Health Status, and
health system outcomes. Despite widely divergent Health Disparities in the United States, and Canada:
paths to healthcare delivery and reform in Canada Results of a Cross-National Population-Based
and the United States, Canadians regularly moni- Survey,” American Journal of Public Health 96(7):
tor U.S. policies and practices and have imported 1300–1307, July 2006.
American policy innovations and system strate- Sanmartin, Claudia, Jean-Marie Berthelot, Edward Ng,
et al. “Comparing Health and Health Care Use in
gies. The CIHR offers several funding programs to
Canada and the United States,” Health Affairs 25(4):
support international collaborations involving
433–42, July–August 2006.
Canadian researchers and has supported strategic
Sawyer, Eleanor. Guarding Canada’s Health System: The
initiatives with U.S. granting bodies.
History of the Canadian Healthcare Association,
1931 to 2006. Ottawa, Ontario, Canada: CHA Press,
Future Implications 2006.
Shah, Chandrakant P. Public Health and Preventive
Health services research continues to place an
Medicine in Canada. 5th ed. Philadelphia: Saunders,
emphasis on partnerships between researchers and 2003.
policymakers in an effort to address key health- Soroka, Stuart Neil. Canadian Perceptions of the Health
care issues in Canada. The CHSRF has identified Care System: A Report to the Health Council of
the following research themes for the coming Canada. Toronto, Ontario, Canada: Health Council
years: workforce and the work environment; qual- of Canada, 2007.
ity and patient safety; value-based decision mak-
ing and public engagement; change management
for improved practice and improved health; nurs- Web Sites
ing leadership, organization, and policy; and pri-
Canadian Association of Health Services and Policy
mary healthcare.
Research (CAHSPR): http://www.cahspr.ca
Ana P. Johnson and Heather Stuart Canadian Health Services Research Foundation
(CHSRF): http//www.chsrf.ca
See also Access to Healthcare; Administrative Costs; ; Canadian Institute for Health Information (CIHI):
Canadian Association for Health Services and Policy http://secure.cihi.ca/cihiweb/splash.html
Research (CAHSPR); Canadian Health Services Canadian Institutes of Health Research (CIHR):
Research Foundation (CHSRF); Canadian Institute of http//www.cihr-irsc.gc.ca
Health Services and Policy Research (IHSPR); Health Canada: http//www.hc-sc.ga.ca
International Health Systems; National Health Insurance Statistics Canada: http//www.statcan.ca
Health Services Research in Dentistry and Oral Health 563
the impact of professionally applied fluorides, in

Health Services Research in addition to fluoride rinses, varnishes and gels, and
Dentistry and Oral Health community water fluoridation; financing of dental
care; unmet needs in dental care; health literacy;
Research on oral health and related issues and and workforce studies. Behaviors and habits that
conditions differs from research in dentistry, affect oral health, including smoking and other
which may include clinical interventions and out- tobacco uses, and dietary practices, are also impor-
comes. The two domains share numerous com- tant subjects for researchers. Dental care and ser-
mon characteristics and overlap in some subject vice utilization; health disparities; issues specific to
areas, but they also represent distinct and different women’s oral health, such as osteoporosis; and
points of reference in research. oral health concerns of people with disabilities are
The oral health domain includes the dimensions active areas of research.
of eating, taste, drinking, speech, personal self- Research in oral health also focuses on microbial
image, appearance, social interaction, employment elements, anatomical systems and their function,
and employability, attitudes and knowledge regard- tissue and nerve systems, and cellular and molecu-
ing oral health, effects across the age span, disease lar genetics. Many bacterial, viral, and fungal enti-
prevention and risk factor analysis, and studies of ties contribute directly to the onset of a variety of
the oral health status of populations, among many dental diseases. Understanding the effects of these
others. In contrast, research in dentistry includes agents is critical to disease prevention and health
all aspects of clinical care and evidence-based protection. Examples of research regarding ana-
assessments of its outcomes, instrumentation, tomical systems include chewing and swallowing,
methods, materials, patient management and satis- and muscle and joint functioning. Other research
faction, diseases, immune disorders, and injuries, areas include tissue and nerve systems; the struc-
to name a few. tures and fluids of the oral cavity, such as teeth,
This entry begins by discussing recent research saliva, mucosa, bone, and the tongue; as well as tis-
topics relating to oral health, dentistry and the sue regeneration and engineering. Current research
overlap between the two. Next, this entry shows promise that new teeth and new bone can be
addresses health services research specifically and “grown” for replacement of missing or damaged
the various factors that affect such research. segments of the jawbone (mandible). Research
Finally, this entry touches on the future directions involving nerves and nerve signaling also includes
of health services research for dentistry and oral studies regarding pain, its derivation and modula-
health. tion, and the response to and coping with pain.
Saliva and, to some extent, tissue cells from the
inside of the cheek (buccal mucosa) are increas-
Recent Research Topics
ingly being studied due to their potential diagnos-
Recent studies have shown associations between tic value. Saliva, as a serum exudate of blood, has
chronic oral infections and heart and lung diseases, been shown to be an effective diagnostic aid for a
stroke, and low-birth-weight and premature babies. wide range of systemic health conditions, includ-
Additionally, several associations have been found ing human immunodeficiency virus (HIV) and
between chronic and severe periodontal (gum) dis- hepatitis A and B, as well as for various drugs and
ease and diabetes. Injury and oral wound healing environmental toxins. The use of saliva as a source
are also significant research topics. Wound healing for host DNA has facilitated detection of a wide
in the oral cavity (the mouth) is accomplished in a range of viral and bacterial infections whose pres-
unique environment of moisture, temperature, and ence is difficult to detect. This has become an
bacteria. Injury can occur in various sports and important area of ongoing research because obtain-
through falls, motor vehicle collisions, and vio- ing saliva samples is relatively simple, noninvasive,
lence. Devices to protect against oral injury are and inexpensive.
also subjects for further investigation. Comprehending the genetic code for bacteria
Research that cuts across these two domains and other microbial entities that cause oral
and shares common facets include the following: diseases, such as cavities in the teeth or gum
564 Health Services Research in Dentistry and Oral Health
(periodontal) disease, is fundamental to the ability dental records must be reviewed and summarized
to protect against these conditions. These oral and pertinent data recorded. The latter step usu-
flora also form colonies on oral structures, result- ally entails data coding of some sort. Consequently,
ing in the development of biofilms. The composi- large-scale population studies of this type are pos-
tion, mechanisms of actions, and adhesion capacity sible only when federal agencies undertake the
of these biofilms are important areas of research study as a unique investigation or combined within
because of their importance in oral health and a larger study.
their broad application to other aspects of health Large-scale population opinion and informa-
beyond the oral cavity. tion surveys have been employed effectively to
conduct health services research regarding oral
health issues. Surveys are somewhat less expensive
than research based on direct observation. They
Health services research entails multidisciplinary can be conducted in person, by telephone, via mail,
approaches that may include economics, political and through the Internet. Through surveys, issues
science, and medical sociology, to identify the such as patient satisfaction, access to care, and
most effective ways to deliver health services, experiences in healthcare settings can be assessed.
document quality, reduce medical errors, and
improve patient safety. Identifying effective ways
Secondary Data Sets
to organize and manage health services, analyzing
healthcare financing and costs, determining meth- The government, using various health-related
ods to improve access to and utilization of care, population surveys conducted by federal agencies,
and ultimately improving the outcomes of care are and health insurance plans are also sources of
among the inquiry domains of health services data. These secondary data sets provide reliable
research. information to facilitate health services research.
Biological, behavioral, and psychological facets For example, the federal National Center for
of health services research provide important views Health Statistics (NCHS) conducts the National
to better understand health needs and utilization of Health and Nutrition Examination Survey
services, as well as the health disparities experienced (NHANES) and the National Health Interview
by various populations. In effect, the evidence base Survey (NHIS). Such surveys have been conducted
derived from studies focused in these directions periodically on a national sample and contain oral
should serve to inform public policy on health health status; dental-care-related observations;
issues and improve the systems of health services. and questions regarding utilization of services,
Health services research in dentistry has made access to care, cost of care, patient satisfaction,
significant contributions to the scientific literature and perceptions of quality of care received. When
despite the many difficulties encountered in con- these types of surveys include direct clinical obser-
ducting this type of research. At the same time, vations, it becomes possible to conduct research
health services research in the field of dentistry is that validates patients’ perceptions regarding qual-
still in its developmental stages. Societal issues that ity of care.
affect oral health and, conversely, oral health con- Other sources of federal data with useful appli-
ditions that affect societal issues, have received cations for health services research in dentistry
sparse attention. include the Centers for Medicare and Medicaid
However, it is in these areas that dental research- Services (CMS), the Health Resources and Services
ers are most challenged in their attempts to Administration (HRSA), the Agency for Healthcare
advance health services research. Large-scale pop- Research and Quality, and the Bureau of Labor
ulation studies are expensive and time-consuming. Statistics (BLS). Other sources of data include the
Studies that require direct observation must include Health Plan Employer Data and Information Set
dentists, support staff, and appropriate clinical (HEDIS), the Employee Benefit Research Institute
facilities. People, as study subjects, must be sched- (EBRI), and the National Association of Dental
uled for examination and assessment. Finally, Plans (NADP).
Medicaid Data who have no form of dental-insurance coverage,

there are no reliable data sources pertinent to their
Medicaid data from states that cover dental care
utilization of dental care.
are also available for analysis. Medicaid covers
While select data can be obtained from dental-
approximately 40 million people in the nation,
insurance carriers, the data may be limited due to
mainly children and single mothers. However,
the proprietary nature of the insurer’s business
there are limitations to the utility of these sources
interests, among other reasons. Furthermore, such
of secondary data. Not all states cover dental care
data may have been collected and organized in
under their Medicaid programs. A few states
such a manner that it may not be comparable with
cover services for adults, and the types and range
data sets from other private-insurance entities. In
of services vary substantially among those states.
any case, since private health insurance is available
Over three decades ago, federal legislation estab-
for only a segment of the population, data from
lished a guarantee of dental care to Medicaid-
such sources cannot be generalized to the entire
eligible children through the Early Periodic
population.
Screening, Diagnostic, and Treatment (EPSDT)
benefit. Even so, state Medicaid authorities have
shown that fewer than 20% of the practicing den- Data From Public Health Departments
tists surveyed provided care that was paid for
Oral health services may be provided within state
through their state program. Other analyses have
and local public health departments; however,
shown that only about 20% of EPSDT-covered
such services typically relate to disease prevention,
children receive dental care in a given year.
health promotion, and health protection. In some
Furthermore, as states elect to purchase dental
instances, care for needy and underserved popula-
care for Medicaid eligible individuals through
tions is also provided. In addition, population
managed-care organizations, rather than pay pro-
surveys are part of the public health function of
viders directly, additional barriers to accessing
these organizations. However, such surveys are
Medicaid service data from these intermediary
conducted infrequently, are undertaken in the
sources have developed.
context of specific interests within a particular
public health jurisdiction, and may not be con-
ducted in a manner that allows for generalization
Dental Insurance Data to the entire population. Consequently, these sur-
There are approximately 140 million people in the veys generally have marginal value for health ser-
nation who have dental-care benefits through vices research.
their place of employment or who purchase dental
coverage separately from a variety of dental-insur-
Data on Dentists
ance plans. Dental-insurance carriers include
major national commercial plans, regional and The American Dental Association (ADA) con-
state-specific companies, as well as carriers orga- ducts periodic and special surveys of dentists.
nized as Delta Dental Plans and Blue Cross Blue These surveys tend to relate to various aspects
Shield Plans. Within this spectrum of plans, there of dental practice and experience, finance,
is substantial variation in the manner in which and practice trends. The American Dental
dentists are structured to provide care. These Education Association (ADEA) conducts surveys
variations include managed-care options such as of dental schools and students pertinent to the
preferred provider organizations (PPOs) and den- process and outcomes of training and education
tal health maintenance organizations (DHMOs), of dentists.
indemnity plans, discount plans, and reduced-fee Within dental practice settings, there are unique
plans, among others. However, data indicated challenges in accumulating data necessary and suf-
only a 50% to 70% annual utilization rate for ficient for purposes of health services research.
persons with these forms of dental-insurance ben- There are nearly 160,000 actively practicing den-
efits. For the approximately 50% of Americans tists in the United States. The vast majority, more
566 Health Services Research in Dentistry and Oral Health
than 90%, are in private practice. Of those dentists dentistry suffers from a lack of standardized start-
in private practice, 80% are general practitioners. ing points, such as diagnoses, and must rely essen-
The other 20% are specialists in one or more of tially on service data independent of diagnosis. It
the nine formally recognized dental specialty disci- also follows that outcome data are difficult to
plines (orthodontics, oral and maxillofacial sur- assess from a health services research perspective
gery, oral and maxillofacial radiology, periodontics, when there is no clear indication of the diagnostic
pediatric dentistry, endodontics, prosthodontics, starting point and the association between services
dental public health, and oral and maxillofacial rendered and disease conditions is unclear.
pathology). In medical practice, many physicians Further challenges are encountered in the rela-
tend to practice in groups and congregate their tive lack of electronic clinical records in dental
practices and services in hospital practice settings. practice. While electronic clinical records are
However, nearly 70% of dentists practice solo, becoming more common, they are not ubiquitous
another 20% practice with one partner, and the among dental practices. Abstracting and summa-
remainder (about 10%) practice in groups of three rizing data from paper records is time-consuming
or more. and expensive.
Dental Clinical Records

The Role of the Health Information
Within dental practice, there is no single, or even Portability and Accountability Act
dominant, standard office protocol or format for
The Health Information Portability and
data collection. There have been efforts to develop
Accountability Act (HIPAA) is an important hur-
agreed-on data sets applicable to all patient ser-
dle to health services research in dentistry. This
vices based on a common record format. However,
federal legislation was enacted in 1996 and obli-
there has been limited success in this regard. As
gates researchers to obtain specific permission
noted previously, there are numerous dental health
from patients prior to accessing any patient-re-
insurance plans. Among the plans, there is wide
lated information. This restriction applies to hos-
variation in claim formats, forms, data require-
pitals, medical and dental offices, clinics, and any
ments, and information configurations. There are
other sources of healthcare service. As an exam-
56 dental schools in the United States; however,
ple, this requirement presents a challenge in
they use and teach different formats and methods
attempts to link data sets such as insurance claims
for obtaining patient clinical records, history
and census data, where a patient’s name or some
taking, and general aspects of data collection.
other specific identifier is needed to link the data
Consequently, there are few persuasive external
sets. However, once that is accomplished, the data
influences to achieve more uniformity in record
can be structured in a manner that ensures that no
keeping and data collection in dental practice.
individual patient can be identified by means of
Fees and payment for dental services, whether
the resultant information.
private and out of pocket or paid by some form of
dental insurance, are based on procedures rather
than diagnoses. Diagnostic codes are being devel-
oped and are used increasingly in dental practices; Patient Care Options
however, they are not the current norm. Data sets Dental care is also affected by a relatively high
centered on diagnoses, and dental services provided degree of individual patient and provider options
in the context of those diagnoses, would be a valu- and preferences within a range of possible treat-
able addition to the capacity of health services ment approaches for particular situations. For
research in dentistry. The standards and criteria for example, there are choices among types of restor-
diagnoses in dentistry can be readily defined and ative materials (amalgam, gold, porcelain, resin)
confirmed. The treatment response consistent with as well as options among the types of restorative
the diagnosis can vary based on many consider- procedures. This variation among treatment
ations. Consequently, health services research in options and procedures adds to the complexity
of determining the outcomes, among other research. Increased utilization of electronic clini-
aspects, of health services research in dentistry. cal records in dental practice would enhance
Differences in service patterns may be functions opportunities and simplify the process of collect-
of provider preferences, patient preferences, cost ing data. Efforts to create greater uniformity for
considerations, true differences in patient health examination of records and developing more
status, or cultural differences among population common data fields would also facilitate data
groups. collection and analysis.
Caswell A. Evans
Obtaining Agreements to Conduct Research
See also Dentists and Dental Care; Electronic Clinical
The solo and independent nature of private dental Records; Employee Health Benefits; Health Insurance;
practice also poses challenges to health services Health Insurance Portability and Accountability Act of
research regarding obtaining agreements rom den- 1996 (HIPAA); National Institutes of Health (NIH)
tists to participate in research. For the most part,
dentists are not engaged in research of this nature,
nor were they trained in health services research Further Readings
while in dental school. Substantial effort is required
to obtain the participation of private dentists in American Dental Association. The 2000 Survey of
research projects. The significance of the research, Dental Practice. Chicago: American Dental
the dentist’s unique contribution to its comple- Association, 2002.
American Dental Association. 2000–2001 Survey of
tion, and the time involved in participation are a
Predoctoral Dental Education. Vol. 5, Finances.
few of the many issues that must be resolved to
Chicago: American Dental Association, 2002.
the dentist’s satisfaction.
Bailit, Howard L. “Dental Insurance, Managed Care and
Traditional Dental Practice,” Journal of the American
Dental Association 130(12): 1721–27, December 1999.
Future Implications Bailit, Howard L. “Health Services Research,” Advances
As the field of health services research in dentistry in Dental Research 17: 82–85, December 2003.
develops and matures, new steps are being taken Evans, Caswell A., and Dushanka V. Kleinman. “The
in support of these research efforts. In 2005, the Surgeon General’s Report on America’s Oral Health:
National Institute of Dental and Craniofacial Opportunities for the Dental Profession,” Journal of
Research, at the National Institutes of Health the American Dental Association 131(12): 1721–28,
December 2000.
(NIH), awarded $75 million for three 7-year
Hayden, William J. “Dental Health Services Research
grants to develop practice-based research net-
Utilizing Comprehensive Clinical Databases and
works. These networks involve dentists in practice
Information Technology,” Journal of Dental
and establish a more “real-world” setting in which
Education 61(1): 47–55, January 1997.
to assess dental practice and procedural issues
Reisine, Susan. “Social, Psychological and Economic
with greater scientific rigor. Over the 7-year Impact of Oral Health Conditions, Dieases, and
period, each network will conduct 12 to 20 short- Treatments.” In Social Sciences and Dentistry: A
term studies comparing the benefits and different Critical Bibliography, vol. 2, edited by L. K. Cohen
outcomes of various and alternative treatment and P. S. Braynt. London: Quintessence, 1984.
options, dental materials, and disease prevention Schleyer, Titus K. L., Heiko Spallek, William C. Bartling,
strategies under a wide range of patient and clini- et al. “The Technologically Well-Equipped Dental
cal conditions. Office,” Journal of the American Dental Association
Research in dentistry, and particularly in 134(1): 30–41, January 2003.
health services research, could be enhanced by U.S. Department of Health and Human Services. Oral
dental schools increasing their emphasis on Health in America: A Report of the Surgeon General.
research as part of the curriculum. Dentistry and Rockville, MD: National Institute of Dental and
dentists would benefit from more involvement in Craniofacial Research, 2000.
568 Health Services Research in Eastern Europe
Web Sites Europe. The two regions followed very different

American Dental Association (ADA): http://www.ada.org patterns of development in their economies, pub-
American Dental Education Association (ADEA): lic health, and healthcare. The 45-year socialist
http://www.adea.org period can be viewed as one of the largest experi-
Employee Benefits Research Institute (EBRI): ments in European history.
http://www.ebri.org During the socialism period, the healthcare sys-
National Association of Dental Plans (NDAP): tems of the Eastern European countries were
http://www.ndap.org dominated by the Soviet Union and the rule of the
National Institute of Dental and Craniofacial Research state. The state became responsible for organizing,
(NIDCR): http://www.nidcr.nih.gov managing, delivering, and financing all healthcare
services. In many Eastern European countries,
healthcare coverage became universal, based on
citizenship, and most healthcare services were pro-
Health Services Research vided officially free of charge. However, informal,
under-the-table payments by patients to physicians
in Eastern Europe were common. The informal payments were com-
mon because of the very low salaries of physicians.
Health services research investigates the relation- The number of physicians and hospital beds were
ship between the factors of access, cost, quality, high compared with Western European countries.
and the organization of care and health and In terms of public health, the gap in life expec-
medical outcomes. This entry describes how tancy between the Eastern European and Western
health services research has developed in the European countries was closing during the 1950s
Eastern Europe region. The region consisted of and early 1960s. However, from the mid-1960s,
eight socialist countries at the time of the fall of the health status in Eastern European countries
the Soviet Union in 1991: Bulgaria, Czechoslovakia, stagnated or deteriorated, whereas in Western
Hungary, the German Democratic Republic, European countries it improved steadily. The age-
Poland, Romania, the Soviet Union, and standardized mortality rates rose in Eastern
Yugoslavia. After significant social and political European countries and fell in the Western European
change, these eight countries now represent countries. The gap in life expectancy was widening
25 independent nations. Fifteen of them are steadily, and the divergence had become even
successor states of the former Soviet Union: larger during the first half of the 1990s.
Armenia, Azerbaijan, Belarus, Estonia, Georgia, The economics of the healthcare systems of
Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Eastern and Western European countries followed
Moldova, the Russian Federation, Tajikistan, a similar pattern. The gap in healthcare expendi-
Turkmenistan, Ukraine, and Uzbekistan. Ten tures between Eastern and Western European
other countries comprise the rest of the region: countries widened from 1960 to 1990. Healthcare
Bulgaria, Croatia, Czech Republic, Hungary, the expenditures, expressed in terms of purchasing-
former Yugoslav Republic of Macedonia, Poland, power parity, were comparable between the Eastern
Romania, Serbia and Montenegro, Slovakia, and and Western European countries around 1960. In
Slovenia. The Czech Republic, Hungary, Poland, 1987, however, Western European countries spent
Slovakia, and Slovenia joined the European four times more public funds on healthcare than
Union (EU) in 2004. Bulgaria and Romania fol- Eastern European countries. Three years later, this
lowed in 2007. gap became even larger. Healthcare expenditures
decreased in the Eastern European countries from
1987 to 1990, just before the beginning of the
Healthcare During the Socialist Period
social and political changes.
After World War II, from 1945 to 1990, Europe The widening gap in healthcare expenditures
was divided by the Iron Curtain into two distinc- between the Eastern and Western European coun-
tive regions: the capitalist countries of Western tries may have contributed to the significant gap
Europe and the socialist countries of Eastern in life expectancy. The problem, however, was not
Health Services Research in Eastern Europe 569
only the smaller amount of money spent on approaches resulted in the separation of healthcare
healthcare but also the ineffective spending and providers, including general practitioners, outpa-
the distribution across sectors. The former policy- tient care, hospitals, and healthcare-financing
makers of Eastern European countries attached agencies, such as health insurance funds. Countries
great importance to demonstrating the power of such as Hungary and Slovenia decided to establish
socialist healthcare in terms of quantity. They a single healthcare financing agency, while other
emphasized hospital care instead of primary care, Eastern European countries preferred to allow
and thus they increased the total number of hos- many types of health insurance. Countries with
pital beds and physicians, instead of focusing on multiple-payer systems include the Czech Republic,
the effectiveness and the quality of healthcare. Poland, and Slovakia. In Hungary, the former
Around 1990, the number of physicians per National Institute of Social Security was divided
1,000 population was 2.52 in Western European into the National Health Insurance Fund
countries compared with 4.07 in Eastern European Administration and the National Pension Fund
countries. The number of hospital beds per 1,000 Administration, while the Social Insurance Fund’s
population was 37% higher in Eastern European budget was divided into the Health Insurance
countries. These policies decreased the already Fund and the Pension Insurance Fund.
limited resources in areas such as public health, Under the past socialist system, the Eastern
health promotion and prevention, and health European countries’ primary method of healthcare
information systems. And it became clear that financing was through global budgets. After the
this approach did not lead to better health political shift, many of the countries introduced
outcomes. novel payment mechanisms for healthcare financ-
Before 1990, hospitals in Eastern European ing, including fee-for-service, Diagnostic Related
countries were financed through global budgets, Groups (DRG), and capitation.
which were calculated or based on historical In the past, the former policymakers of the
costs and many other noneconomic factors. Eastern European countries had little interest in
There were no financial incentives for cost con- the effectiveness of health services interventions.
tainment or cost-effectiveness. The first formal Important tools of health policy decision making
steps toward healthcare reform occurred around were not used in healthcare systems. During the
1990. At the time, it was recognized that the past two decades, however, efforts have been made
social security functions of retirement pensions in many Eastern European countries to strengthen
and health insurance could not be reformed with- the institutional resources and tools of health pol-
out restructuring the entire healthcare system of icy decision making.
each country.
The Development of Health Services
Restructuring the Healthcare Systems Research: The Case of Hungary
After the fall of the Soviet Union, a peaceful revo- After the fall of the Soviet Union, Hungarian
lution took place in Eastern European countries. researchers were sent to foreign universities to
Social and political changes were accompanied by receive formal academic training in health services
two phenomena: the economic performance, research. At the time, this was the only way for
including net material production and industrial many young researchers in Eastern European
output, fell markedly, which led to a decrease in countries to obtain advanced degrees in health
the gross domestic product (GDP), and the health services research, because health services research
status of the population declined. topics were not included in their educational sys-
After 1990, many Eastern European countries tems. The cost of education for these researchers
decided to return to the Bismarckian tradition of was covered mainly by a World Bank loan. A few
solidarity based on social insurance of their health- years ago, after evaluating various projects in
care system. Leaving behind the former Soviet-type Hungary, the World Bank concluded that the
system, compulsory health insurance schemes were most successful and sustainable project was the
introduced. The application of purchaser-provider one that invested in human infrastructure. By
570 Health Services Research in Eastern Europe
2000, this effort successfully produced a corps of The Hungarian National Health Insurance
highly trained Hungarian experts with interna- Fund Administration launched a program
tionally acknowledged qualifications and experi- for monitoring the quality of hospital care in
ence in health services research. However, because 2002. This quality indicator program, a pay-for-
of the lack of appropriate academic and govern- performance type of program, helps the national
mental institutions, many highly qualified insurance fund strengthen its purchasing role of
researchers decided to stay abroad, and they were obtaining high-quality health services. The fund
lost to the Hungarian healthcare system. Further has decided to develop this indicator system for
more, many of those researchers who did return measuring and evaluating the quality of health
to Hungary have been employed in the private services to support overall quality improvements.
sector. The national insurance fund seeks to ensure, in all
Some of the researchers who returned to the possible ways, that everyone can find the evalua-
country after receiving their advanced degrees tion points adequate to their field of interest—
abroad became the core team that further devel- that is to say, that the financial point of view is
oped health services research in Hungary. They not dominant in the development of the indicator
helped form a number of academic institutions system.
and departments, including the Health Services As a requirement for membership in the EU,
Management Training Centre at Semmelweis which Hungary joined in 2004, the country was
University in Budapest, the School of Public required to have a transparent, accountable cover-
Health at the University of Debrecen in eastern age process applied by the national health insur-
Hungary, the Health Economics and Health ance fund for the pricing and reimbursement of
Technology Assessment Unit at Corvinus Univer pharmaceuticals. To meet the EU transparency
sity in Budapest, and the Department of Health requirements, Hungary passed the appropriate
Insurance and Health Policy at the University of legislation in April 2004. Since that time, anyone
Pecs in southern Hungary. Later, the Health who wants to be reimbursed for the cost of certain
Economics Research Centre was established at drugs must submit a formal application according
Eotvos Lorand University in Budapest and the to the EU directives.
Institute of Health Economics at the University of Perhaps the most important change resulting
Szeged in southern Hungary. from EU membership has been the increased pro-
A key issue of Hungarian healthcare policy was fessionalization of Hungary’s decision-making pro-
the introduction of cost-effectiveness concepts and cess. It has resulted in the application of scientific
methods into the decision-making process. The first evidence in coverage decisions, equity, cost-effec-
step toward achieving greater cost-effectiveness tiveness, publicity, transparency, accountability,
was the establishment of methodological standards and the consideration of budget constraints.
published by the Hungarian Ministry of Health. In 2004, the National Institute for Strategic
These standards regulate the guidelines for con- Health Research was established to guide Hungary’s
ducting economic evaluations. The aim of the governmental health policy decision making by
guidelines is to encourage rational, transparent undertaking activities in four areas: (1) health infor-
public-healthcare-spending decisions. The guide- matics and information policy, (2) health econom-
lines are continuously being refined and evaluated ics, (3) health services and health system research,
every 2 years. and (4) the health technology assessment and cover-
The Hungarian Health Economics Association age policy. The establishment of the institute was an
was founded in 2003 and has a current member- important step toward the inclusion of health ser-
ship of about 100 individuals. The association vices research into the governmental decision-
holds monthly meetings where presentations are making process. The institute serves as an important
made on various health economic topics. The resource for the Ministry of Health and the National
meetings serve as an interdisciplinary forum for Health Insurance Fund Administration.
healthcare professionals in the field of health During the development of health services
economics, health services research, and health research in Hungary, researchers studied the
technology assessment. healthcare systems of a number of countries,
Health Services Research in Germany 571
including Australia, Sweden, the Netherlands, the Further Readings

United Kingdom, and the United States. They also Boncz, Imre, and Andor Sebestyen. “Health Services
studied the published international literature, par- Research in Hungary,” Medical Journal of Australia
ticularly focusing on health insurance coverage 184(12): 646–47, June 19, 2006.
policies, prescription drug pricing and reimburse- Boncz, Imre, and Andor Sebestyen. “Financial Deficits in
ment, healthcare technology assessment, price/ the Health Services of the U.K. and Hungary,” Lancet
volume agreements, Diagnosis Related Groups, 368(9539): 917–18, September 9, 2006.
evidence-based guidelines, and performance mea- Chawla, Mukesh. Health Care Spending in the New EU
surement. Subsequently, these studies have made a Member States: Controlling Costs and Improving
significant impact on Hungarian health policy Quality. Washington, DC: World Bank, 2007.
decision making. Mete, Cem, ed. Economic Implications of Chronic Illness
Hungarian health services researchers are cur- and Disability in Eastern Europe and the Former
rently addressing topics such as (a) the overall Soviet Union. Washington, DC: World Bank, 2008.
access to healthcare, (b) inequalities in access and Szocska, Miklos K., Janos M. Rethely, and Charles
utilization of health services, (c) cost containment Normand. “Managing Healthcare Reform in
strategies, (d) quality-of-care improvements, and Hungary: Challenges and Opportunities,” British
(e) the efficiency of resource allocation. Medical Journal 331(7510): 231–33, July 23, 2005.
Web Sites
Future Implications
European Union (EU), Delegation of the European
After the fall of the Soviet Union, the former
Commission to the USA: http://www.eurunion.org/eu
socialist countries of Eastern Europe underwent
World Bank: http://www.worldbank.org
fundamental social and political changes, which
World Health Organization (WHO), Regional Office for
greatly influenced their healthcare systems. One of Europe: http://www.euro.who.int
the greatest challenges faced by these countries
was the restructuring of their Soviet-type socialist
state healthcare systems into modern health insur-
ance-based systems. Since that time, there has
been a gradual development of health services Health Services Research
research in the Eastern European countries. This in Germany
development included the training of profession-
als, the establishment of academic departments,
Health insurance plays a vital role in the supply
the development of new public policies and rec-
and demand of healthcare. Health services
ommendations in line with those of the EU and
researchers in Germany and the United States
other international organizations, the strengthen-
study the function and nature of health insurance,
ing of public institutions, and the inclusion of
the various types of insurance plans, and the
health services research and related fields in the
impact of insurance on healthcare. The German
government decision-making process. These
healthcare system provides valuable lessons for
achievements serve as a strong base for the future
the United States and other countries that are try-
development of health services research activities
ing to develop health insurance programs that are
and projects, especially in the field of international
universal in scope and comprehensive in coverage.
collaborations.
Furthermore, the growing literature on compara-
Imre Boncz tive health insurance policies suggests that nations
are learning from each other.
See also Comparing Health Systems; Health Economics;
International Health Systems; National Health Background
Insurance; Payment Mechanisms; Public Policy;
Technology Assessment; World Health Organization Germany pioneered national health insurance.
(WHO) It was the first nation in the world to enact
572 Health Services Research in Germany
compulsory health insurance legislation. In pharmacists, and other healthcare providers. The
1883, the conservative politician and German ratio of healthcare providers to population in
Chancellor Otto von Bismarck (1815–1898) Germany is above the average of Organization for
devised a system of health insurance coverage, Economic Co-operation and Development (OECD)
as well as accident insurance and old-age pen- countries.
sions. Specifically, he established the Statutory In terms of utilization, the German population
Health Insurance System and other programs to tends to overutilize healthcare services. Therefore,
improve the situation of the country’s large government policymakers have recently introduced
working class, to coopt similar socialist propos- a number of measures to restrict and limit utiliza-
als, and to win an upcoming election. tion of services and provide stronger guidance for
Traditionally, the German population has patients. For example, in 2004, for the first time in
enjoyed a very high degree of free access to both the German health systems’ history, a government
healthcare providers and healthcare insurers. In reform introduced user fees to curb the utilization
2007, the Statutory Health Insurance System was of outpatient healthcare services.
composed of about 240 fiscally autonomous sick- The latest government reforms, the Statutory
ness funds, which insures about 86% of the total Health Insurance Modernization Act of 2004 and
German population. These funds are compulsory the Statutory Health Insurance Competition
for those earning less than 3,975 euros a month Strengthening Act of 2007, promoted more coor-
and for individuals who are unemployed, students, dination of care by restricting patient choice and
disabled, pensioners, poor, and homeless. Contri helped patients to better navigate the healthcare
butions to the funds are based mainly on wages system. The 2007 reform significantly changed the
and salaries and are obtained through a payroll system by encouraging competition among health-
tax. In 2006, the average contribution rate was care providers and health insurers.
13.25%. An earlier reform, the Health Care Structure
Individuals with a salary above the income Act of 1993, introduced for the first time free
level or who are self-employed can either volun- choice among the sickness funds for the majority
tarily remain in the social healthcare system or of the insured. Since then, the German healthcare
opt out of it and purchase comprehensive risk-re- system has increasingly become more competitive.
lated private health insurance coverage. In 2007, Both the Coalition Government of Christian
a little more than 10% of the population was Democrats and the Liberal Party (1982–1998), and
enrolled in a plan from 1 of 52 private health the coalition of Social Democrats and The Greens
insurance companies. Until the most recent gov- (1998–2005) were faced with increasing healthcare
ernment reform, private health insurance compa- expenditures and felt pressured to apply stricter
nies increased their reserves to guarantee lower healthcare cost containment measures. Thus, vari-
premiums for insuring older individuals. Thus, it ous government reforms during the past 20 years
became less attractive to switch from one to have steadily increased both the level of copay-
another private insurer the longer the individual ments and the number of copayments imposed on
stayed in a particular plan. prescription drugs and health services.
Miners, sailors, farmers, and soldiers may enroll The Social Code Book V, the legal framework
in other social insurance programs, so that alto- for the German Social Health Insurance System,
gether the entire German population is insured stipulates that the system must provide all medi-
against the risk of illness and they have compre- cally necessary services. Compared with other
hensive healthcare benefits. OECD countries, the German system provides a
broad set of benefits. For example, it covers outpa-
tient and inpatient services, medications, dental
Infrastructure and care, and rehabilitation services. Some services,
Government Reform Efforts however, are excluded from coverage, but they
Compared with other industrialized nations, have not caused any access problems so far. The
Germany’s healthcare infrastructure is well devel- specific healthcare services offered by the sickness
oped, providing easy access to physicians, nurses, funds are determined by law. And the funds offer
Health Services Research in Sub-Saharan Africa 573
95% of all required services. The sickness funds, Busse, Reinhard, and Annette Riesberg. Health Care
inpatient and outpatient healthcare providers, and Systems in Transition: Germany. Copenhagen,
the Federal Joint Committee jointly determine Denmark: WHO Office for Europe, 2004.
which services are reimbursable. The Federal Joint Cheng, Tsung-Mei, and Uwe E. Reinhardt.
Committee is a decision-making body comparable “Shepherding Major Health System Reforms:
with the United Kingdom’s National Institute for A Conversation With German Health Minister
Health and Clinical Excellence (NICE). Ulla Schmidt,” Health Affairs 27(3): w204–w213,
The importance of integrated-care contracts has April 2008.
Henke, Klaus-Dirk, and Jonas Schreyogg. Towards
continually grown over the years. Most of these
Sustainable Health Care Systems: Strategies in Health
contracts are regional in scope and cover certain
Insurance Schemes in France, Germany, Japan and
diseases and treatments (e.g., heart disease and
the Netherlands: A Comparative Study. 2d ed. Genf,
artificial hips).
Germany: Auflage, 2005.
Some of Germany’s healthcare organizations
have changed over the past decades. For example,
policlinics were frequent providers of healthcare in
Web Sites
the former German Democratic Republic (GDR/
East Germany). After the German reunification in Commonwealth Fund: http://www.commonwealthfund.org
1990, most of these policlinics closed and were Federal Ministry of Health (Bundesministerium fur
replaced with outpatient care centers organized as Gesundheit BMG): http://www.bmg.bund.de
in the western German states. Today, only about Federal Statistical Office (Statistisches Bundesamt):
30 policlinics still exist, and most of the former http://www.destatis.de
policlinics now operate as outpatient care centers. World Health Organization Office for Europe:
The 2004 government reform led to a renaissance http://www.euro.who.int
of outpatient care centers in the entire country. On
average, the new outpatient care centers, which are
generally managed by physicians or hospitals, have
a staff of four physicians. Health Services Research
in Sub-Saharan Africa
Future Implications
The German healthcare system will likely continue Health services research in sub-Saharan Africa dif-
to evolve. It may incorporate cost and quality-offers from its North American and European coun-
care concepts from other countries, including the terparts in several ways. It is often referred to as
United States, and other nations, including the logistics research or operations research, and care
United States, may attempt to expand insurance delivery is severely resource constrained. The
coverage similarly as the German system. shortage of staff, transportation, supplies, and
equipment leads to differences in the types of care
Klaus-Dirk Henke provided. Health services research in literature
from sub-Saharan Africa is focused on the major
See also Comparing Health Systems; Healthcare Financial diseases and health conditions confronting this
Management; Health Economics; Health Insurance; part of the world. Thus, this type of research is
International Health Systems; National Health largely organized and funded around major health
Insurance; Public Health conditions, such as malaria, tuberculosis, measles,
meningitis, diarrhea, HIV/AIDS, infant and child
health, and maternal mortality/morbidity.
Further Readings
Berg, Manfred and Geoffrey Cocks, eds. Medicine and
Health Conditions
Modernity: Public Health and Medical Care in
Nineteenth- and Twentieth-Century Germany. New In 2006, more than 65% of the total people in the
York: Cambridge University Press, 2002. world who suffer from HIV/AIDS (the human
574 Health Services Research in Sub-Saharan Africa
immunodeficiency virus) are found in sub-Saharan chronic cough, high fever, weakness, and drastic
Africa. This erosion of the immune system results weight loss. It is spread through indirect contact,
in tuberculosis and pneumonia, which are the mostly through coughing or sneezing. Treatment
immediate cause of death. Major risk factors for includes the use of Bacille Calmette-Guerin
HIV/AIDS in this region are unprotected sex, mul- (BCG), which is commonly used as a preventive
tiple sex partners, and the transfer of the virus measure against TB in Africa. One of the major
from the mother to the fetus during pregnancy. In approaches to the treatment of TB is Directly
sub-Saharan Africa, women aged 15 to 24 years Observed Therapy Short-Course (DOTS). Under
are considered to be at high risk of contracting DOTS, health workers closely monitor the treat-
HIV/AIDS. Currently three quarters of the document to ensure that patients complete the full
mented cases are found among this group. Almost course of medication, preventing the develop-
6 million people in sub-Saharan Africa are in need ment of new, drug-resistant strains of TB. The
of medical treatment. Organizations such as the DOTS strategy has proven to be an effective
Joint United Nations Programme on HIV/AIDS medical approach.
(UNAIDS) and the World Health Organization Africa accounts for more than a third of the
(WHO) are working to provide antiretroviral world’s annual deaths associated with measles.
treatment to 3 million individuals. Additional This virus causes approximately 345,000 deaths
goals may be set by other organizations to support worldwide each year, mostly among children.
the initiative. More than 20 million people are affected with this
Malaria is predominately spread by the female virus every year. Measles can cause blindness and
anopheles mosquito and accounted for more than brain damage, and it also induces children’s sus-
1 million deaths in 2005. Between 350 and 500 ceptibility to pneumonia and diarrhea. It is highly
million cases are reported worldwide each year. contagious and spreads mostly through coughing
More than 80% of the world’s malaria deaths and sneezing. Vaccination is extremely effective
occur in Africa. The disease accounts for 18% of against the disease. Since the cost of immunization
all child deaths in the sub-Saharan region. The is approximately $1 for each child in Africa,
major prevention strategies for malaria control the Measles Initiative and the World Health
include the use of insecticide-treated mosquito nets Organization/United Nations Children’s Fund
and indoor insecticide sprays. Some African mos- (UNICEF) Strategy for Sustainable Measles
quitoes have developed resistance to many antima- Mortality Reduction aim to reduce measles deaths
larial medications, making treatment more difficult with comprehensive vaccination programs. Since
and the costs of care more expensive. its implementation in Africa in 1999, there has
A total of 7.7% of deaths in Africa were caused been an overall drop of 60% in all documented
by diarrhea and its related complications in 2006. measles cases.
Diarrhea is a symptom of infection from bacterial, Tetanus in sub-Saharan Africa leads to 84,000
viral, and parasitic organisms primarily spread deaths every year and a total of 2 million deaths
through contamination of water and food. Most worldwide. Tetanus is a potentially fatal disease of
deaths result from dehydration, and children are the central nervous system. It most commonly
at higher risk than adults. The majority of treat- originates in wounds that become infected with
ments include oral rehydration, which is a low- bacteria. Neonatal tetanus passes from the mother
cost therapy. to the fetus.
Tuberculosis (TB) is a frequent killer of the The “Meningitis Belt” has the world’s highest
individuals who suffer from HIV/AIDS. It is esti- rates of patients infected with the disease. This
mated that more than half of the people living geographical region includes Senegal in western
with HIV/AIDS will contract TB during their life- Africa, stretching to Ethiopia in the east. Meningitis,
time. In some regions of sub-Saharan Africa, up a frequently fatal bacterial disease, infects the
to 70% of individuals with sputum smear–posi- membranes of the brain and spinal cord. Burkina
tive pulmonary tuberculosis are HIV-positive. Faso was the first African country to experience an
About 8 million new cases develop each year in epidemic of a new strain of meningitis known as
the world. Symptoms of tuberculosis include a W135. In 2005, the world price of the vaccine
Health Services Research in Sub-Saharan Africa 575
ranged from $4 to $50, which is unaffordable in cancer, and vaccines represent the remaining
many African nations. The WHO and other global articles, in descending order of frequency.
health organizations are currently negotiating to Professional society membership, dedicated
lower the price of the vaccination, making it more journals, focused-funding organizations, large
affordable. libraries, and dedicated faculty positions define
the social structure of health services research in
North America. These structural elements are
Health Services Research Activities
lacking in sub-Saharan African health services
As a result of concentrating on specific disease research. Relevant journals such as East African
conditions, health services research in sub- Journal of Medicine are not easily accessed, espe-
Saharan Africa is often published and presented cially in electronic versions. Researchers are often
in disease-specific journals and conferences, as unaware of the work of others and are unlikely to
opposed to health services research–specific pub- cite coexisting research in the area, making it dif-
lications and events. These conferences include ficult to locate relevant articles through citations
the Union World Conference on Lung Health and citation scores. In spite of these barriers,
and the International AIDS Conference. Addi there is a rich, high-quality body of health ser-
tional health services research from the region vices research from this region. A recent examina-
can be found in the gray literature of unpub- tion of scientific articles showed that from a total
lished dissertations, government briefs, and the pool of 44,000 articles worldwide, approximately
reports of nongovernmental organizations 1,300 articles dealt with topics in sub-Saharan
(NGOs). Problems that are of great focus include Africa.
issues related to poverty, vulnerable populations,
distance traveled, shortage of healthcare work-
ers, lack of supplies, and irregularity of available Future Implications
medications. Research studies conducted in sub- The field of health services research in this area
Saharan Africa tend to collect primary data on a of Africa has some advantages. This research can
small group of individuals, relying on hundreds be carried out at low cost and often with high
of respondents and subjects as opposed to thou- response rates. Some health interventions have
sands. Large computerized longitudinal data- low costs and large health benefits. Perhaps
bases and secondary data analyses are not because of this, cost-benefit analysis is a more
typically used in the sub-Saharan African health acceptable analytical method. Graduate education
services research. Survey instruments often in this area of study is available in sub-Saharan
require translation into local languages, and Africa—for example, at Makerere University in
there is an identified need for repositories of such Uganda. Local faculties prefer to assign articles
translations. that include authors and coauthors from the
A large portion of health services research in the region. Local researchers are well aware of their
region is underwritten by international agencies health problems and are interested in studies that
and nongovernmental organizations. Frequent top- show how to improve them. There is a need for a
ics include the cost-effectiveness of scarce resources core, accessible group of excellent articles on
applied to treatment. Vulnerable populations are health services research to be available for teach-
the main area of focus, with nearly half of the pub- ing purposes.
lished articles in the medical literature addressing
women and about 40% focusing on children. Andreea Seicean, Sinziana Seicean, Ilya Litvak,
Communicable disease control is another major Lakisha C. Miller, Imelda Namagembe,
area of focus in the developing world, reflected in Achilles Katamba, and Duncan Neuhauser
the health services research articles coming out of
sub-Saharan Africa, which are overwhelmingly See also Access to Healthcare; Acute and Chronic
disease specific. AIDS is the primary focus of these Diseases; Health Literacy; Health Services Research,
articles, representing more than 16% of works. Definition; Infectious Diseases; Public Health; Public
Primary care, poverty, bioethics, malaria, TB, Policy; World Health Organizations (WHO)
576 Health Services Research in the People’s Republic of China
Further Readings Health, conducted the first health services research

Cole, Forrest, ed. U.S. National Debate Topic 2007– in China. This initial research examined the utili-
2008: Healthcare in Sub-Saharan Africa. Bronx, NY: zation and provision of healthcare in Shanghai
H. W. Wilson, 2007. using a household interview survey. Based on the
Fatola, Toyin, and Matthew M. Heaton, eds. Health results obtained, a comparison of health out-
Knowledge and Belief Systems in Africa. Durham, comes between Shanghai and Washington, D.C.,
NC: Carolina Academic Press, 2008. revealed that the health status of these two cites
Feldman, Douglas A., ed. AIDS, Culture, and Africa. was similar. The results suggested that the similar-
Gainesville: University Press of Florida, 2008. ity of health outcomes in China was due to the
Garcia, Marito, Alan R. Pence, and Judith L. Evans, eds. wide coverage of basic healthcare services pro-
Africa’s Future, Africa’s Challenge: Early Childhood vided by a healthcare system that was composed
Care and Development in Sub-Saharan Africa. of the government’s welfare plan, labor insurance,
Washington, DC: World Bank, 2008. and the collective health systems. The comparison
Jamison, Dean T., Richard G. Feachem, Malegapuru W. with Washington, D.C., also revealed that
Makgoba, et al., eds. Disease and Mortality in Sub- Shanghai spent substantially less on health expen-
Saharan Africa. 2d ed. Washington, DC: World Bank, ditures.
2006. Since the 1980s, Chinese health services
research has proliferated, and it has been applied
to many projects at both the local and the national
Web Sites levels. The original Shanghai Household Interview
Society for Sub-Saharan Africa Health Service Research: Survey assessed past episodes of illness, the use of
http://epbiwww.cwru.edu/hsrssa health services in the past 2 weeks, and the num-
UNAIDS: http://www.unaids.org ber of hospitalizations in the past year, as well as
World Bank: http://www.worldbank.org surveying outpatient use. Since then, these initial
World Health Organization (WHO): http://www.who.int assessments have been expanded to include vari-
ous types of healthcare services. China has also
developed the National Health Service Survey,
which has been conducted in the years 1993,
1998, and 2003 throughout the various regions of
Health Services Research in the country.
the People’s Republic of China
Current Research
During the past 25 years, the People’s Republic of
China has undergone tremendous social change Over the past decades, health services research in
and economic growth. China’s healthcare system, China has focused on the growing unmet health-
however, has failed to keep pace with many of these care needs of the country, healthcare utilization,
changes. As a result, China has a growing need to financing, costs, quality, access to care, and
improve its delivery of healthcare to its people in healthcare reform. Currently, China is considering
both rural and urban areas. Health services research whether its healthcare system should be more of a
has begun to play an important role in guiding this free-market system or a revised, centrally planned
effort, with its emphasis on the issues of access, system. Health services research is helping the
cost, quality, and the outcomes of healthcare. government to make this decision.
One critical issue China is facing is the rapidly
rising healthcare costs. This increase is a result of
more severely ill patients seeking healthcare, the
History
use of new medical technologies, and the overpre-
Researchers from the United States introduced scribing of medications. The high cost of health-
health services research to the People’s Republic care in China has made it unaffordable for many
of China in the early 1980s. Specifically, in 1981, of the poor, resulting in a decrease in the demand
the Shanghai Medical University, School of Public for healthcare.
Health Services Research in the People’s Republic of China 577
Another important issue of concern is the for simple noninvasive care is set below cost and
underutilization of healthcare providers in China high-tech diagnostic care is set above cost, the for-
due to reduced patient demand. As the number of mer is generally underprovided, while the latter is
healthcare providers has increased, patient case overprovided. As a consequence, healthcare costs
load and occupancy at township hospitals has have escalated in concurrence with the rapid adop-
decreased. As a result, provider productivity has tion of new medical technologies. Provider incen-
declined accordingly. tives that encourage longer patient hospitalization
Health services research studies have shown have also contributed to the rising costs.
that China, like other countries, has a limited sys- Other health services research studies on pro-
tem to monitor and ensure the quality of its health- vider performance in China have shown that pro-
care. The skill level of healthcare practitioners has viders respond to changes in payment arrangements.
been found to be low, especially at the village level. A study that examined prospective payment in
Additionally, a large body of evidence suggests that Hainan Province hospitals found that the average
some level of wasteful, inefficient, and/or inappro- expenditure for admission decreased to below the
priate care is being delivered in China, particularly level of other hospitals that were paid on a fee-for-
in the overprescribing of medications. Although service basis and the growth in spending on high-
evidence shows that healthcare quality in China tech services declined. Another study showed that
has been improving, the improvements are mostly when the city of Shanghai switched payments for
restricted to large urban areas. Furthermore, despite its government insurance program to capitation
the general satisfaction with providers’ attitudes for outpatient care, escalation of costs slowed.
and service delivery, dissatisfaction with physician China’s transition from a referral-based system
communication concerning patients’ health status, to one that allows patients to choose the level of
as well as conflict between providers and family provider that they can afford has caused the over-
members, appears to be common. utilization of higher-level provincial and county
Inequities in the delivery of healthcare between hospitals, mostly by high-income patients.
urban and rural areas and across income groups Meanwhile, lower-level township hospitals typi-
further complicates China’s healthcare system. cally are underutilized and used mostly by indigent
Currently, the healthcare delivery system in urban patients. Furthermore, studies have found that the
areas is far more developed than in rural areas, and decentralization of China’s healthcare system has
the gap in the quality of care between these areas created greater inequity between richer and poorer
continues to grow. regions. It also has led to overlapping and frag-
The reasons for the Chinese healthcare system’s mented services.
shortcomings continue to be investigated. Some Some of the issues highlighted above regard-
analysts blame China’s health service deficits on ing China’s healthcare system are due to inap-
the country’s movement away from a centrally propriate, unnecessary, or lack of government
planned healthcare system, while others look to intervention. Other issues also reflect the govern-
decentralization and the adoption of a market ment’s concern with taking an active and positive
economy as a much needed remedy. These coun- role in healthcare service delivery. The overall
terperspectives have important implications for findings of health services research studies have
healthcare reform, especially as China debates the led to a greater understanding of the system and
merits of competition versus government interven- provided the basis for policymakers and program
tion in healthcare. Research assessing the conse- managers to continue to monitor, evaluate, and
quences of competition between providers, as well improve the effects of China’s healthcare reform
as across and within markets, would be useful in efforts.
informing this controversy and in setting future
policy.
Future Implications
China’s current fee-for-service payment struc-
ture and third-party payer system has resulted in Although the People’s Republic of China has
the overprovision of services in more profitable made significant progress in certain areas of
areas of care. Additionally, because reimbursement its healthcare system, such as in reducing infant
578 Health Services Research in the United Kingdom
mortality and increasing life expectancy, improve-

ments in other areas are needed. The lack of fund- Health Services Research
ing of needed healthcare programs and the lack of in the United Kingdom
access to affordable and high-quality care are of
concern. Because of the various shortcomings in
In the United Kingdom, health services research is
China’s healthcare delivery system, a growing
seen as being research that, from its inception,
need exists for more well-designed health services
aims to improve the quality and efficiency of
research studies to guide the ongoing healthcare
health services. In turn, a high-quality health ser-
system reform efforts in rural and urban areas.
vice is seen as one that is effective, humane, and
Health services research has begun to play a piv-
equitable. The concerns of health services research
otal role in improving the quality of life of the
in the United Kingdom differ somewhat in empha-
Chinese people, and it will continue to play an
sis from those in the United States, reflecting dif-
integral role in the ongoing transformation of
ferences in the history of its development. To
China’s healthcare system.
understand the role of health services research,
Wei Liu and Judith Levy consideration must be given to its development,
current organization, funding opportunities, aca-
See also Access to Healthcare; Comparing Health demic efforts, literature, and research capacity
Systems; Cost of Healthcare; Healthcare Markets; and training. Despite major achievements in this
International Health Systems; Public Health; Quality area over the past two decades, challenges and
of Healthcare; World Health Organization (WHO) opportunities still exist. Although many of the key
features of health services research are similar in
all four jurisdictions in the United Kingdom, this
Further Readings account focuses on the largest, England.
He, Wan, Manisha Sengupta, Kaitl Zhang, et al. Health
and Health Care of the Older Population in Urban
and Rural China: 2000. International Population
History
Reports Series P-95, No. 07–2. Washington, DC: Researchers at the London School of Hygiene and
Government Printing Office, 2007. Tropical Medicine were the first in England to
Ma, Sai, and Neeraj Sood. A Comparison of the Health formally adopt the term health services research,
Systems in China and India. Santa Monica, CA: starting a discussion on the topic in 1988. Research
RAND Center for Asia Pacific Policy, 2008. on health services, however, has a long history in
Scheid, Volker. Currents of Tradition in Chinese the United Kingdom. In the mid-19th century,
Medicine, 1626–2006. Seattle, WA: Eastland Press, Florence Nightingale (1820–1910) was not only
2007. proposing how hospitals and nursing should be
Tao, Julia Laifo-Wah, ed. Philosophy and Medicine:
organized, but as a statistician, she was also
Asian Studies in Bioethics and the Philosophy of
assessing the performance of providers and com-
Medicine. Vol. 6, China: Bioethics, Trust, and the
paring the outcomes of London hospitals. By the
Challenge of the Market. Dordrecht, the Netherlands:
end of the century, Henry Burdett, a leading hos-
Springer, 2008.
Wang, Mei-Ling, Shuo Zhang, and Xiao-wan Wang.
pital administrator, was systematically collecting
WTO, Globalization and China’s Health Care
data on the resources and activities of hospitals
System. New York: Palgrave Macmillan, 2007. and dispensaries throughout the country, which
he compiled in extensive annual reports. In the
early 20th century, E. A. Groves, a surgeon in
Bristol, was advocating the need for standardized
Web Sites reporting of clinical cases such that comparisons
China Health Economics Institute (CHEI): of the effectiveness of care could be undertaken.
http://www.nhei.cn/english While such individual contributions were impor-
World Bank: http://econ.worldbank.org tant, they represented isolated initiatives without
World Health Organization (WHO): http://www.who.int any systematic support. In 1913, the government
Health Services Research in the United Kingdom 579
established the Medical Research Council (MRC) Medical School in London and at the University of
to support and promote medical research. Although Sheffield. The MRC continued to provide some
this effort included some limited funding for what funds, though it principally supported laboratory
is now called health technology assessment, its and clinical research. Despite this, it was the latter
interests extended no further into health services that the House of Lords Select Committee on
research. The most significant early achievement Science and Technology were more concerned
of the MRC was the funding of the first random- about when they deliberated on the country’s
ized controlled trial (RCT) in the world, which research needs in 1986. The Lordships’ conclusion
dealt with the treatment of tuberculosis. It repre- was that the National Health Service’s (NHS)
sented a major challenge to the traditional notion greatest need was for research on health services
of “evidence,” which had been based largely on and, to a lesser extent, public health. In 1991, the
physicians’ observations and experiences. Other NHS Research and Development Programme was
RCTs followed, culminating in 1972 with the pub- established under its first director, Michael
lication of the seminal book Effectiveness and Peckham, a medical oncologist with management
Efficiency, written by Archibald L. Cochrane experience in academic medicine.
(1909–1988), a medical epidemiologist, and funded The following 5 years were extraordinarily pro-
by the Nuffield Provincial Hospitals Trust. ductive and exciting for the field of health services
Meanwhile, a more radical challenge to medical research in the United Kingdom. The Cochrane
knowledge was being developed by a medical Collaboration, an initiative led by a medical epide-
demographer, Tom McKeown, who, in his book miologist, Iain Chalmers, was established built on
The Role of Medicine, suggested that healthcare a pilot project in obstetrics and neonatal care. The
had made only a modest contribution to improve- initial aim of the Collaboration was to assemble all
ments in population health compared with envi- the RCT evidence on the effectiveness of health-
ronmental, nutritional, and social changes. care and to synthesize it to produce policy and
Although both Cochrane and McKeown had practice recommendations. Although it initiated in
practiced clinically, they focused on public health the United Kingdom, the Cochrane Collaboration
or social medicine rather than clinical medicine. rapidly expanded to become one of the largest,
Unlike the United States, where health services most comprehensive initiatives ever undertaken in
research had its origins largely in internal medi- the healthcare field.
cine, in the United Kingdom, work on evaluating Meanwhile, in England, new commissioned
healthcare and challenging the established tenets research programs were being established. For the
of medicine was housed in public health. This per- first time, researchers, managers, and lay people
sists to the present day and has influenced the were contributing to identifying research priorities
focus of British health services research. The focus and commissioning studies in areas that had often
in the United Kingdom has also differed from that been neglected. Starting in 1992 with mental
in the United States in two other ways. First, there health and learning disability, seven national pro-
is less concern about cost and cost containment, grams were established over the following 3 years.
reflecting the existence of a global, capped budget In time, these were replaced with two major pro-
and a greater focus on effectiveness and cost-effec- grams focused on health technology assessment
tiveness (reflecting not only the field’s origins in (HTA) in 1994 and service delivery and organiza-
public health epidemiology but also the existence tion (SDO) in 1999. In addition, reviews of a wide
and acceptance of mechanisms for explicit ration- range of methods needed in health services research
ing). Second, there is less focus on the influence of were commissioned, which resulted in a series of
race and ethnicity on equity and more focus on monographs, an extensive textbook, and a shorter
socioeconomic status. handbook providing state-of-the-art accounts for
The development of health services research researchers.
during the 1970s and 1980s was fairly piecemeal. Those early initiatives culminated in the first
The English Department of Health recognized its Scientific Basis of Health Services conference in
importance by establishing and supporting some London in 1995, an international gathering that
research units, in particular at St Thomas’ Hospital subsequently traveled the world, including
Amsterdam, Toronto, Sydney, and Washington, Primary Care Research and Development Centre
D.C., with biannual meetings over the following in Manchester, the Nursing Research Unit in
decade. Meanwhile, the NHS Research and London, and the Centre for Health Economics in
Development Programme flourished, with both York. And from the start of the NHS Research and
the HTA and SDO programs growing in size and Development Programme in the early 1990s,
stature. The SDO programs addressed the meth- regional research and development support units
odological challenges in conducting research on were established in the NHS to try to spread
the organization of services, published two research activity away from the “centres of excel-
books, and have increasingly encompassed the lence” in leading universities and to encourage the
challenge of knowledge transfer to managers and uptake of research evidence into clinical practice.
policymakers. With the establishment of a single research fund
After a few years of consolidation and stability, in 2007, the NIHR has become the lead organiza-
the NHS Research and Development Programme tion responsible for coordinating all public fund-
was redesignated as the National Institute of ing of health services research, including that
Health Research (NIHR) in 2006. While the fund- provided by the MRC Health Services and Public
ing streams and support for the field were unchanged Health Research Board. The only element of pub-
or enhanced, leaders called for greater central lic funding not included is the Economic and
direction and more transparency of the funds that Social Research Council (ESRC), which provides
had traditionally been allocated to NHS providers, some support for social science research on health
mostly hospitals, to support research infrastructure services. In addition to public funding, some char-
and medical academic posts. Even while these ities and foundations also provide funding, in
changes were being introduced, the government, particular the Nuffield Trust and The Health
and in particular the Treasury, became increasingly Foundation.
concerned about the division of responsibility for
health research between the NIHR and the MRC.
Organizations, Journals, and Training
This concern culminated in 2007 with proposals to
move the NIHR away from the Department of Although quintessentially a multidisciplinary and
Health (DH), creating an independent agency multiprofessional activity, health services research
while at the same time ensuring that it pursued a in the United Kingdom continues to be fragmented
coordinated policy with the MRC under an intellectually. Researchers have tended to retreat to
umbrella body, the Office for Strategic Coordination the safety and confines of their own disciplinary
of Health Research (OSCHR). The impact of these organization: the epidemiologists to the Society
changes is awaited. for Social Medicine, sociologists to the British
Sociological Association Medical Sociology Group,
and economists to the Health Economics Study
Funding
Group. This has been unsatisfactory for several
The debate as to whether the responsibility for reasons. First, it has discouraged multidisciplinary
public funding of health services research should research and exchange. Also, within each disciplin-
lie with the DH or the MRC has been going on for ary organization, attention to health services
several decades. The compromise solution had research has inevitably been diluted by other, more
been for the DH to fund the more applied, policy- dominating interests of each discipline. It has
oriented studies, leaving the MRC to fund micro, impeded the development of a higher profile for the
evaluative research with a particular focus on the field. In addition, this area of study has been frag-
clinical effectiveness and cost-effectiveness of spe- mented between key areas of healthcare. Too often,
cific healthcare interventions. Another difference researchers have focused their energies exclusively
has been that the DH has mostly used its funds to in topic- or profession-oriented organizations such
commission research, while MRC funds have been as the Health Services Research and Pharmacy
devoted to responsive or investigator-led studies. Practice Group, the United Kingdom’s Federation
The DH has also funded research units, includ- of Primary Care Research Organizations, and the
ing—in addition to the two mentioned earlier—the Royal College of Nursing Research Society.
Health Services Research in the United Kingdom 581
After at least two decades of unsuccessful Health Foundation has targeted particular groups
attempts to establish an organization to unify the such as nurses and allied health professionals.
field in the United Kingdom, the Health Services
Research Network was established in 2005.
Major Achievements
Nested within the main membership organization
that represents NHS bodies, both purchasers The profound impact that health services research
and providers, it has similar aims to those of has had on health services in the United Kingdom
AcademyHealth in the United States. The develop- is not sufficiently recognized. Despite all the chal-
ment of a more coordinated and coherent pres- lenges that the field has faced and its low level of
ence for health services research has also been resources and support compared with biomedical
enhanced by the decision by the Higher Education and clinical research, it has had an immense influ-
Funding Councils to designate, for the first time, ence on healthcare policy and the way health
health services research as one of the 67 areas that services are organized, managed, and regulated.
make up the whole of academia for the all-impor- The key features of the NHS have largely been
tant Research Assessment Exercise in 2008. This driven by the challenges thrown down by leaders
assessment is held every 7 years. in the field in the 1970s and the subsequent
In the United Kingdom, the field depended research carried out since the 1980s that revealed
largely on generalist journals, such as the British unjustifiable variations in the performance of
Medical Journal and the Lancet, for publishing healthcare providers. This research provided poli-
its output until the 1980s. Research of a clinical cymakers and managers with the confidence to
nature could also be published in specialist medical challenge established, unquestioned medical views
journals. While encouraging the interest of clini- and to require providers to be publicly account-
cians, this practice may have exacerbated the able. These measures have included demands for
fragmentation of health services research. The rigorous demonstration of the effectiveness,
alternative for researchers has been single- humaneness, and equity of care, which is the basis
disciplinary journals, such as the Journal of of contemporary performance management and
Epidemiology and Community Health, Journal of regulation. In parallel, requirements to justify the
Health Economics, Social Science and Medicine, rapidly increasing expenditure on healthcare
and Sociology of Health and Illness. American resulted largely from economic research on the
subject-specific or generalist journals have rarely cost-effectiveness of interventions and on finan-
been interested in research from the United cial management.
Kingdom. However, over the past 20 years, the Some of the main achievements of the NHS
situation has improved with the establishment of Research and Development Programme have been
some subject-specific journals in the United mentioned: (a) a shift in emphasis from responsive
Kingdom, including Health Services Management to commissioned research to meet the priorities
Research, Quality and Safety in Health Care, and needs of the health service; (b) establishment
Journal of Health Services Research and Policy, of the Cochrane Collaboration, which has mapped
and Journal of Evaluation of Clinical Practice. out what is known and what is not known about
The capacity to conduct health services research what works in healthcare; (c) support for method-
has steadily increased. There are now many rele- ological research to enable health services research
vant Masters’ level courses available, some provid- to become more rigorous and heighten its scientific
ing a broad, multidisciplinary introduction and status; and (d) recognition of the need for research
others focusing on one of the relevant disciplines. not only on health technologies but also on the
And with the development of research units and way services are delivered and organized.
departments in universities, opportunities for doc- Other key achievements have been the adop-
toral studies have grown. Like other areas, funding tion of the field as a distinct unit of assessment in
for students remains the limiting factor. Fellowships, the universities’ most recent Research Assessment
particularly doctoral and postdoctoral, are pro- Exercise and the development of high-quality
vided by the two principal sources of public fund- clinical databases in some key areas of healthcare,
ing, the MRC and the NIHR. In addition, the including critical care, cardiac surgery, acute
myocardial infarction, that provide a productive See also Comparing Health Systems; Equity, Efficiency,
base for research, planning, and patient manage- and Effectiveness in Healthcare; International Health
ment. The creation of the National Institute for Systems; National Health Insurance; Public Policy;
Health and Clinical Excellence (NICE) and Rationing Healthcare; United Kingdom’s National
Health Service (NHS); United Kingdom’s National
National Service Frameworks also arose from
Institute for Health and Clinical Excellence (NICE)
health services research’s demonstration of varia-
tions in inputs, processes, and outcomes.
Further Readings
Future Implications Aaron, Henry J., William B. Schwartz, and Melissa Cox.
The field of health services research has histori- Can We Say No?: The Challenge of Rationing Health
cally faced the challenge of persuading both col- Care. Washington, DC: Brookings Institution Press,
leagues in biomedical and clinical research of its 2005.
scientific worth and managers and policymakers Black, Nick. “Health Services Research: Saviour or
Chimera?” Lancet 349(9068): 1834–36, June 21, 1997.
as to its practical value. In addition, in the United
Black, Nick. “UK Health Services Research Network: At
Kingdom, there are several other challenges to be
Last, a Health Services Research Organization,”
met. First, there is increasing focus in the NHS on
Journal of Health Services Research and Policy
the research needs of the pharmaceutical industry,
12(Suppl. 1): 1–2, April 2007.
which is seen as creating wealth for the country, Black, Nick, John Brazier, Ray Fitzpatrick, et al., eds.
rather than on improving the health of the public. Health Services Research Methods: A Guide to Best
Second, the field must learn to cope with the Practice. London: BMJ Books, 1998.
increasing diversity of healthcare providers as the Clarke, Aileen, Pauline Allen, Stuart Anderson, et al., eds.
government encourages greater competition. Studying the Organization and Delivery of Health
Third, there is a need for research to reflect the Services: A Reader. New York: Routledge, 2004.
increasing integration of health and social care. Cochrane, Archibald. L. Effectiveness and Efficiency:
Fourth, researchers have to gain sufficient politi- Random Reflections on Health Services. London:
cal knowledge to handle the government’s politi- Nuffield Provincial Hospitals Trust, 1972.
cal ideology, which is decreasingly tolerant of Daly, Jeanne. Evidence-Based Medicine and the Search
research that questions its beliefs. Finally, there is for a Science of Clinical Care. Berkeley: University of
the challenge of dissuading authorities of the need California Press, 2005.
for inappropriate bureaucratic restraints on health Fulop, Naomi, Pauline Allen, Aileen Clarke, et al., eds.
services research in the name of protecting the Studying the Organization and Delivery of Health
ethical rights of the patients and the staff. Services: Research Methods. New York: Routledge,
Given these potential obstacles, health services 2001.
research can respond in several ways: (a) by enhanc- McKeown, Thomas. The Role of Medicine. Princeton,
ing patient/public involvement in research policy NJ: Princeton University Press, 1990.
and priority setting, (b) by demonstrating the value O’Brien, Mary, and Martha Livingston, eds. Ten
of such research to health services and research Excellent Reasons for National Health Care. New
funders, (c) by improving the transfer of research- York: New Press, 2008.
Sibbald, William J., and Julian F. Bion. Using Health
based knowledge to policymakers and managers,
Services Research to Improve Quality: Update in
(d) by assisting in improving the commissioning of
Intensive Care Medicine. New York: Springer, 2002.
healthcare, (e) by exploiting high-quality clinical
Smith, Ian. Building a World-Class NHS. New York:
databases for research, (f) by increasing clinician
Palgrave Macmillan, 2007.
involvement in the field, and (g) by getting more
involved in deploying rigorous methods in quality
improvement initiatives. Given these opportunities,
Web Sites
the future for health services research in the United
Kingdom has much potential. Cochrane Collaboration: http://www.cochrane.org
United Kingdom’s National Health Service
Nick Black (NHS) Confederation, Health Services Research
Health Services Research Journals 583
Network: http://www.nhsconfed.org/specialist/ public health and health administration, (2) pub-

specialist-1789.cfm lications that are important for research gather-
United Kingdom’s National Institute for Health ing but not essential to the library collection, and
Research, Health Services Research Programme: (3) publications that are of interest to practitio-
http://www.hsr.nihr.ac.uk ners. These core categories provide comprehen-
sive coverage for journals and other publications
that serve health service researchers and public
health practitioners. The database also includes
Health Services links to additional information about the jour-
nals, such as the International Standard Serial
Research Journals Number (ISSN), pricing, indexing of the journal
articles within the PubMed database, and links
Access to peer-reviewed journal literature is an to publishers’ Web sites. Most of the journals in
important part of health services research. Two the list are indexed within PubMed. Health
resources that help identify key journals in health services researchers would be most interested
services research are the Core Public Health in the core list subject of Health Services
Journals Project—Health Services Administration Administration.
and the Institute for Scientific Information’s
annual Journal Citation Reports (JCR). Most of
these journals are indexed in the U.S. National Essential Core Publications
Library of Medicine’s PubMed database, and spe- The Core Public Health Journals Project identi-
cialized queries are available to focus on the fies those publications that are considered essential
health services research literature. for libraries specializing in the field of public
health and health administration. The 2006
Essential Core list for the subject of Health Services
Core Public Health Journals Project
Administration includes the following:
In 2001, the Core Public Health Journals Project Administration and Policy in Mental Health, pub-
began with the purpose of identifying a list of core lished by Springer 6 times a year; American Journal
public health journals that every library in the of Managed Care, a monthly journal published by
field should have. Compiled and reviewed by pub- Medical World Communications; Health Affairs,
lic health librarians and public health profession- published 6 times a year by the University of
als, this list will result in a database that helps the Pennsylvania; Health Care Financing Review, a
Association of Schools of Public Health in its subscription quarterly journal of the Centers for
accreditation process. The Public Health/Health Medicare and Medicaid Services (CMS); Health
Administration Section of the American Library Care Management Review, a bimonthly publica-
Association (ALA) supports this ongoing and col- tion from Lippincott, Williams & Wilkins; Inquiry,
laborative project. The list of core journals serves a quarterly journal published by Excellus Health
as a starting point for researchers performing sys- Plan; International Journal of Technology Assess
tematic reviews of the health services literature. It ment in Health Care, a quarterly journal from Cam
is regularly updated, and the project plan calls for bridge University Press; Joint Commission Journal
a new version of the list to be produced every 2 on Quality and Patient Safety, published monthly
years. In 2006, the Core Public Health Journals by Joint Commission Resources; Journal for
Project received the Medical Library Association’s Healthcare Quality, the bimonthly journal for the
Louise Darling Medal for Distinguished National Healthcare Quality Association; Journal
Achievement in Collection Development in the of Health and Human Services Administration,
Health Sciences. published by Southern Public Administration
Modeled after the Brandon-Hill list, the Core Foundation 4 times a year; Journal of Health Care
Public Health Journals Project categorizes jour- Finance, a quarterly journal from Aspen Publishers;
nals into three groups: (1) those journals that are Journal of Health Politics, Policy, and Law, pub-
essential for a library that has specialization in lished 6 times a year by Duke University Press;
584 Health Services Research Journals
Journal of the American Medical Directors Asso of University Programs in Health Administration;
ciation, a monthly publication from the American Journal of Health Care for the Poor and Under
Medical Directors Association; Medical Care, pub- served, a quarterly journal from Johns Hopkins
lished by Lippincott, Williams & Wilkins 12 times University Press; Journal of Health Economics,
a year; Medical Care Research and Review, a published by Elsevier 6 times a year; Journal of
bimonthly journal of Sage Publications; and Health Law, a publication of the American Health
Milbank Quarterly, published 4 times a year by Lawyers Association; Journal of Healthcare
the Milbank Memorial Fund and Blackwell Information Management, a quarterly journal of
Publishing. the Healthcare Information and Management
Systems Society; Journal of Healthcare Mana
gement, published bimonthly by the Health
Research Level Core
Administration Press; Journal of Healthcare Risk
The Research Level Core list is important for Management, a publication of the American
comprehensive library collections, helping Hospital Association; Journal of Law, Medicine
researchers and graduate students in a particular & Ethics, a quarterly journal of American Society
field. The 2006 Research Level Core list for of Law, Medicine & Ethics; Journal of Legal
Health Services Administration includes the fol- Medicine, published quarterly by Taylor & Francis;
lowing: American Journal of Law & Medicine, Journal of Nursing Administration, published 11
published 3 times a year by the American Society times a year by Lippincott, Williams
of Law, Medicine & Ethics; American Journal of & Wilkins; Journal of Public Health Manage
Medical Quality, a bimonthly journal of Sage ment and Practice, a bimonthly publication
Publications; Cost Effectiveness and Resource of Lippincott, Williams & Wilkins; Journal of
Allocation, an online journal published by BioMed Public Health Policy, published quarterly by
Central; European Journal of Health Economics, Palgrave Macmillan; Managed Care Quarterly,
published by Springer-Verlag 4 times a year; a publication of Aspen Publishers; Medical Deci
Evaluation and the Health Professions, a quar- sion Making, published 6 times a year by Sage
terly journal from Sage Publications; Evidence- Publications; Mental Health Services Research, a
Based Healthcare & Public Health, a quarterly publication from Springer that is not indexed by
journal from Elsevier that is not indexed in PubMed; PharmacoEconomics published 12 times
PubMed; Frontiers of Health Services Management, a year by Adis International; and Value in Health,
published quarterly by the Health Administration a bimonthly journal published by Blackwell
Press; Health Care Analysis, published 4 times a Publishing.
year by Springer; Health Economics, a monthly
journal from John Wiley & Sons; Health Policy,
The Gray Literature and Others
published by Elsevier 15 times a year; Health
Policy and Planning, a bimonthly journal of Besides the Essential Core and the Research
Oxford University Press; Health Research Policy Level Core lists, the Core Public Health Journals
and Systems, an online journal published by Project also categorizes the gray literature, which
BioMed Central; International Journal for Quality includes newsletters, annual reports, and other
in Health Care, a bimonthly journal of Oxford publications that may be of interest to practitio-
University Press; International Journal of Health ners. For the subject of Health Services Admini
Services, published 4 times a year by Baywood stration, the 2006 list includes the following:
Publishing Company; Joint Commission: The AHA (American Hospital Association) News
Source, a monthly publication from Joint Online, Environment of Care News, Healthcare
Commission Resources that is not indexed for Executive, Healthcare Financial Management,
PubMed; Journal of Ambulatory Care Management Hospitals and Health Networks, Joint Commi
and Journal of Behavioral Health Services & ssion Benchmark, Joint Commission Perspectives
Research, each published quarterly by Lippincott, on Patient Safety, Modern Healthcare, and the
Williams & Wilkins; Journal of Health Admini state’s and surrounding states’ medical associa-
stration Education, a publication of the Association tion journals.
Health Services Research Journals 585
Journal Citation Reports Health Services Literature Searches
The Institute for Scientific Information (ISI) Each year, more than 3,000 articles and reviews are
produces the annual Journal Citation Reports to published in more than 40 health services research
provide citation data on journals, as well as cal- journals. Additional health services research articles
culations of the journal’s impact factor, imme- can be found in other health sciences journals, such
diacy index, cited half-life, citing half-life, and as the American Journal of Public Health, the
source data. These are quantitative methods for Journal of the American Medical Association, and
determining the relative importance of journals the New England Journal of Medicine. Most of the
within subject categories. JCR is only available journal literature is indexed within online data-
through a subscription. Most academic research bases produced by the U.S. National Library of
libraries provide licensed access to this Medicine (NLM). From 1994 to 2000, the NLM
resource. and the AHA jointly produced HealthSTAR (Health
JCR is produced annually as two editions: the Services Technology, Administration, and Research),
JCR Science Edition, which covers more than an online database focused on the clinical and non-
5,900 journals on science and technology, and the clinical aspects of healthcare delivery. HealthSTAR
JCR Social Sciences Edition, which covers another contained citations and abstracts from the journal
1,700 journals in the social sciences. Health ser- literature as well as monographs, technical reports,
vices research journals can be found in both edi- and other research materials from 1975 onward.
tions. The JCR Science Edition covers the category Topics covered in HealthSTAR included evaluation
Health Care Sciences and Services. This edition of patient outcomes; effectiveness of procedures,
has journals that cover health services, hospital programs, products, services, and processes; admin-
administration, healthcare management, health- istration and planning of health facilities, services,
care financing, health policy and planning, health and manpower; health insurance; health policy;
economics, health education, history of medicine, health services research; health economics and
and palliative care. The JCR Social Sciences financial management; laws and regulation; per-
Edition covers the category Health Policy and sonnel administration; quality assurance; licensure;
Services. The journals listed in this edition include and accreditation.
those that cover healthcare systems, including Although the NLM no longer offers HealthSTAR
healthcare provision and management, financial as a separate database, the health services journal
analysis, healthcare ethics, health policy, and qual- literature continues to be indexed and included in
ity of care. Because the target audience of each PubMed. PubMed provides free access to MEDLINE
edition is different, a health services administra- (Medical Literature Analysis and Retrieval System
tion journal may be listed in either with different Online), NLM’s premier biomedical database, con-
data for impact factor, immediacy index, cited taining more than 15 million journal citations.
half-life, and citing half-life. When using either Most of the core health services research journals
editions of the JCR, it is important to use the are included in PubMed, and the citations include
appropriate subject category and edition to review links to the full-text versions of journal articles at
the data for a journal. participating publishers’ Web sites.
An often-cited measure of a journal’s impor- Specialized PubMed search queries on healthcare
tance is its impact factor. Although JCR is a sub- quality and costs are available via the Pilot Health
scription-based resource, most publishers will list Services Research (HSR) Filters Project from the
the journal’s impact factor from their Web site. National Information Center on Health Services
This measure refers to the frequency with which a Research and Health Care Technology (NICHSR)
typical article in a journal has been cited within a Web site. These specialized PubMed queries can be
particular year or period of time. The impact fac- used to identify journal citations that correspond to
tor, however, should not be the sole basis for judg- a specific health services research study category
ing the prestige of a journal. Information from the with a broad or narrow scope. The health services
JCR is intended to complement information from research study categories are appropriateness,
other journal resources. process assessment, outcomes assessment, costs,
586 Health Surveys
economics, and qualitative research. These special- National Information Center on Health Services
ized PubMed search queries were designed as tools Research and Health Care Technology (NICHSR):
to assist researchers, clinicians, health policy ana- http://www.nlm.nih.gov/nichsr
lysts, and planners. For comprehensive searches, PubMed (MEDLINE): http://www.ncbi.nlm.nih.gov/
researchers can use PubMed directly to further pubmed
search the health services research journal literature.
Future Implications Health Surveys

Health services researchers rely on the scientific
literature to make advances in the field. Several Health surveys are one of the methods most com-
mechanisms and clearinghouses help make these monly used in health services research for obtain-
peer-reviewed journals and other publications ing measures of various indicators of health
accessible and organized for the use of researchers knowledge, attitudes, behaviors, and demographic
and other health administration professionals. The characteristics. They collect data by self-report,
databases, which are updated regularly, will con- whereby participants (called respondents) reply to
tinue to grow, capturing publications and infor- questions presented in a self-completion question-
mation that will further health services research. naire or by an interviewer via telephone or face-
to-face. Health services researchers conduct health
Helen Look surveys or use the findings from health surveys
conducted by others (called secondary analysis) to
See also AcademyHealth; Healthcare Web Sites; Health perform needs assessments, develop cross-
Economics; Health Services Research, Definition; sectional profiles of populations, monitor popula-
Medical Sociology; National Center for Health tions or cohorts longitudinally, or collect pretest
Statistics (NCHS); National Information Center on and/or posttest measures in studies using experi-
Health Services Research and Health Care Technology
mental or quasi-experimental designs.
(NICHSR); Public Health
Health surveys are an effective and efficient
method for estimating the characteristics of large
populations using data collected from representa-
Further Readings tive samples, analyzing comparisons across vari-
Entwistle, Vikki, Michael Calnan, and Paul Dieppe. ous study units (most often, these are individuals,
“Consumer Involvement in Setting the Health Services but they also can be groups such as households or
Research Agenda: Persistent Questions of Value,” organizations), and/or analyzing comparisons
Journal of Health Services Research and Policy within study units over time. This is attributable to
13(Suppl. 3): 76–81, October 2008. three key features.
Litwin, Mark S. “Health Services Research,” Seminars in First, most health surveys are conducted with
Radiation Oncology 18(3): 152–60, July 2008. large numbers (usually several hundred and some-
Shi, Leiye. Health Services Research Methods. 2d ed. times thousands) of participants, who are selected
Boston: Delmar Cengage Learning, 2007. using random (probability) sampling procedures.
Wilczynski, Nancy L., R. Brian Haynes, John N. Lavis, Random sampling avoids potential selection bias
et al. “Optimal Search Strategies for Detecting Health that might be present—for example, if participants
Services Research Studies in MEDLINE,” Canadian were recruited by soliciting volunteers through
Medical Association Journal 171(10): 1179–85, advertising. Second, health surveys collect data in a
November 9, 2004. structured, standardized manner from each respon-
dent. This is accomplished by presenting each ques-
tion to each respondent using the same mode of
Web Sites delivery, to the extent possible in a similar setting
American Library Association (ALA): http://www.ala.org and under similar conditions, and using the same
Institute for Scientific Information (ISI): question wording, question order, and response
http://scientific.thomsonreuters.com choices. Third, almost all responses to health
Health Surveys 587
survey questions are recorded in a quantitative for- about respondents’ health knowledge and health
mat, such as counts of persons or events; numerical attitudes/beliefs, which are not measurable reliably
positions on rating scales; or by assigning numeri- except by self-report. Health surveys also are often
cal codes to nominal, categorical responses such as used to collect information about respondents’
types of health insurance. This precoded response behaviors for which there are no records or the
aspect facilitates data processing and analysis, espe- reliability of existing records is unacceptable, or in
cially when combining similar responses and com- cases where it is difficult or not possible to gain
paring responses across and within respondents (in access to records. Finally, when appropriate strate-
the case of a longitudinal design). gies are used, health surveys can be effective in col-
lecting sensitive information. For example,
anonymous strategies may be used to ask about atti-
Advantages
tudes, such as racial prejudice, that most respondents
There are numerous advantages or strengths of are reluctant to express publicly. Also, similar strate-
health surveys that make them useful for con- gies may be used to ask about private behaviors,
ducting health services research. The following such as sexual practices, or about illegal behaviors,
points generally are characteristic of health sur- such as illegal use of drugs and other forms of sub-
veys, but they do not necessarily apply to all stance abuse.
health surveys. A final area of strength is that health surveys are
First, as was already mentioned, health surveys, efficient in terms of time and financial resources.
especially those conducted by U.S. federal govern- They enable health services researchers to collect
mental agencies such as the National Center for large data sets quickly and at relatively low cost
Health Statistics (NCHS) and Centers for Disease per unit of information. Health surveys typically
Control and Prevention (CDC), usually collect collect data from large numbers of respondents
data from large, randomly selected samples. and measure large numbers of variables per respon-
Random sampling avoids selection bias and enables dent. Moreover, they do so much faster than is
health services researchers to apply inferential sta- possible with most other data collection methods,
tistical procedures when estimating population especially for a study of the same size and design
characteristics (called parameters). complexity. Although data collection time varies
Second, the previously mentioned structured, depending on the data collection mode, sample
standardized manner in which health surveys col- size, design complexity, and staff resources, the
lect primarily quantitative data facilitates data col- data collection phase for most relatively large
lection, processing, and analysis. This also enhances health surveys ranges from about 4 to 12 weeks.
the ability of health services researchers to repli- Combined with the efficiency derived from using a
cate previous health surveys with different popula- structured, standardized data collection protocol
tions and/or to study the same populations or in which almost all responses are precoded in a
cohorts longitudinally. quantitative format, health surveys may collect and
Third, health surveys are a very flexible research analyze large, complex sets of data in a very timely
method that can be used to collect data about manner. This enables health services researchers to
various study units (e.g., individuals, households, avoid or minimize potential historical influences
organizations). They can be implemented in a wide that may threaten the interpretation of the data. It
variety of settings, ranging from a respondent’s also enhances health services researchers’ ability to
home to external sites such as schools, work sites, be responsive to time-sensitive data applications,
and health clinics. Finally, they can be used to such as in making decisions about initiating, revis-
study populations that are distributed broadly ing, or terminating health programs, or advocating
across large geographic areas, such as cities, coun- health policies or legislation.
ties, states, and countries.
Fourth, the self-report aspect of health surveys
Cautions About Health Surveys
enables health services researchers to collect informa-
tion about variables that are not observable directly. While they are efficient, the total financial resources
For example, most health surveys ask questions required to conduct health surveys effectively,
588 Health Surveys
especially large, complex ones, can be relatively Another common application of this strategy is
high. Moreover, while they enable health services for members or agents of the research team to dis-
researchers to collect data quickly, all surveys tribute, in person, self-completion questionnaires
require a substantial amount of time for planning to persons in the survey sample. The sample mem-
and preparation. This time varies with the size and bers are asked to complete the questionnaire and
complexity of the survey, but it almost always is return it directly to the person from whom they
several times as much as is required for the survey received it, place it in a collection box, or send it
data collection phase (also called the field phase). to the researchers via standard mail, using a post-
Conducting any health survey effectively requires age-paid, preaddressed return envelope that is
a well-trained, experienced, and supervised research provided along with the questionnaire. This strat-
team. It is feasible for small, simple surveys to be egy may be employed with individuals, such as
conducted by a small research team—for example, samples consisting of clinic patients waiting to see
by an experienced survey researcher training and health services providers, or with groups, such as
supervising staff, who are available within or samples consisting of students in classrooms or
through an organization that is sponsoring or col- teams of workers at work sites.
laborating on a survey. However, virtually all Technological advances have led to the intro-
large, complex health surveys are conducted by duction of several computer-based strategies for
health services researchers collaborating with expe- conducting self-completion questionnaire health
rienced, professional academic or commercial sur- surveys. The most prevalent of these are e-mail
vey research organizations. surveys, Internet surveys, and computer-assisted
self-interviews (CASIs), which is the most expen-
sive of these strategies.
Health Survey Data Collection Modes E-mail surveys are conducted by sending e-mail
Health survey data are collected by two basic messages to samples of persons for whom e-mail
strategies, whereby respondents are asked to reply addresses are available, such as college students or
to questions presented in self-completion ques- members of professional associations. They are
tionnaires or read aloud by interviewers. There asked to complete and return via e-mail a ques-
are several ways in which these strategies may be tionnaire that is attached to or embedded in the
employed, either individually or in combination. e-mail message or that may be downloaded from a
Selecting the one most appropriate for a particular Web site.
health survey requires considering several aspects Internet surveys are conducted in two ways.
regarding relative administrative feasibility and One strategy is to send e-mail messages to the
data quality. sample members (again, e-mail addresses must be
available) inviting them to participate in the survey
by visiting a Web site where a questionnaire may
be completed online. The second strategy is to
Self-Completion Questionnaires
invite survey participation via pop-up windows
Self-completion (also called self-administered) presented to Web site visitors, for example—
questionnaires generally are the least expensive persons who visit Web sites for health information
and easiest to implement survey data collection clearinghouses or health services providers.
mode, placing the smallest demand on staff, equip- CASIs are conducted by arranging for research
ment, and other resources. The most widely used team members to meet with respondents in person.
application of self-completion questionnaires is in Respondents are asked to complete a questionnaire
mailed surveys, whereby a questionnaire and a let- that has been programmed into a laptop/notebook
ter are sent via standard mail to a sample of per- computer. The computers are provided by the
sons whose names and addresses are available. The research team members, who explain and monitor
respondents are asked to complete the question- the respondents’ use of the computer to complete
naire and return it to the researchers using a post- the questionnaire using the keyboard to enter code
age-paid, preaddressed return envelope that is numbers corresponding to their responses to the
enclosed with the questionnaire. questions. Another form of this data collection
Health Surveys 589
mode is audio computer-assisted self-interviews to enter code numbers corresponding to the

(A-CASI), whereby the respondents complete the responses to the questions, which are stored
questionnaire using a laptop/notebook computer directly into databases for processing and analysis.
supplemented by a synchronized recording of an While various configurations of desktop or laptop/
interviewer reading aloud the instructions, the notebook computers may be used for CATI sur-
questions, and the response choices. veys, which usually are conducted at survey inter-
viewing centers, CAPI interviewers are equipped
with laptop/notebook computers for ease of porta-
Interview Surveys bility in the field.
Health surveys use two basic strategies to col-
lect data by conducting interviews. These are tele-
Telephone Interview Surveys
phone interviews and face-to-face interviews (also
called personal interviews). In both these modes, Telephone interview surveys are conducted by
survey respondents are asked to reply to questions trained and supervised interviewers who call the
and response choices that are read aloud by inter- persons in the sample on the telephone to inter-
viewers. Telephone interviews are the most widely view them using the survey questionnaire as the
used mode for conducting survey interviews interview guide. This requires that the sample
because of their versatility, data quality, and time members have current telephone access, and there
and cost efficiency. While face-to-face interviews must be a means for the researchers to obtain their
generally are the most expensive and time-consum- telephone numbers. Although some members of
ing survey data collection mode, they are also the U.S. population do not live in households with
generally considered to provide the best data qual- telephone access, U.S. Census reports routinely
ity among all survey modes. However, in most indicate that more than 90% of the population
cases, this is not a substantial advantage over con- have telephone access, providing the most thor-
ducting interviews via telephone. ough means of contacting of this large and geo-
Prior to recent technological developments, most graphically dispersed population at the least
interview surveys were conducted by interviewers expense. One strategy for obtaining telephone
reading questions and response choices from paper numbers for sample members is to use appropriate
copies of survey questionnaires and recording existing lists, such as directories, for example, for
responses directly on the questionnaires. This employees of certain companies, or lists compiled
paper-and-pencil-interview (PAPI) format is still from records, for example, for patients who have
used effectively for small-scale, low-budget inter- used services at certain health clinics during par-
view surveys. However, technological advances ticular time periods.
have led to the widespread use of computer-assisted A second strategy is to use one of several forms
strategies for conducting interview surveys. of specialized random sampling, referred to gener-
Although there are many variations of these and ally as random-digit dialing (RDD). This is
new ones continue to be developed, the most preva- employed when appropriate lists of telephone
lent strategies are very similar to the CASI described numbers for sample members are not available
earlier. In fact, CASI strategies were derived from and, usually, the identity of the sample members is
the interview technologies that were first developed also not known to the researchers. For example,
for telephone interview surveys and then were this describes the situation health services research-
applied to face-to-face interview surveys. ers confront when planning telephone interview
Computer-assisted telephone interviews (CATI) surveys with random samples of all adults living in
and computer-assisted personal interviews (CAPI— the United States. This strategy also is used for
face-to-face interviews previously were called “per- telephone interview surveys with samples of popu-
sonal” interviews, thus the P in CAPI) are conducted lations in smaller geographic units, such as cities,
by interviewers reading aloud questions and counties, and states.
response choices displayed on monitors by com- Unfortunately, there are no master directories of
puters into which the survey questionnaire has telephone numbers for all U.S. households with
been programmed. The interviewers use keyboards telephone service that may be used as sampling
590 Health Surveys
frames from which to select random samples. Even sampling firms, usually via the Internet. However,
for smaller geographic units such as cities, many most researchers will be served best by collabo-
households with telephone service are not included rating with experienced professional academic
in telephone directories because they have requested or commercial survey research organizations
their numbers to be unpublished or unlisted. Also, providing a full range of telephone interview
new residents who have been assigned a telephone survey services.
number since the publication of the most recent
Face-to-Face Interview Surveys
directories will not be included in them. These
exclusions may result in unrepresentative samples Face-to-face interview surveys are conducted by
due to substantial sample coverage bias and lead to trained and supervised interviewers who interview
errors in estimating population characteristics. survey sample members in person, using the survey
In its most comprehensive form, RDD would questionnaire as the interview guide. In most cases,
randomly select a set of all 10 digits constituting a these interviews are conducted in respondents’
telephone number (3-digit area code + 3-digit pre- homes, but they also may be done at schools, clin-
fix code + 4-digit line code) to compose a sample ics, work sites, and other appropriate locations.
of n telephone numbers to be called in conducting In the most straightforward situation, face-to-
a survey. However, this procedure is never used face interviews are conducted in respondents’
because it is very inefficient in that most of the homes with a random sample selected from a list
telephone numbers it generates will not be useful that includes the sample members’ residential
for the intended survey. Some numbers will not be addresses. For example, the sample may be selected
in service, some will be assigned to businesses or from a directory, such as one of employees, or
institutions rather than to households, and some from records, such as for health clinic patients.
will be assigned to households located outside the Face-to-face interview surveys are very expen-
city or other geographic area designated as the sive in terms of time and money when the sample
survey target. is selected from the general population, such as all
In practice, alternative RDD strategies address adults residing in a large city. This is because,
these problems through multiple-stage sampling similar to the problem described regarding sam-
designs using information about groups of num- pling for telephone interview surveys, no adequate
bers that are known to be in service in the target list of names and addresses is available to serve as
population. These designs greatly improve effi- a sampling frame. The usual procedure for such
ciency by reducing the proportion of telephone surveys is to select a sample using a multistage
numbers that will be called that are not in service cluster sampling design called area probability
or are not assigned to members of the survey target sampling.
population. For example, the first stage might con- This involves randomly selecting a series of
sist of selecting some or all the area code + prefix increasingly smaller geographic units, then ran-
code combinations known to be in service in the domly selecting individual dwelling units, and
target population. This information is combined then randomly selecting one eligible person within
with one of several alternative strategies for each dwelling unit. For example, for a survey of
obtaining all or part of the 4-digit line code to cre- adult residents of a large city, the sampling design
ate a sample of n telephone numbers to be called might first select a random sample of neighbor-
in conducting a survey. This is a simple illustration hoods, then randomly select census tracts within
of an RDD sampling design. Several alternative those neighborhoods, and then randomly select
RDD strategies are available, some of which are city blocks within selected census tracts. At the
quite complex and require specialized expertise block level, usual practice calls for sending research
and resources. staff members into the field to develop on-site
For large-scale RDD telephone interview sur- maps of the selected blocks and list the addresses
veys, it is virtually essential for health services of all dwelling units on those blocks. Then a ran-
researchers to contract for the services of experi- dom sample of dwelling units is selected using this
enced survey professionals. RDD samples information. Finally, interviewers are sent to the
may be purchased directly from professional selected dwelling units to interview one person at
Health Systems Agencies (HSAs) 591
each unit. When more than one eligible person Web Sites
resides at a dwelling, the interviewer randomly American Association for Public Opinion Research
selects one of them to interview. Virtually all (AAPOR): http://www.aapor.org
surveys that involve this type of complex sam- American Statistical Association, Survey Research
pling design are conducted by health services Methods Section: http://www.amstat.org/sections/srms
researchers collaborating with experienced pro- Behavioral Risk Factor Surveillance System:
fessional academic or commercial survey research http://www.cdc.gov/brfss/index.htm
organizations. Council of American Survey Research Organizations
(CASRO): http://www.casro.org
Frederick J. Kviz National Center for Health Statistics (NCHS):
http://www.cdc.gov/nchs
See also Cohort Studies; Cross-Sectional Studies; Data
Sources in Conducting Health Services Research;
General Health Questionnaire; Health Indicators,
Leading; Measurement in Health Services Research;
Satisfaction Surveys; Short-Form Health Surveys
(SF-36, -12, -8)
Health Systems
Agencies (HSAs)
Further Readings Health systems agencies (HSAs) were regional
health-planning organizations. They were estab-
Aday, Lu Ann, and Llewellyn J. Cornelius. Designing lished under the authority and funding of the
and Conducting Health Surveys: A Comprehensive National Health Planning and Resource Develop
Guide. 3d ed. San Francisco: Jossey-Bass, 2006. ment Act of 1974 (PL 93–641), which was signed
Bradburn, Norman M., Seymour Sudman, and Brian
into law by President Gerald R. Ford in January
Wansik. Asking Questions: The Definitive Guide to
1975. This act, repealed in 1986, created Title XV
Questionnaire Design—For Market Research,
and Title XVI of the Public Health Service Act,
Political Polls, and Social and Health Questionnaires.
which addressed health planning and resource
San Francisco: Jossey-Bass, 2004.
Couper, Mick P., Reginald P. Baker, Jelke G. Bethlehem,
development.
et al., eds. Computer Assisted Survey Information
Collection. New York: Wiley, 1998.
Czaja, Ronald, and Johnny Blair. Designing Surveys: A Background
Guide to Decisions and Procedures. Thousand Oaks, Voluntary health-planning efforts began in the mid-
CA: Pine Forge Press, 1996. 1940s, involving community, business, and health
Dillman, Don A. Mail and Internet Surveys: The provider leaders who were usually associated with
Tailored Design Method 2007 Update With New
community chests or the United Way. They con-
Internet, Visual, and Mixed-Mode Guide. 2d ed. New
ducted health planning, coordination, and studies
York: Wiley, 2006.
in local communities using local funding.
Fink, Ariene. The Survey Kit. 2d ed. Thousand Oaks,
During the Great Depression and World War II,
CA: Sage, 2002.
Groves, Robert M., Paul P. Biemer, Lars E. Lyberg, et al.,
there was very little hospital construction in the
eds. Telephone Survey Methodology. New York:
nation. Existing hospitals became obsolete, and
Wiley, 2001. more than 40% of the nation’s counties had no
Groves, Robert M., Floyd J. Fowler Jr., Mick P. Couper, hospitals at all. To address this problem, the U.S.
et al. Survey Methodology. San Francisco: Jossey- Congress passed the Hospital Survey and
Bass, 2004. Construction Act (PL 725) in 1946, better known
Krosnick, Jon A. “Survey Research,” Annual Review of as the Hill-Burton Act (named after the bill’s spon-
Psychology 50: 537–67, 1999. sors Senators Lister Hill [D-AL] and Harold H.
Levy, Paul S., and Stanley Lemeshow. Sampling of Burton [R-OH]). The act established a program
Populations: Methods and Applications. 3d ed. New that provided states with federal matching funds
York: Wiley, 1999. for the construction and modernization of health
592 Health Systems Agencies (HSAs)
facilities. The Hill-Burton program required states by the health-planning agencies or proposed capi-
to develop medical facilities plans in order to guide tal expenditures or changes in services by health
the allocation of federal funds. The Hill-Burton facilities. The programs were also called Deter
program was amended in 1962 so that planning at mination of Need, or DON. These policy initia-
the regional level could be supported using federal tives strengthened the area of health planning
funds in selected areas of the country. HSAs con- because state health-planning agencies, with the
tinued the history of federally sponsored health involvement of “b” agencies, engaged in CON,
planning at the regional level that began with the Section 1122 reviews, or both.
amendments to the Hill-Burton program and pro- Under the Comprehensive Health Planning
vided support for substate planning for medical Program, there were no resources allocated to
facilities. meet the needs identified in plans for health, and
When the Social Security Act was amended in healthcare costs continued to increase at rates
1965 to include the Medicare and Medicaid pro- higher than the overall inflation. During the early
grams, a concern emerged that the demand for 1970s, the hospital industry initiated the volun-
medical services by elderly and poor populations tary effort, or VE, to contain costs, but that
might be overwhelming and that health planning effort failed.
was required. The Comprehensive Health Planning
Act of 1966 (PL 89–749) was passed, which cre-
Establishment and Role of HSAs
ated state health-planning agencies, area-wide
comprehensive health-planning agencies, funding These historical factors set the stage for the pas-
for health planning education and consumer train- sage of PL 93–641, the Health Planning Act. Title
ing, block grants to states, and funding for demon- XV of the Public Health Service Act established
stration programs. state health-planning and development agencies
The areawide comprehensive health-planning (SHPDAs), statewide health coordinating councils
agencies, known as “b” agencies because they (SHCCCs), HSAs, and centers for health planning
were funded under section 314(b) of the act, were (CHPs), for technical assistance and research.
the predecessors of the HSAs. A system of about Under this legislation, states were required to
200 regional comprehensive health planning orga- establish CON programs or risk losing federal
nizations developed plans for health and, in many funds. Each state also defined the geographic
cases, assisted state governments in regulating boundaries of health service areas; HSAs were
capital investments by health facilities. These “b” established to conduct health planning and imple-
agencies were required to have boards of directors mentation activities for each health service area by
with a consumer majority. developing health systems plans (HSPs) and annual
In 1972, amendments to the Social Security Act implementation plans (AIPs). The federal govern-
reflected a national concern over growing healthcare ment, as part of this policy, issued national guide-
costs. These amendments included Section 1122, lines for health planning for use by SHPDAs and
which placed limitations on federal participation in HSAs. In addition, HSAs reviewed the proposed
unnecessary capital expenditures by requiring, in the uses of federal funds in their health service areas,
states where an agreement existed with the federal as well as the appropriateness of existing services.
government, that a designated state-level health- Like the “b” agencies, HSA boards required a
planning agency review and approve proposed capi- consumer majority. The consumers on the boards
tal expenditures by health facilities. Failure to receive had to be representative of the socioeconomic,
approval could result in reimbursement being linguistic, and racial characteristics of the health
excluded for depreciation and interest expense asso- service area.
ciated with the “unnecessary” capital investment Title XVI of the Public Health Service Act called
under the federal Medicare, Medicaid, and Maternal for an area health development fund, requesting
and Child Health programs. $1.00 per capita as seed money toward implemen-
During this period, a few states initiated tation. However, this federal funding was not
Certificate of Need (CON) programs through leg- appropriated during the history of the National
islation or executive order that required approval Health Planning Act.
Health Workforce 593
Current Status
Health Workforce
Federal support for health planning ended in
1986, just 11 years after the National Health
Healthcare in the United States is delivered by a
Planning Act was enacted. At the time, under the
variety of providers. Some of these individuals
Reagan administration, leaders examined health-
hold licenses to practice within a discipline that is
care cost containment strategies, debating the
regulated by some state entity, while others are
effectiveness of government regulation versus that
considered to be unlicensed support personnel.
of free-market competition. The blend of health
Collectively, those individuals who are healthcare
planning with regulation through the CON pro-
professionals and those who work in healthcare
gram made the implementation of health plans by
facilities are referred to as the health workforce.
HSAs difficult and fueled opposition to the pro-
The size and characteristics of the health work-
gram by health providers.
force can be viewed from the perspective of both
While HSAs are no longer funded, health
health professions and healthcare facilities. In
planning at the local level, in some form, contin-
2006, 17.3 million individuals made up the health
ues without federal support in most states. This
workforce, constituting 11.8% of the nation’s
planning is accomplished through the assessment
total workforce, making it one of the largest
and health-planning activities conducted by local
employment sectors in the country.
public health departments and their partners.
The health workforce is diverse in terms of the
educational preparation required for employment.
Richard H. Sewell Some jobs require only limited on-the-job training,
some require college preparation at the associate
See also Access to Healthcare; American Health Planning and baccalaureate levels, others require postgradu-
Association (AHPA); Certificate of Need (CON); ate-level college preparation. Most professions
Health Planning; Hospitals; Public Policy; Rationing that require licensure require at least a college
Healthcare; Regulation degree at the associate degree level.
Health Professions and Occupations

Further Readings
The health professionals traditionally included
Harrington, Charlene, and Carroll L. Estes, eds. Health in the health workforce are physicians, nurses,
Policy: Crisis and Reform in the U.S. Health Care dentists, pharmacists, chiropractors, optome-
Delivery System. 5th ed. Sudbury, MA: Jones and trists, podiatrists, physical therapists, occupa-
Bartlett, 2008. tional therapists, speech-language pathologists,
Melhado, Evan M. “Health Planning in the United States and audiologists. Each of these professions
and the Decline of Public-Interest Policymaking,” requires practitioners to hold a license to prac-
Milbank Quarterly 84(2): 359–440, June 2006.
tice. Some of the licenses are issued to cover
Piper, Thomas R. National Directory of Health
practice in a single jurisdiction, usually a state;
Planning, Policy, and Regulatory Agencies.
others may provide multistate licensure. Most
Columbus, MO: American Health Planning
require some form of national standardized pre-
Association, 2003.
licensure examination.
The title “physician” is reserved for either doc-
tors of allopathic medicine (MD) or doctors of
Web Sites osteopathy (DO). Both of these professions require
American Health Planning Association (AHPA): formal postgraduate preparation beyond the bac-
http://www.ahpanet.org calaureate degree and formalized professional
American Planning Association (APA): practice or residency after licensure before inde-
http://www.planning.org pendent practice is permitted. The area of practice
American Public Health Association (APHA): selected will determine the number of years of
http://www.apha.org residency training required.
594 Health Workforce
Nurses represent the largest segment of the baccalaureate degree is not a requirement for
health professional workforce. Graduates of pro- admission to schools of chiropractic medicine, the
grams leading to the associate, baccalaureate, or professional education is usually 4 years, with
entry master’s degree may be eligible to take the extensive clinical practice. Doctors of podiatric
licensing examination required to become regis- medicine (DPM) focus on care and management
tered nurses (RNs). Advanced education in nursing of conditions of the foot and ankle. Like the chi-
occurs at the master’s and doctoral-degree levels. ropractor, the podiatrist is educated in a 4-year
Advanced-practice licensure is available to nurse first professional degree program, with extensive
practitioners, nurse anesthetists, nurse midwives, clinical work accompanying the education. Podi
and clinical nurse specialists in some states. Nurses atrists may choose to complete additional post-
holding advanced-practice licensure have an graduate training in order to expand their medical
expanded scope of practice over that of RNs. The and surgical skills. Doctors of optometry (OD)
scope is defined in state statutes and through pro- also engage in 4 years of professional education to
fessional accreditation and certification bodies. receive the degree. Although many of the schools
Dentists are educated primarily at the postbac- offering optometry do not require the baccalaure-
calaureate level, with 4 years of professional edu- ate degree as a condition of admission, it is impor-
cation leading to either the doctor of dental science tant to know the regulation of the state licensing
(DDS) or the doctor of dental medicine (DMD) boards with practice jurisdiction. In some states,
degree. The curricula for both degrees are essen- licensure is contingent on completion of not only
tially the same, preparing the practitioner to coor- the first professional degree but also the founda-
dinate oral healthcare for patients. Both degrees tion education.
are considered first professional degrees with post- Physical therapists provide services that help
graduate clinical specialization and advanced restore function, improve mobility, relieve pain,
internships and fellowships available. and prevent or limit permanent physical disabili-
Pharmacists are trained to distribute drugs pre- ties of patients suffering from injuries or disease.
scribed by physicians and other health practitio- They restore, maintain, and promote overall fit-
ners and provide information to patients about ness and health. Physical therapy education has
medications and their use. The scope of practice moved from the baccalaureate level to the gradu-
for pharmacists is established at the state level and ate level in the past 15 years, with the last bacca-
has been expanded in some states to include pre- laureate-level physical therapists graduating before
scriptive authority and administration of immuni- 2002. Just as in 1999, when the decision was made
zations. Education for pharmacy, once at the to move physical therapy education to the gradu-
5-year baccalaureate level, has moved to the 6-year ate level, the professional association is now con-
doctoral level based on a 1989 decision by the sidering establishing the entry physical therapy
American Council of Pharmaceutical Education degree as the professional doctorate. As of January
(ACPE). As in medicine, the doctoral degree in 2007, 167 of the 210 programs offering physical
pharmacy (PharmD) is an entry-into-practice therapy preparation were at the doctor of physical
degree. An internship is also generally required. therapy level. This number has grown from 67
Pharmacists holding licensure prior to the change offering the practice doctorate in 2002.
in educational requirements remain eligible to Occupational therapists help people improve
practice within their discipline unless state law pre- their ability to perform tasks in their daily living
cludes it. Some, however, see the former baccalau- and working environments. They work with indi-
reate-level-prepared pharmacists forced to return viduals who have conditions that are mentally,
to school to remain competitive in the workforce. physically, developmentally, or emotionally dis-
Chiropractors, podiatrists, and optometrists abling. They also help them develop, recover, or
are also educated with doctoral degrees that are maintain daily living and work skills. As in physi-
considered first professional degrees. Doctors of cal therapy, occupational therapy education has
chiropractic (DC) practice a drug-free, hands-on moved from the baccalaureate level to a required
approach to healthcare that includes patient graduate degree, with the last programs converting
examination, diagnosis, and treatment. While the in 2005.
Health Workforce 595
Speech-language pathologists, sometimes called hygiene, and provide other preventive dental care.
speech therapists, assess, diagnose, treat, and help Although most education preparing dental hygien-
prevent speech, language, cognitive-communication, ists is at the associate-degree level, some programs
voice, swallowing, fluency, and other related disor- award certificates, associate degrees, and even mas-
ders. They work with people who cannot produce ter’s degrees. Licensure is required to practice dental
speech sounds, or cannot produce them clearly; hygiene, and a dentist must supervise that practice.
those with speech rhythm and fluency problems, Respiratory therapists evaluate, treat, and care
such as stuttering; people with voice disorders, for patients with breathing or other cardiopulmo-
such as inappropriate pitch or harsh voice; those nary disorders. Practicing under the direction of a
with problems understanding and producing lan- physician, respiratory therapists assume primary
guage; those who wish to improve their communi- responsibility for all respiratory-care therapeutic
cation skills by modifying an accent; and those treatments and diagnostic procedures. Most of this
with cognitive-communication impairments, such practice occurs in the hospital setting. Respiratory
as attention, memory, and problem-solving disor- therapists complete at least an associate degree;
ders. They also work with people who have swal- however, most are required to hold a baccalaureate
lowing difficulties. In 2005, 47 states required degree for practice as therapists.
speech-language pathologists to be licensed if they Physician assistants (PA) emerged as a distinct
worked in a healthcare setting, and all states health profession in the 1970s. As the name
required a master’s degree or equivalent. implies, these professionals work with physicians
Audiologists assist people who have hearing, across all specialty areas and practice settings. PAs
balance, and related ear problems. They examine are formally trained to provide diagnostic, thera-
individuals of all ages and identify those with the peutic, and preventive healthcare services, as dele-
symptoms of hearing loss and other auditory, bal- gated by a physician. Educational preparation for
ance, and related sensory and neural problems. the role varies, but the professional training is usu-
They then assess the nature and extent of the ally at least 26 months in length.
problems and help the individuals manage them. Radiologic technologists and technicians take
The educational preparation for audiologists has X rays and administer nonradioactive materials
moved from the master’s degree to the clinical into patients’ bloodstreams for diagnostic pur-
doctoral degree, and it is expected to become the poses. Some specialize in diagnostic imaging tech-
new standard for licensure in the 49 states where nologies, such as computerized tomography (CT)
audiology practice is regulated. Several states are and magnetic resonance imaging (MRI). Graduation
currently in the process of changing their regula- from an accredited program is generally required
tions to require the doctor of audiology (AuD) for licensure, although the length of education var-
degree or its equivalent. ies from certificate to degree.
Nuclear-medicine technologists administer
radiopharmaceuticals to patients and then monitor
Allied Health Professions
the characteristics and functions of tissues or
Several fields constitute the allied health disciplines organs in which the drugs localize. Education for
or professions. The types of occupations included this field varies from 1 to 4 years, with preparation
under the allied health umbrella vary, but often at the certificate, associate-degree, or baccalaure-
include, dental hygienists, respiratory therapists, phy- ate-degree level. About 70% of the jobs in this
sician assistants, radiologic- and nuclear-medicine field are in hospitals.
technologists and technicians, ultrasonographers, Diagnostic medical sonographers, also known as
medical- and clinical-laboratory technicians and ultrasonographers, use special equipment to direct
technologists, medical-records and health infor- nonionizing, high-frequency sound waves into areas
mation technologists, medical-office assistants, of the patient’s body. Sonographers operate the
emergency medical technicians and paramedics, equipment, which collects reflected echoes and
and licensed practical nurses. forms an image that may be videotaped, transmit-
Dental hygienists remove soft and hard deposits ted, or photographed for interpretation and diagno-
from teeth, teach patients how to practice good oral sis by a physician. Training for this field is similar
596 Health Workforce
in length to that required for radiologic-medicine work under supervision, licensure is required in all
technologists and nuclear-medicine technologists, 50 states and the District of Columbia. To obtain a
although beginning in 2005, at least an associate license, an individual must graduate from an approved
degree was required to be registered. Unlike most of program and pass a standardized test (NCLEX-PN).
the other professions described, a license to practice Most educational programs are 1 to 2 years in length,
is currently not required. More than 50% of those some leading to a certificate of completion or
employed in the field work in hospitals. diploma, and others leading to an associate degree.
Medical- and clinical-laboratory technologists
and technicians perform complex chemical, bio-
logical, hematological, immunologic, microscopic, Other Personnel
and bacteriological tests. The usual requirement
There are a variety of other support personnel
for an entry-level position as a clinical-laboratory
included in the estimated 4.5 million individuals
technologist is a bachelor’s degree with a major in
who are classified as part of the healthcare work-
medical technology or in one of the life sciences.
force because they work in healthcare settings.
Registration and licensure are required in some but
The list of categories of personnel classified as
not all states.
other support changes as new fields in healthcare
Medical records and health information man-
are developed, new ways of delivering healthcare
agement professionals are responsible for the data
are created, and workforce specialization contin-
storage, archiving, and retrieval of health informa-
ues to develop. These other individuals include
tion. Education for this occupation occurs at both
patient services support staff, such as nursing
the associate- and the baccalaureate-degree levels.
assistants, orderlies, and technicians; non-pa-
As attention has been directed to the privacy
tient-care services, such as food services and
concerns relating to electronic medical records and
janitorial/cleaning personnel; and administrative
the federal Health Insurance Portability and
staff.
Accountability Act (HIPAA), the complexity of
health information management has increased.
Medical-office assistants perform administrative
Healthcare Settings
and clinical tasks to keep the offices of physicians,
podiatrists, chiropractors, and other health practi- Just as there is great variety and diversity in the
tioners running smoothly. The job responsibilities healthcare professions and occupations, there also
vary vastly based on the setting. Formal education, is great variety in the places where healthcare
if required, is usually at the vocational and techni- workers are employed. Although hospitals, includ-
cal levels, requiring 1 to 2 years of training. ing acute-care, psychiatric, and specialty facilities,
The specific responsibilities of emergency medi- employ the largest segment of the health work-
cal technicians (EMTs) and paramedics depend on force, there are other types of healthcare settings.
their level of qualification and training. These These other types of facilities include nursing and
health professionals provide field emergency assis- personal-care facilities; home health care organiza-
tance in incidents such as automobile accidents, tions, offices, and clinics; and medical and dental
heart attacks, drowning, childbirth, gunshot laboratories. More than 13 million members of the
wounds, and disaster management, where immedi- health workforce, or 8.9% of the overall work-
ate medical attention is required. EMTs have addi- force, work in designated healthcare facilities.
tional advanced training to perform more difficult Hospitals collectively account for 41% of the
prehospital medical procedures. Completion of a total health workforce employed in healthcare set-
specialized training and certification process is tings in the nation. The second largest segment of
required, and most states require that EMTs and employment is in nursing and personal-care facili-
paramedics get recertified every 2 years. ties, where an additional 21% are employed. Offices
Licensed practical nurses (LPNs), or licensed voca- of physicians, dentists, and other health profession-
tional nurses (LVNs), care for the sick, injured, con- als combined employ approximately 26%, with the
valescent, and disabled under the direction of remainder spread between ambulatory-care facili-
physicians and RNs. Although LPNs and LVNs ties, laboratories, and home health care.
Healthy People 2010 597
The size of the health workforce in hospitals is Committee on the Future of Health Care, Workforce for
one of the major reasons why attention is directed Older Americans, Board on Health Care Services.
toward issues identified as effecting hospital care Retooling for an Aging America: Building the Health
delivery. For example, as the largest employer of Care Workforce. Washington, DC: National
nurses, the reported vacancy rates and the length Academies Press, 2008.
of time required to fill RN positions have driven Druss, Benjamin G., Steven C. Marcus, Mark Olfson,
workforce development initiatives to improve the et al. “Trends in Care by Nonphysician Clinicians in
supply of nurses. Strategies to increase the number the United States,” New England Journal of Medicine
348(2): 130–37, January 9, 2003.
of RNs as direct-care providers, including the use
Fried, Bruce, and Myron D. Fottler, eds. Human
of patient simulation, have significantly influenced
Resources in Healthcare: Managing for Success.
the education of nursing students.
3d ed. Chicago: Health Administration Press, 2008.
There is significant regional variation in which
type of healthcare entities employ the health work-
force. For example, ambulatory-care settings, includ-
ing offices, clinics, and similar facilities, employ Web Sites
significantly more of the health workforce in the Bureau of Health Professions (BHPr):
western states and Florida, while hospitals are even http://bhpr.hrsa.gov/healthworkforce
larger employers in the northwest mountain states. Bureau of Labor Statistics (BLS): http://www.bls.gov
Center for Health Workforce Studies (CHWS):
http://chws.albany.edu
Other Employment Settings
The health workforce also comprises more than 4
million health professionals who work in settings
that are not traditionally counted as healthcare Healthy People 2010
facilities. Almost all health professionals working
in these alternative settings hold professional Healthy People 2010 is the latest in a once-per-
degrees. In most cases, they also have licenses to decade series of reports produced by the federal
practice within their discipline. Some of these set- government to chart the state of America’s health.
tings include consulting firms, educational set- The principal purpose and long-standing theme of
tings, insurance companies, pharmaceutical and Healthy People is to promote health and prevent
equipment sales, and law firms. Some health pro- illness, disability, and premature death. The exten-
fessionals work in other settings where their edu- sive report is composed of 467 health objectives
cational preparation is not related to their role. As organized into 28 focus areas under 2 overarching
shortages in many professions grow, more atten- goals: (1) increase quality and years of healthy life
tion is being directed to reengaging some of these and (2) eliminate health disparities. While very
workers in health services settings. comprehensive and seemingly daunting in scope,
Healthy People 2010 is intended to be used by a
Linda F. Samson
variety of public health, professional, and com-
munity audiences and is formatted into three
See also Access to Healthcare; Complementary and
parts, each providing a different focus and level of
Alternative Medicine; Licensing; Nurse Practitioners
content detail. Available as a document, Healthy
(NPs); Nurses; Pharmacy; Physician Assistants; Physicians
People is most accessible in an electronic format
on the Internet.
Further Readings
Bureau of Health Professions. Physician Supply and
Purpose
Demand: Projections to 2020. Washington, DC: U.S.
Department of Health and Human Services, Health In its 25-plus-year history, Healthy People has
Resources and Services Administration, Bureau of served several interrelated purposes. First, it is a
Health Professions, 2006. strategic plan for improving health presented
598 Healthy People 2010
through a comprehensive array of related health of state, local, and private-sector efforts against
objectives that set measurable targets for health Healthy People targets.
improvement efforts by all levels of government Finally, Healthy People establishes, as national
as well as the private sector and community policy, efforts that improve population health by
healthcare agencies. Most states and many locali- increasing quality and years of healthy life and
ties, along with nongovernmental agencies, have eliminating health disparities, the two goals of
adopted the Healthy People objectives in their Healthy People 2010. Indeed, Healthy People is as
own plans and programs or have used these close as the United States has ever come to a
objectives as the underlying rationale for their national policy on health.
efforts.
Second, it is a compendium of summary health
Origins
statistics on the leading causes of death, illness,
and disability arrayed by race/ethnicity, age, and The original, Healthy People: The Surgeon
socioeconomic status, and for multiple time peri- General’s Report on Health Promotion and
ods. Healthy People is one of the most frequently Disease Prevention, was released by U.S. Surgeon
referenced data sources by health services research- General Julius Richmond in 1979 to focus the
ers, policy analysts, planners, and health adminis- nation on health promotion and illness preven-
trators in presenting baseline information on tion at a time when the federal government was
various health conditions. increasingly concerned about the decade-long
Third, Healthy People establishes a framework unabated rise in national healthcare spending.
for understanding the determinants of health As the vast bulk of this spending was on medical
placed within a broad systems context that recog- care to treat illness and disability, it was believed
nizes that health is more than the presence or that a greater emphasis on promoting health and
absence of medical care. The health of individuals preventing illness might slow the growth in
and communities is determined by a variety of fac- healthcare costs. At the time, the United States
tors, including individual biology and behavior, was experimenting with national health plan-
the physical and social environment, broader poli- ning as a way to better coordinate a fragmented
cies and interventions that improve community and pluralistic healthcare system, which is com-
health, along with access to quality healthcare ser- posed of thousands of independent private and
vices. Healthy People and this framework have public healthcare providers, each determining
been widely included in public health textbooks, individually what services would be provided to
graduate-level courses, and professional-education which populations or market areas. Unlike other
programs. industrialized countries, market forces are the
Fourth, Healthy People is a report card that can primary organizing mechanism, with govern-
be used to gauge progress and establish perfor- ment, mainly involved at the state and local
mance standards and accountability for the vast levels, playing little role beyond minimal regula-
American healthcare enterprise of public health tion of quality, life safety, or professional stan-
and health services delivery. Its cradle-to-grave dards. National health planning introduced a
approach reports the state of the nation’s health mechanism for coordinating health services at
from infant mortality to the chronic conditions the local level, with strong guidance of these
and causes of death most often associated with old efforts from the states and by the federal govern-
age. At least two national reports issued by the ment. National objectives for the availability of
federal government, one for 1990–2000 and the medical-care services had been set, and the state
other after the year 2000, reported on progress of and local health-planning agencies were charged
the nation in meeting the Healthy People objec- with using these standards to plan more effective
tives. Both reports scored the nation’s efforts, not- and less expensive state and local healthcare
ing both progress and deficiencies, and used the systems.
results to exhort policymakers in the public-health Healthy People was an extension of these
and medical-care arenas toward greater action. efforts, moving beyond goals for access to health-
Myriad other reports have graded the effectiveness care services to goals for reducing the illnesses and
Healthy People 2010 599
health conditions underlying the need for these attention was also given to improving the health
services. Taking a life-stage approach, Healthy status of population groups demonstrating higher
People 1979 set 15 specific goals and subgoals for risk for a particular disease or condition. Feasibility
reducing morbidity and mortality in five stages of of achievement was more explicitly taken into
life—infancy, childhood, adolescents/young account in setting objective targets to make the
adults, adults, and, finally, older adults. In addi- objectives for the year 2000 more realistic, and a
tion to these specific targets, another 15 recom- workbook was developed to facilitate implementa-
mendations were offered, organized around tion of the objectives at the state and local levels.
preventive health services, health protection, and
health promotion. Patrick Lenihan
See also Acute and Chronic Diseases; Disease; Health

A National Health Improvement Plan Planning; Morbidity; Mortality; Mortality, Major
Causes in the United States; Public Health; Public
The 1979 Surgeon General’s Report was more an
Policy
agenda and a statement of national health policy
than an implementable plan. And in 1980, a com-
panion piece—Promoting Health/Preventing
Disease: Objectives for the Nation—set forth 226 Further Readings
specific, measurable health objectives in a plan of Andrulis, Dennis P., Lisa M. Duchon, and Hailey M.
action for reaching the Healthy People goals. Reid. Healthy Cities, Healthy Suburbs: Progress in
These objectives, referred to as “the 1990 health Meeting Healthy People Goals for the Nation’s 100
objectives,” called for improvements in health Largest Cities and Their Suburbs. Brooklyn: SUNY
status, risk reduction, public and professional Downstate Medical Center, 2002.
awareness, health services and protective mea- Benbow, N., ed. Big Cities Health Inventory: The Health
sures, along with surveillance and evaluation. of Urban America, 2007. Washington, DC: National
Development of the 1980 report involved con- Association of County and City Health Officials,
sultations with and comments from more than 500 2007.
individuals and organizations from the private and Keppel, Kenneth G. “Ten Largest Racial and Ethnic
governmental sectors. This highly participative Health Disparities in the United States Based on
development process was followed in the two sub- Healthy People 2010 Objectives,” American Journal
sequent versions of Healthy People, which involved of Epidemiology 166(1): 97–103, July 1, 2007.
as many groups as possible in the early stages, Keppel, Kenneth G., Jeffrey N. Pearcy, and Richard J.
including comments from the public. This partici- Klein. Measuring Progress in Healthy People 2010.
patory process was formalized into the Healthy Statistical Notes, No. 25. Hyattsville, MD: National
Center for Health Statistics, September 2004.
People Consortium as the organizational vehicle
Maiese, Deborah R., and Claude Earl Fox. “Laying the
for the development of Healthy People 2000 and
Foundation for Healthy People 2010. The First Year
the 2010 report.
of Consultation,” Public Health Reports 113(1):
Achievement of the 1990 Healthy People objec-
92–95, January–February 1998.
tives was mixed, with success in areas such as U.S. Department of Health and Human Services, Office
hypertension, childhood infectious diseases, and of the Surgeon General. Healthy People: The Surgeon
injury prevention. Progress toward other objec- General’s Report on Health Promotion and Disease
tives was slower, and new health challenges Prevention. Washington, DC: U.S. Department of
emerged. It was clear by middecade that an Health and Human Services, 1979.
updated Healthy People for the year 2000 would U.S. Department of Health and Human Services.
be needed. This version expanded the scope of the Promoting Health/Preventing Disease: Objectives for
effort to 339 objectives organized into 21 priority the Nation. Washington, DC: U.S. Department of
areas, including new areas such as cancer and HIV Health and Human Services, 1980.
infection. The emphasis on prevention was U.S. Department of Health and Human Services. Healthy
increased, with inclusion of more screening to People 2010. 2 vols. Washington, DC: Government
detect diseases before symptoms appeared. Specific Printing Office, 2000.
600 Home Health Care
Web Sites benefits. And a U.S. Supreme Court ruling in the

Healthy People 2010 Online Documents: 1999 Olmstead v. LC case, which determined that
http://www.healthypeople.gov/Document institutionalization should be the last resort for
National Center for Health Statistics (NCHS), Healthy people with mental disabilities, has also increased
People 2010: http://www.cdc.gov/nchs/hphome.htm the demand for home health care.
Types of Services Provided

Home health care covers a broad spectrum of
Home Health Care diagnostic, therapeutic, and social support ser-
vices. The medical component of home health
Home health care usually consists of formal, care is advised by a physician and is usually
skilled healthcare provided by licensed profession- administered by a physician assistant or nurse
als in a patient’s home on the advice of a physi- practitioner. It includes the professional services
cian. Originally applicable to only posthospitalization of a physician, nurse, dentist, podiatrist, rehabili-
patients, it now encompasses care for people of all tation specialist, psychologist, dietitian, optome-
ages at risk for institutionalization. The aim of trist, and social worker at home. In terms of
home care is to enable the sick and the disabled to Medicare, a single episode of home health care
live independently with dignity in the comfort of cannot exceed more than 60 days. While the
their homes during recovery and rehabilitation, number of subsequent episodes is unlimited, each
close to the support of family and friends. Home has to be certified by the caring physician as
care is generally used for patients who have been required for reimbursement purposes. Skilled
discharged from the hospital and need skilled care care in nursing, speech therapy, and physical/
and rehabilitation, older adults with functional occupational therapy are provided by trained
limitations, children with special needs, people medical professional staff, who administer, moni-
with severe physical or mental disabilities, veter- tor, and evaluate healthcare. Other services
ans, and people with HIV/AIDS. include medical-social services and assistance
from a home health aide (reimbursable only when
recommended for people receiving skilled care).
History
The duties of the home health staff are to follow
Home health care provided by non–family mem- the physician’s orders, adhere to prescribed rou-
bers emerged as an option in the United States tines, monitor general health and medications,
during the early 20th century. Efforts to reduce teach informal caregivers and patients themselves
costs and improve conditions for the acutely ill to ensure continuity of care, and arrange all
and newborn babies and their mothers were aspects of prescribed care. It is the responsibility
spearheaded by the Metropolitan Life Insurance of Medicare-certified agencies to keep the attend-
Company in 1909. The Voluntary Nurses ing physician up-to-date on the patient’s condi-
Association (VNA), now in existence for more tion and requirements; other agencies are exempt
than a century, provided home care to the sick. from this requirement.
When a shortage of physicians stimulated the The services provided by home health care
expansion of home-based nursing services during agencies can be broadly classified into five groups:
World War II, home care was transformed to its (1) medical/skilled nursing, (2) equipment and/or
present form. The federal government became medications, (3) personal-care services, (4) thera-
involved in home care following the Kerr-Mills peutic services, and (5) psychosocial services. In
recommendations to give aid to medically needy 2004, about 75% of Medicare home health care
Americans 65 years of age or older; benefits were patients received skilled nursing care, while
extended in 1965 to include disabled and depen- less than 2.5% received physician care. Total per-
dent children. The 1988 Duggan v. Bowen court sonal care, composed of continuous home care,
case expanded coverage criteria for home health a companion, homemaker/household (including
Home Health Care 601
meals-on-wheels) services, transportation, and of agencies exist in rural areas, where just 21% of
respite care, is received by nearly 45%. Therapeutic- home health care agencies are located. In urban
care services, in the form of dietary and nutri- areas, the average length of service was 312 days,
tional services; physical, occupational, respiratory, with a median of 76 days, while rates in rural areas
or speech therapy; and other high-tech care, is were about 1.5 times higher. The maximum length
received by nearly 37% of home health care of service was reported by for-profit agencies, with
patients. Nearly 13% were recipients of durable the shortest service by voluntary nonprofit agen-
medical equipment (DME) and medications, and cies. Median lengths of service provided to those
psychosocial services, consisting of counseling older or younger than 65 years of age were similar,
and psychological, social, or spiritual care, were though the average duration of care for women
provided to about 12% of total home care was 1.25 times longer than for men.
patients. Staffs of home health care agencies are primar-
High-tech home health care is a growing com- ily composed of professional and vocational nurses
ponent, constituting nearly 25% of total home (45%) and home health aides (39%), with the
care spending. It has allowed early discharge of remainder consisting of physical, occupational,
seriously ill patients who need intermittent or con- and speech therapists, and social workers.
tinuous skilled nursing care, with hospices provid-
ing the bulk of care. Close coordination between
Accreditation and Licensure
physicians, nurses, pharmacists, equipment sup-
pliers/technicians, home health care agencies, and Accreditation is a voluntary process in which home
family members provides 24-hour care and moni- health care agencies seek a “stamp of approval”
toring of patients, devices, and drugs. Perceived as from respected nonprofit organizations certifying
more cost-effective than hospitalization, more that the agency meets national standards of care.
health insurance companies and employer-based Licensure and certification are issued by a govern-
benefit plans have made high-tech home health ment agency (federal or state) and are usually
care reimbursable. necessary to seek reimbursements for home health
care. Licensure and certification requirements
may vary by state. Often, licensure regulations are
Home Health Care Agencies
minimal and may not require an on-site survey.
The federal Balance Budget Act of 1997 signifi- Different standards apply to agencies certified by
cantly curtailed Medicare reimbursements of home Medicare and private agencies, with Medicare
health care agencies, resulting in the closure of having more stringent standards requiring a larger
nearly one third of the nation’s agencies, particu- investment.
larly in underserved and rural areas. Medicare’s
hospital prospective payment system (PPS), which
Profile of Patients and Demand
was implemented in 1983, caused a shift of service
provision away from VNAs and local health The majority of individuals receiving home health
departments to the hospital and insurance sectors, care are elderly. At least 2 million individuals in
which formed their own agencies and links to the nation, half of whom are 65 years of age or
streamline posthospitalization care. older, are permanently homebound; millions more
National statistics from 2004 show that 8,100 are temporarily homebound with illness or injury;
Medicare-certified home health care agencies pro- and they all need home health care of some kind,
vided care to nearly 2.4 million disabled and whether intermittent, part-time or continuous,
elderly people. The majority (57%) of these agen- skilled or unskilled. The great increase in the
cies were voluntary nonprofit organizations, 34% aging and disabled populations due to increased
were for-profits, and the rest were government longevity as a result of advances in medicine and
owned. About two thirds of them have affiliations technology will continue to fuel a demand for
with hospitals, corporations, or health mainte- home health care in the years to come. According
nance organizations (HMOs). A disparate number to the 2000 U.S. Census of Population, nearly two
602 Home Health Care
thirds of the 1.3 million individuals receiving payments, while private insurance pays about
home health care were females. Detailed data 25%, and Medicaid and out-of-pocket payments
from 2004 show that more than 1 million indi- each account for about 20%.
viduals receiving home health care were White, Medicare regulations require that a licensed
compared with 200,000 who were Black, Asian, physician, who also certifies the need for intermit-
Pacific Islander, or other racial group combined. tent skilled-nursing and/or rehabilitation care,
Marital status influences the services used for declare enrollees “homebound.” Being home-
home health care. Widowed individuals accounted bound implies that leaving home requires a con-
for 35% of patients seeking the maximum siderable effort; is usually performed only with
Medicare benefit, while married people repre- supportive devices, special transportation, or
sented 32%. Only 18% of those who were single another person; and occurs infrequently. To be
or never married were provided services, and the eligible for Medicaid coverage, the individual
rest have unknown marital status. About two must meet financial eligibility criteria and other
thirds of the individuals receiving home health parameters that differ significantly from state to
care live with family members, less than a third state. Provision of long-term care services is man-
live alone, while the remaining live with nonfam- datory in all states for individuals who are
ily members or have unknown living arrange- Medicaid eligible and qualify for institutional
ments. More than 80% have a primary caregiver, care. Similar criteria are in place for most private
typically a spouse or child/child-in-law. About and public agencies that pay for home health care.
10% rely on paid help, and the remaining 5% rely Government insurance programs severely restrict
on friends and neighbors or others. the extent of home health care services, treating
them as a complement to family care. Seeking
reimbursable home care is generally a cumber-
Patients’ Rights
some, long-winded process.
Individuals who use home health care services
from accredited Medicare and other agencies have
Problems in Home Health Care
certain patients’ rights. They have a right to
choose their own recognized agency, be treated Home health care agencies are governed by their
with respect, appoint family or guardians to act own rules and regulations. Personnel are usually
on their behalf, receive a copy of their planned available only on weekdays between 9 a.m. and 5
care itinerary, complain about inefficient services, p.m., and there is no assurance that the same indi-
and expect continuity of care. Home health care viduals offer treatment, to build patient confidence
agencies are responsible for ensuring competency and ensure continuity of care. Rescheduling is not
and continuity of care. uncommon, which may disrupt family routines
and clash with the schedule of other caregivers.
Retention and lack of qualified staff, particularly
Costs, Funding, and Eligibility
nurses who provide the bulk of services, in this
The total national costs for home health care sector is a frequent problem. Delays in payment
were nearly $40 billion in 2000. Of the total from government agencies are the norm, making it
costs, $30 billion was spent on providing skilled difficult for agencies to meet financial deadlines.
and unskilled care, while the remaining $10 bil- Meeting the regulatory guidelines of Medicare and
lion accounted for expenditures on home respira- Medicaid, which are major suppliers of home
tory ($3.5 billion) or infusion therapy ($4.5 health care, involves extensive paperwork and
billion) and DME. The total national costs of multiple billings. Quality assurance and account-
home health care are projected to be nearly $60 ability of noncertified agencies is nonexistent.
billion by 2010. Access to home health care agencies may be diffi-
Payments for home health care are covered by cult, particularly outside urban areas. Medicaid
a variety of providers. The government pays for recipients must often “spend down” to meet eligi-
more than half the total national home health bility criteria. Disparities exist, with the uninsured
care costs. Medicare accounts for nearly 30% of and poor consuming fewer services. Overall, home
Hospice 603
health care is labor intensive, and the out-of- Web Sites

pocket costs may not be sustainable for long even Home Health Nurses Association (HHNA):
among the relatively affluent population. http://www.hhna.org
Medicare.Gov—Home Health Compare:
Future Implications http://www.medicare.gov/HHCompare
National Association for Home Care and Hospice
Home health care is likely to increase in the future (NAHC): http://www.nahc.org
as people increasingly live longer but do not retain National Center for Health Statistics (NCHS):
the ability to lead independent lives due to infirmi- http://www.cdc.gov/nchs
ties of normal aging coupled with disabilities due to
chronic diseases. In an era where families are
smaller, more nuclear, and living further apart, tra-
ditional family caregivers are becoming scarce.
Currently, state and private agency support is inad- Hospice
equate to provide sustenance to all the needs of
chronically disabled individuals. Home health care Hospice is a philosophy as much as it is a concept.
is an attractive alternative to institutionalization as It is a fundamental belief in a peaceful and ratio-
it promotes independence, provides better quality nal end of life directed by the person and not by
of life, and is more cost-effective than prolonged healthcare or payment systems, or laws. Hospice,
hospitalization. Though Medicare and Medicaid as a concept, is the treatment for pain and suffer-
strive to meet these needs, more must be done, such ing, with the recognition and acceptance that cure
as health services researchers focusing on this aspect is not possible. Multidisciplinary teams, often
of providing equitable long-term healthcare. including volunteers, join patients, their families,
and friends in creating a peaceful end-of-life expe-
Karen E. Peters, Benjamin C. Mueller, rience. Medicare and Medicaid benefits are now
Sunanda Gupta, and Nicole E. Stoller available for hospice care, making it a more viable
choice for many. In 2007, the number of Medicare-
See also Access to Healthcare; Continuum of Care; or Medicaid-approved hospice facilities in the
Disability; Hospice; Long-Term Care; Medicaid; nation totaled 3,078. These facilities provided
Medicare; Nurses services to more than 1.3 million individuals and
their families.
Further Readings History

Duggan v. Bowen, 691 F. Supp. 1487 (D.D.C. 1988). In ancient times, “hospitium” was a concept that
Harris, Marilyn, ed. Handbook of Home Health Care
dictated that travelers, passing through, were
Administration. 5th ed. Sudbury, MA: Jones and
given hospitality, including clothing and entertain-
Bartlett, 2009.
ment in private homes. Hosts and travelers knew
Magee, Mike. Home-Centered Health Care: The Populist
each other or were part of a family known to the
Transformation of the American Health Care System.
Woodbury, CT: Spencer Books, 2007.
host. More public hospitality, perhaps between
Marrelli, Tina M., and Patrice D. Artress. Handbook of
two cities rather than families, was seen in ancient
Home Health Standards and Documentation Roman times. During the Middle Ages across
Guidelines for Reimbursement. 5th ed. St. Louis, Europe, travelers might find hospitium in hospitia,
MO: Mosby-Elsevier, 2009. buildings attached to monasteries. Hospitia came
Olmstead v L.C., 119 S. Ct. 212187 (1999). to serve travelers making holy pilgrimages and the
Prieto, Emily. Home Health Care Provider: A Guide to sick. Essentially, the hospitia were guesthouses
Essential Skills. New York: Springer, 2008. offering shelter, food, and comfort for the weary.
Smith, Sheri, Rosalind Ekman, and Lynn Pasquerella. As in the past, the modern-day hospice provides
Ethical Issues in Home Health Care. 2d ed. care and comfort to the weary traveler. Only
Springfield, IL: Charles C. Thomas, 2008. today, the journey is to the end of life.
604 Hospice
Modern-day hospice began in England during family as a unit. As a philosophy of care, it can be
the mid-1960s, when Dame Cicely Saunders, a implemented in a variety of settings. Individuals
physician, established St. Christopher’s Hospice in can receive hospice services in their own homes, a
London. It was a facility characterized by light, nursing home or other residential facility, a hospi-
gardens, small groupings of patients, and areas for tal, or a freestanding hospice facility. Most recipi-
families to gather. The care received in this envi- ents obtain care in their own home or in nursing
ronment translated the philosophy into modern homes. The care team consists of family, physician,
practice. Florence S. Wald, the dean of the Yale registered nurse, patient-care assistant, chaplain,
School of Nursing, opened the first hospice in the social worker, psychologist, dietitian, volunteer,
United States in Connecticut in 1974. and bereavement counselors for the loved ones.
An individual’s family or friends may refer the
individual to a hospice, but a physician must docu-
Definition
ment the diagnosis and life expectancy of the indi-
The word hospice originates from the Latin hospi vidual. Persons with less than 6 months to live are
tium, meaning a guesthouse. This origin perpetu- eligible for hospice benefits through Medicare, and
ates the confusion that hospice is always a unique Medicaid in 43 states. Many private health insur-
and specific place. While there are facilities that ers also offer hospice coverage. Hospice recipients,
are either partially or entirely used for hospice with physician input, may receive more than 6
care, the place is not the most important compo- months of hospice services when they live beyond
nent. The essential components of hospice as a the original life expectancy.
philosophy are the unwavering commitment to In terms of national statistics (2006), the aver-
relief of pain and suffering when a person is diag- age length of service in a hospice is 59 days, and
nosed with a life-limiting disease, an unyielding the median length of service is 21 days. Most
belief in the irreducible wholeness of personhood recipients obtain care in their own homes (47%) or
that addresses the meaning of life and death, the in nursing homes (22%). Most of those in hospice
quality of life and death, an understanding of have a cancer diagnosis (44%), followed by heart
spirituality, and a steadfast dedication to the right disease (12%) and those with dementia (10%).
to make choices and decisions about one’s own Other medical conditions include, but are not lim-
care at the end of life. ited to, lung, liver, or kidney disease, HIV/AIDS,
Hospice is not about suicide, euthanasia, or stroke, or motor neuron diseases. The majority
absence of care; nor is it about the prolonging of (81%) of hospice recipients are Caucasians, fol-
life or the quickening of death. It is about provid- lowed by African Americans (8%), and Asians,
ing comfort and palliative care at the end of life, Hawaiians, or Pacific Islanders (2%). Most hos-
when the treatment of a disease is no longer pice recipients are 65 years of age or older (81%).
appropriate or possible. Palliative care is defined Specifically, 65- to 74-year-olds account for 17%
as the relief of pain, suffering, and stress caused of the total admissions, 75- to 84-year-olds for
by illness and disease. Services are directed at 31%, and 85-year-olds and older for 33%.
both the individual and the family. The individual
is assured that relief of pain and suffering are
Components of Hospice
paramount in all endeavors. The family is com-
forted by the attention to the relief of the pain and Prior to a hospice admission, a meeting occurs
suffering and supported through the grieving pro- with the individual, the physician, the hospice rep-
cess that accompanies a rational and dignified end resentative, and the family (as appropriate). In this
of life. meeting, discussions about the diagnosis, goals of
care, and types of support occur. Specifically, hos-
pice focuses on the physical, psychosocial, and
Hospice Philosophy and Services
spiritual needs of its recipients. Emphasis is placed
The overarching goal of hospice is to ensure com- on the relief of symptoms (pain, shortness of
fort and dignity to the dying individual and the breath, and muscle spasm), thereby promoting
Hospice 605
comfort for the individual. The individual, as long and Medicaid) for care provided must abide by an
as possible, directs the care provided; and when no individual’s advanced directive. All 50 states recog-
longer able to direct this care, his or her wishes are nize the legality of advanced directives. However,
followed until death occurs. each state uses its own version, but all are essen-
If individuals move into a facility wherein hos- tially the same.
pice, as a philosophy of care, is practiced, they are An advance directive is created before the need
encouraged to create a home environment with arises. A living will and a durable power of attorney
their own furniture, linen, photographs, and music. (for healthcare, as separate from all other arenas)
Individuals determine their visitors and visiting are two major components. Individuals create liv-
hours and use their own clothing, and family or ing wills to address the type and amount of health-
friends are encouraged to prepare food, especially care to be provided at the end of life and/or when
the patient’s favorite foods. The goal of creating a they cannot communicate their wishes, such as in a
hospice facility is to make the environment like an healthcare emergency. A durable power of attorney
individual’s home while providing the expert care is another document that identifies the person who
needed to alleviate pain and suffering. the patient authorizes to make decisions when he or
After death occurs, hospice provides loved ones she is unable, for example, to execute the terms of
with bereavement counseling. This has a variety of the living will. Each state has specific regulations
forms, from personal telephone calls to letters, and laws as to what a durable power of attorney
support groups, and individual counseling, to can and cannot authorize with regard to an indi-
annual services that honor all who have died in a vidual’s healthcare, but the key is that a specific
specific hospice. person is designated by the individual in advance of
The Hospice Association of America (HAA), an the need. The individual makes the decision to
affiliate of the National Association for Home appoint the said individual freely and without any
Care and Hospice (NAHC), developed a Hospice type of coercion. The person so designated speaks
Patient’s Bill of Rights that is based on dignity and on the individual’s behalf when he or she is no lon-
respect for all recipients; the ability to make deci- ger able to, advocates the plans the individual made
sions regarding care, privacy, and confidentiality; and documented in the living will, and is the deci-
knowledge of financial charges and payments; and sion maker when healthcare consent is required.
the right to the highest quality of care. These rights While advanced directives are legal documents,
are embraced widely by the nation’s hospices. there is no requirement that attorneys create them.
There are no specific forms or formats required,
although forms are readily available. An adult-age
Advanced Directives
individual with decision-making capacity may cre-
As the hospice philosophy and practices gained ate and/or change a living will at any time and
acceptance, there emerged a need to have a resource designate a person who will have durable power of
to guide the family and caregivers when individuals attorney in healthcare matters. In most states, the
were no longer able to speak for themselves or to advance directives need to be witnessed by two
make decisions. Thus, advanced directives were cre- parties. The signatures affirm that the person sign-
ated. By definition, an advanced directive is a state- ing the living will is indeed whoever it states it is,
ment of what healthcare an individual wishes to that this person is of sound mind at the time of the
receive or not receive when that person no longer signature, and that the documents are signed freely.
possesses the capacity to make a healthcare decision Both the living will and the durable power of attor-
and/or is not able personally to address the issue. In ney documents should be shared with the individ-
1990, the U.S. Congress passed legislation that cre- ual’s loved ones and healthcare providers so that
ated the Patient Self Determination Act. This act they are available when the need arises.
mandates that healthcare providers and healthcare Advance directives are the legal system’s way of
agencies ensure that patients have information and assisting an individual in determining the quality
education about advanced directives. Furthermore, of life at the end of life. Like hospice, advance
any agency that accepts federal funds (i.e., Medicare directives neither prolong life nor hasten death.
606 Hospital Closures
They provide healthcare providers with the treat- Web Sites

ment wishes of individuals at the end of life. American Academy of Hospice and Palliative Medicine
(AAHPM): http://www.aahpm.org
Future of Hospice Hospice Foundation of America:
http://www.hospicefoundation.org
In an era of growing consumerism in the United National Association for Home Care and Hospice
States, individuals are increasingly educated about (NAHC): http://www.nahc.org
their bodies and their medical conditions. Most National Hospice and Palliative Care Organization
individuals want to be fully informed and actively (NHPCO): http://www.nhpco.org
involved in decisions about and for them. To
many, quality of care is as important, if not more
important, than the quantity of care. At the same
time, pain and suffering are unacceptable, and all Hospital Closures
efforts must be made to alleviate them. Additionally,
death and conversations about death and dying As the nation’s healthcare system continues to
often are feared and delayed. Discussions typically evolve, the role and need for hospitals is changing.
occur only when faced with major decisions and Sophisticated patient care technology is no longer
in a highly emotional context. the exclusive domain of hospitals. Some of the
Hospice as a philosophy encourages quality of most advanced breakthrough technology does not
life at the end of life. It promotes neither artificial require traditional healthcare settings. The phar-
prolongation of life nor artificial hastening of maceutical sector has grown, basing its economic
death. Hospice is about determination and choice, justification on the ability to prevent hospital
quality of life and not quantity, advocacy for self care. Physicians and a variety of commercial ven-
and others, relief of pain and suffering at the direc- tures have become competitors for the business of
tion of the individual, and a rational and peaceful healthcare that once routinely went to hospitals.
end to life as we currently know it. As a result of these changes, many hospitals may
be at risk of closing in the future. Therefore, it is
E. Carol Polifroni and Lynn Allchin important for health services researchers to assess
both the factors associated with hospital closures
See also Cost of Healthcare; Home Health Care; Long- and the effect that those closures have on the com-
Term Care; Medicaid; Medicare; Nursing Homes; munity a hospital serves.
Pain; Quality of Healthcare There have been several evaluations of the
determinants associated with hospital closings.
Further Readings There is also some literature concerning the impact
of hospital closings on other available institutional
Armstrong-Dailey, Ann, and Sarah F. Zarbock, eds.
services, as well as the economic impact of hospital
Hospice Care for Children. 3d ed. New York: Oxford
closings on the community. However, there is very
little literature evaluating the specific health impacts
Fine, Perry G. The Hospice Companion: Best Practices
for Interdisciplinary Assessment and Care of
of hospital closings on the populations remaining
Common Problems During the Last Phase of Life.
in their former service areas.
New York: Oxford University Press, 2008. This entry begins by presenting recent hospital
Fisher, Kenneth A., Lindsay E. Rockwell, and Missy trends and defining hospital closure. Then, it dis-
Scott. In Defiance of Death: Exposing the Real Costs cusses the roles of hospitals and the causes and
of End-of-Life Care. Westport, CN: Praeger, 2008. implications of hospital closures.
Richardson, Ann. Life in a Hospice: Reflections on
Caring for the Dying. Oxford, UK: Radcliffe, 2007.
National Hospital Trends
Saunders, Dame Cicely. Cicely Saunders: Selected
Writings 1958–2004. New York: Oxford University The number of community hospitals in the nation
Press, 2006. and their beds has steadily declined since 1975. In
Hospital Closures 607
1975, there were nearly 5,900 community hospi- effect of each type of hospital closing is not entirely
tals with nearly 950,000 beds. In 2005, however, the same, and to understand the significance of the
there were fewer than 5,000 community hospitals closure, one must recognize the various roles and
(a 15% drop) with about 800,000 beds (a 16% the impact of a hospital on its community.
drop). Yet the number of patients admitted to the
nation’s community hospitals during this time
Hospital Roles
period increased from 33.4 million in 1975 to
35.2 million in 2005 (a 5% increase). Despite the The effects of closures are best understood in rela-
increase in the number of patients admitted during tion to the hospital’s role in the community. When
this same time period, there was a dramatic decline a hospital closes, the community served by that
in the average length of inpatient hospital stays. In hospital loses both a valuable community resource
1975, community hospitals accounted for more as well as an access point to the healthcare deliv-
than 250 million inpatient days of care. In con- ery system.
trast, in 2005, the number had declined to fewer One important role of a hospital in the commu-
than 200 million days of care (a 25% drop). nity is to serve as a point of access to healthcare.
At the national level, changes in technology and Hospitals vary significantly with respect to the
economics have altered the demand for inpatient specific types of care they provide. Thus, a com-
hospital care, and hospital closings have not been munity hospital may provide access to care rang-
as rapid as the changes in the marketplace. The ing from acute emergency care to tertiary-level
resulting occupancy rate of community hospitals specialty care. Consequently, when a hospital
in the nation declined from an average of 75% in closes, access to each type of care rendered by the
1975 to 67.3% in 2005. While this brief view of facility no longer exists for that community. The
national statistics would seem to alleviate concern community must therefore rely on accessing these
that hospital closures are a troublesome phenom- needed services via another local hospital (if one is
enon, the issue is, in reality, more complex. Local accessible), which may or may not provide an
variations, in several metropolitan areas, have equitable level of access.
demonstrated the impact of hospital bed reduc- As a community resource, a hospital is also
tions on increasing bypass hours to trauma cen- often an important source of employment for a
ters, loss of emergency service capacity, and the community. In many communities, the hospital is
spreading instability of charity care that moves the single largest employer. Consequently, the hos-
from closed hospitals to remaining neighboring pital plays an important role in the local economy
hospitals. by injecting money into the community. For exam-
ple, a study of hospital closures in rural communi-
ties between 1990 and 2000 indicated that in
Defining Hospital Closure
communities for which there were no alternative
Hospital closure can be defined in two ways. It hospitals, the closing of a hospital resulted in a
can be defined as the decommissioning of a physi- 1.6% increase in the unemployment rate and a 4%
cal facility that has routinely provided inpatient decrease in per capita income.
health services for a community. Such a hospital is Often, hospitals actively sponsor community
simply no longer there. Hospital closure can also outreach programs that, in effect, contribute to the
be defined as the elimination of all available beds overall wellness of the community. Such outreach
in a facility that have been designated for the type initiatives may include health education, mobile
of care the facility has routinely provided. Such a prevention units, ambulance services, health fairs,
hospital building may still remain standing, but screenings, and first-aid training sessions. A hospi-
the services it provided no longer exist. For exam- tal closure, therefore, means the elimination of
ple, a community hospital may be replaced by a these community outreach services, which can be a
skilled-nursing facility or a behavioral-health facil- significant loss to communities that depend on
ity. In either case, the elimination of hospital beds such services. Some hospitals, such as government
serving the original purpose has taken place. The or not-for-profit organizations, may have fiscal
608 Hospital Closures
obligations that lead them to provide charitable lack the diversity in services and the overall strategic
care for uninsured residents of their community. planning resources necessary to survive an evolving
Such organizations often provide large amounts of market and because there is often less community
uncompensated care for a community and draw opposition to closing these facilities than to closing
additional funds from the state or federal govern- larger hospitals. This study also indicated that the
ment to pay for the cost of that care. racial composition of a hospital’s community was
An often overlooked role of the hospital is that an important factor in assessing the potential for a
of player in the healthcare market affiliated with the hospital to close, especially for a voluntary hospital.
community. Often, communities are served by Hospital closure rates were shown to increase sig-
more than one hospital, and the relationship nificantly for communities with higher percentages
between these facilities in terms of services ren- of African American residents.
dered, payer mix, market share, and so on is A study of urban hospital closures between
extremely important to the viability of each facility. 1980 and 1987 concluded that hospitals that
When a hospital closes, the healthcare market invested in technology that will allow them to offer
changes, and this change affects the business of a variety of services either as a standalone facility
other hospitals in the market. A study of the effect or as a part of a multihospital system are less likely
of rural hospital closures on neighboring hospitals to experience closure. On the other hand, the study
examined this issue. It concluded that a rural hospi- also concluded that hospitals located in communi-
tal closure resulted in a statistically significant ties with higher percentages of African American
increase in patient volume for neighboring hospi- residents were significantly more likely to experi-
tals. However, this volume increase did not trans- ence closure.
late to predicted improvements in the profitability Other studies have examined the determinants
of the neighboring hospitals. Other studies of urban of hospital closure as they related to mergers and
hospital closures have found that when a hospital acquisitions, and the effects of Medicare’s prospec-
closes, uninsured patients disproportionately shift tive payment system (PPS). One study indicated
to the nearest hospitals, endangering their survival. that strategic and institutional variables such as
Finally, hospitals are crystallizing forces, bring- diversification, occupancy rate, and for-profit sta-
ing healthcare resources into a community and tus were critical determinants of hospital viability.
focusing the activity of professionals on the needs The study also concluded that environmental fac-
of the community. When the hospital closes, the tors such as per capita income, physician-to-popu-
attention of those professionals dissipates, and the lation ratio, and hospital-bed-to-population ratio
community residents lose their services. may also influence hospital viability.
Reasons for Hospital Closures Future Implications

Most hospital closures are associated with circum- While hospital closures have occurred as a result
stances in which a facility is no longer able to meet of changing technology and the economics of
its financial obligations. However, it must be healthcare, the impact of the closures has not been
noted that not all financially stressed hospitals studied in the context of the nonroutine roles that
close. Studies have identified a number of other hospitals fulfill in their communities. At the
factors associated with hospital closures. national level, hospital closures seem to be consis-
In assessing the research on factors associated tent with changes in demand for hospital services,
with hospital closures, several recurring themes yet there are significant local anomalies that have
appear. One study of hospital closures in New resulted in displacements of vital emergency ser-
York indicated that facilities that closed had sig- vices and access to service for uninsured patients.
nificantly fewer hospital beds and lower occu- More research is needed to address these and
pancy rates than those facilities that remained other issues.
open. This study asserted that small, low-
occupancy hospitals tend to close because they Benn J. Greenspan
Hospital Emergency Departments 609
See also Access to Healthcare; For-Profit Versus Not-For- and night, regardless of an individual’s ability to
Profit Healthcare; Healthcare Markets; Health pay for the care he or she receives. However, EDs
Insurance; Hospitals; Multihospital Healthcare Systems; are experiencing many problems, and they are
Uncompensated Healthcare; Uninsured Individuals said to be at breaking point. ED patient volumes
are on the rise, and they are increasingly being
Further Readings
used to evaluate and treat nonemergent condi-
Buchmueller, Thomas C., Mireille Jacobson, and Cheryl tions. This has led to EDs that are increasingly
Wold. “How Far to the Hospital? The Effect of overcrowded and overwhelmed, often resulting in
Hospital Closures on Access to Care,” Journal of poor patient outcomes and struggles for sustain-
Health Economics 25(4): 740–61, July 2006. ability. The challenges faced by hospital EDs need
Harrison, Teresa D. “Consolidation and Closures: An to be addressed as they are an essential means of
Empirical Analysis of Exists From the Hospital healthcare delivery for many and an integral part
Industry,” Health Economics 16(5): 457–74, May 2007. of the nation’s healthcare system.
Holmes, George M., Rebecca T. Slifkin, Randy K.
Randolph, et al. “The Effect of Rural Hospital
Closures on Community Economic Health,” Health Background
Services Research 41(2): 467–85, April 2006. Hospital EDs, often colloquially referred to as
Sloan, Frank A., Jan Ostermann, and Christopher J.
emergency rooms (ERs), developed over the 20th
Conover. “Antecedents of Hospital Ownership
century in response to the need to rapidly assess,
Conversions, Mergers, and Closures,” Inquiry 40(1):
stabilize, and treat critically ill patients. Recent data
39–56, Spring 2003.
show that 10% of all ambulatory-medical-care vis-
Succi, Melissa J., Shoou-Yih D. Lee, and Jeffrey A.
Alexander. “Effects of Market Position and
its now occur in EDs. Many patients are evaluated
Competition on Rural Hospital Closures,” Health
in EDs and discharged; however, EDs are also often
Services Research 31(6): 679–99, February 1997. used as a bridge to inpatient admissions.
Sun, Benjamin C., Sarita A. Mohanty, Robert Weiss, et al. Prior to the 1970s, hospital EDs were staffed
“Effects of Hospital Closures and Hospital primarily by internists, surgeons, and other phy-
Characteristics on Emergency Department Ambulance sicians on a rotating-call schedule. With the
Diversion, Los Angeles County, 1998 to 2004,” Annals increasing number of patients seen in EDs and
of Emergency Medicine 47(4): 309–16, April 2006. the recognition of a need for skills to treat high-
acuity patients, the specialty of emergency med-
Web Sites icine (EM) was developed and officially
established in 1979. The first emergency medi-
cine residency training programs were started in
http://www.nonprofithealthcare.org
American Hospital Association (AHA):
the 1970s, and these programs have rapidly
http://www.aha.org
expanded, with 146 accredited programs as of
Center for Studying Health System Change (HSC): 2008. With the development of the specialty,
http://www.hschange.com emergency-residency-trained and board-certified
Healthcare Financial Management Association (HFMA): emergency medicine physicians are increasingly
http://www.hfma.org staffing hospital EDs.
National Center for Health Statistics (NCHS):
Characteristics
Modern hospital EDs are open 24 hours a day and
Hospital Emergency are attached to hospitals with inpatient facilities.
In 2005, a national survey conducted by the
Departments National Center for Health Statistics (NCHS)
found that most EDs (65%) were operated by
The nation’s hospital emergency departments voluntary nonprofit hospitals. Four of 10 were
(EDs) provide critical care to those in need, day located in nonmetropolitan areas, and many were
610 Hospital Emergency Departments
in hospitals with fewer than 100 beds (57%). surgery. In 2005, about 12% of ER visits resulted
However, hospital EDs in metropolitan areas see in hospital admission. The average total length of
86% of all patient admissions, with two thirds of stay for those admissions was 5.2 days, with the
nonmetropolitan EDs seeing fewer than 30 patients leading hospital discharge diagnosis being nonische
per day and two thirds of metropolitan EDs seeing mic heart disease. Most ERs have specialists on call
50 to 200 patients per day. EDs in nonmetropoli- for consultations, which may be over the telephone
tan areas typically have 10 treatment spaces, while or require the specialist to come to the ED, depend-
those in metropolitan areas have 10 to 50. ing on the circumstances.
Hospital EDs see patients on a “walk-in” basis A broad variety of diagnostic tests and tools are
(patients who arrive independently) or by arrival available at EDs. In 2005, diagnostic and screening
via ambulance. In 2005, nearly 18 million patients services were provided for 71% of visits. Blood
(16%) arrived by ambulance, up 25% from 1997. tests were performed for 38% of visits and imag-
Patients are triaged on arrival, which is usually a ing studies done for 44% of visits. Medical proce-
brief assessment by a nurse, after which patients dures were performed for 47% of visits, and
are categorized according to their level of acuity. medications were given or prescribed for 77% of
Triage criteria include vital-sign abnormalities or visits.
specific chief complaints (primary presenting symp- Some hospital EDs have dedicated laboratory
toms) that identify the patients that might have services; more often, laboratory tests for ED
more urgent needs, who are given priority for phy- patients are conducted by hospital laboratory ser-
sician evaluation. In 2005, the leading chief com- vices but earmarked as “stat” and given priority
plaints were abdominal pain, chest pain, fever, and over other inpatient or outpatient laboratory pro-
cough, which accounted for 20% of all visits. cessing. Results from laboratory tests performed in
Higher utilization rates were seen in some pop- the ED are generally expected to be available
ulation subgroups, which included infants, person within 30 to 90 minutes in order to assist in the
75 years of age or older, Medicaid recipients, timely diagnosis, treatment, and disposition of ED
Asians or Pacific Islanders, and African Americans. patients. Most EDs have limited “bedside” testing,
The highest per capita utilization rates were for including urine pregnancy tests and urine dipstick
persons living in nursing homes (147.2 per 100 testing (with results available in minutes); but
individuals). Other high utilization rates were for many EDs are now incorporating some stat bed-
infants under 12 months of age (91.3 visits per side blood tests to assist in treating severely ill
100) and homeless persons (62.7 visits per 100). patients and to improve efficiency.
Private insurance was the most frequent form of Radiologic imaging is typically available in EDs.
payment, accounting for 40% of visits. Medicaid or Plain radiographs (X rays) are routinely available,
State Children’s Health Insurance Program (SCHIP) and most EDs have the use of hospital computed
accounted for 25% and Medicare for 17%. No tomography (CT) scanners, with a growing num-
insurance represented another 17% of visits. ber having dedicated ED CT scanners. Ultrasound
Utilization rates were highest for Medicaid patients services are often available for specific emergency
at 89.4 per 100 individuals, followed by Medicare conditions, and bedside ultrasounds performed by
(51.0 per 100 individuals), no insurance (45.9 per emergency medical physicians are becoming
100), and private insurance (23.8 per 100). increasingly common.
Hospital EDs are staffed by physicians and Many hospital EDs have separate “urgent-care”
nurses and sometimes by technicians, emergency or “fast-track” areas that are dedicated, usually
medical service (EMS) personnel, nurse practitio- only during the highest-patient-volume hours, to
ners, or physicians’ assistants. Most EDs (65%) streamline the care of patients with simple low-
use outside contracts to provide physicians. acuity complaints. These are generally patients
Physicians evaluate patients in the EDs, and those who require minimal diagnostic testing and can be
requiring admission are assigned to an on-call pri- rapidly assessed and treated. Typical complaints
mary-care physician (family practice, internist, or treated in these areas include cough and cold
pediatrician) or occasionally to specialty services symptoms, rashes, lacerations, minor wounds,
such as cardiology, general surgery, or orthopedic minor fractures, and abscesses.
Some hospital EDs have rooms designated as 2005, one fifth of all Americans made one or
resuscitation areas, which have some space and more ED visits, making the ED utilization rate
specialized supplies and are reserved for the most 39.6 visits per 100 individuals. EDs are increas-
severely ill patients. Some Eds also have areas spe- ingly being used by the uninsured, for their ease of
cifically designed for particular types of patients, access and convenient hours. Additionally, many
such as psychiatric patients or asthmatics. Add patients are sent to EDs by their primary-care
itionally, there are pediatric areas in some EDs, as providers for tests or procedures that cannot be
well as dedicated pediatric EDs, which are gener- easily performed in outpatient office settings.
ally found in large urban areas and associated with While many outpatient physicians in the past
pediatric hospitals. would directly admit patients who required hospi-
Many hospital EDs double up as “trauma cen- talization, it is now commonplace in many hospi-
ters.” In certain institutions, trauma patients tals to admit those patients via the ED for
(individuals suffering from physical injury) are stabilization, facilitation of testing, or ease, or
seen in an area separate from other ED patients. because of lack of beds for direct admission. In
In 2005, hospitals designated as trauma centers some rural areas of the nation as well as some
saw 37% of visits. In 2002, there were 1,154 inner-city areas, the ED may be the primary source
trauma centers in the nation. Trauma center des- of healthcare for a large percentage of residents.
ignation varies on a state-by-state basis and is not Also, EDs are increasingly being used for public
uniform. Some states designate only Level I or health surveillance and for disaster preparation
Level II centers, while others use a four- or five- and response.
tiered system and designate every ED as a trauma With the passage of the federal Emergency
center at some level. In general, trauma centers Medical Treatment and Active Labor Act
are ranked according to certain standards, includ- (EMTALA) in 1986, all patients presenting at the
ing the availability of hospital intensive-care ED are required to receive a medical-screening
units, operating rooms, and surgeons and some examination and subsequent stabilization of any
specialists, including orthopedic surgeons and emergency conditions found. The purpose of this
neurosurgeons. law was to prevent patients with emergency condi-
tions from being turned away based on their abil-
ity to pay for services. Ironically, EMTALA has
Growth in Visits
been criticized as actually decreasing access to care
The annual number of hospital ED visits in the by forcing the closure of many EDs and trauma
nation has increased 20% from 1995 to 2005 centers and creating incentives for hospitals to tol-
(96.5 million to 115.3 million). This is equivalent erate long waiting times and divert ambulances to
to 219 visits every minute to the nation’s EDs, or other hospitals while continuing to accept elective
an average of 30,000 visits annually per ED. admissions.
While ED visits are on the rise, the number of
hospital EDs has decreased over this same time
Problems
period from 4,176 to 3,795 (a decline of 9%),
which has caused the average number of visits per The National Academy of Sciences, Institute of
ED to increase by 31%. Moreover, from 2000 to Medicine (IOM), published a series of reports in
2006, there has been a 12% decrease in short- 2006 that identified key ED problems. They
term acute-care beds, while the total area of EDs include the following: (a) many EDs and trauma
has increased 15%. These statistics all demon- centers are overcrowded, (b) emergency care is
strate how Eds are taking on an increasingly larger highly fragmented, (c) critical-care specialists are
share of the healthcare burden, which has led to often unavailable to provide emergency and
numerous problems. trauma care, (d) the emergency care system is ill
While most of the increase in hospital ED visits prepared to handle a major disaster, and (e) EMS
is attributed to the growth in the nation’s popula- and EDs are not well equipped to handle pediatric
tion, more than one third is accounted for by the care. This section discusses these and other prob-
growth in per capita use over that time period. In lems that EDs face.
612 Hospital Emergency Departments
Overcrowding be seen at different hospitals from where their phy-

sicians and records are located).
During the past 20 years, more than 100 medi- More overcrowding has been found in hospitals
cal articles have been published addressing the in areas with larger populations, higher population
issue of overcrowding in the nation’s hospital EDs. growth, or higher percentages of people without
National data from 2004 estimated that 40% to health insurance coverage. The factor most com-
50% of EDs overall experienced crowding, with monly associated with overcrowding is ED board-
two thirds of metropolitan EDs reporting crowding. In particular, hospitals with this problem cite
ing. Overcrowding is often estimated by surrogate difficulty in moving patients to critical care or
markers such as boarding times, time spent on telemetry-monitored beds. The reasons given by
diversion, and left-without-being-seen (LWBS) hospital administrators for not having enough
numbers. “Boarding” patients are those who are inpatient beds are primarily economic. It is more
ready for admission but are waiting in the ED for profitable to staff only a sufficient number of beds
an inpatient bed to become available. Diversion is that are likely to be occupied (which can limit the
the practice of diverting ambulances that bring capacity to staff up for occasional spikes in admis-
patients to particular hospitals to other, presum- sions), and there is competition for available beds
ably less crowded hospitals. When a hospital is among scheduled admissions, such as surgery
“on diversion,” the ED still sees walk-in patients patients (who are generally considered more prof-
but is temporarily relieved of the burden of also itable than ER admissions).
receiving ambulance runs. LWBS patients are those Overcrowding leads to long wait times, decreased
who present to the ED but leave before being physician productivity, poor patient satisfaction,
evaluated by a physician. In 2004, an estimated poor outcomes for patients, lengthened ambulance
2% of patients were LWBS. Most of these patients runs, and lessened ability of hospitals to respond to
leave due to frustration with wait times, and a public health emergencies. In 2005, patients spent
significant proportion of these have been found to an average of 56.3 minutes waiting to see a physi-
be acutely ill and are subsequently admitted to the cian and 3.3 hours for the full duration of the ED
hospital. visit. Steps to address overcrowding include increas-
The nation’s hospital EDs report boarding 22% ing capacity (often increasing the number of ED
of patients, with 73% of them boarding two or beds, using observation units, or adding personnel)
more inpatients. Almost half of the EDs report and improving efficiency. However, these are gen-
boarding patients for an average of 8.9 hours for erally methods of managing crowding problems
more than 4 days per week. Due to overcrowding, rather than reducing them.
EDs have been forced to make creative use of
space. Fifty-nine percent report routinely using
Emergency Medical Services
halls for housing patients, 38% double patients in
rooms, and 47% use nonclinical space for patient Hospital EDs are often used in conjunction with
care. With overcrowding, nurses and physicians EMS. EMS are prehospital services usually pro-
are burdened with taking care of more patients, vided by paramedics; emergency medical techni-
with an average of 4.2 patients per nurse and 9.7 cians (EMTs); or sometimes firemen, who provide
patients per physician. on-site treatment of patients and transport them
In 2003, there were more than half a million with ambulances to EDs. EMS vary greatly; within
diversions, an average of one per minute. A 2004 a community, many services may exist with some
survey reports that approximately one third of volunteer, some paid, some based in fire depart-
U.S. hospitals reported going on ambulance diver- ments, and some operated by hospitals or other
sion sometime in the previous year, and 12% of private companies. Additionally, in some geo-
hospitals in metropolitan areas reported having graphic regions, services are divided into basic life
spent between 5% and 19% of their operating support (BLS) or advanced life support (ALS),
time in diversion status. Diversions can create which differ in skill levels of providers and avail-
problems by increasing ambulance transit times able supplies. Due to the great variation in EMS,
and disrupting patterns of care (forcing patients to the national IOM has identified fragmentation of
services as a problem. It cites poor communication surgeons have been most frequently reported as
between EMS workers and police and fire depart- somewhat difficult to obtain (49%).
ments as well as between EMS and EDs. The IOM
also notes a lack of uniformity in 911 agencies and
Pediatric Care
lack of standards and certification for training
EMS personnel. Children make up 27% of all ED visits, but only
6% of the nation’s ED have all the necessary sup-
plies for pediatric emergency care. Deficiencies
Primary-Care Burden have also been noted in prehospital equipment and
Hospital ED have increasingly been used for nonin EMS training for pediatric patients. Improved
urgent conditions. An estimated one third to one pediatric preparedness is found in hospitals with
half of all ED visits are for nonurgent conditions inpatient pediatric services, with higher pediatric
that probably could have been seen in a primary- volume, with teaching-hospital status, located in
care outpatient setting. Several reasons have been particular geographic regions, and with higher per
postulated for this trend, including ease of access, capita income in the community.
lack of health insurance coverage, and erroneous
patient perceptions of “urgent” and “emergent” Lack of Language Translation Services
conditions. One study showed that of patients
with nonurgent conditions who presented to the Non-English-speaking patients face significant
ED, 27% reported that they used it for all their barriers to care when translation services are not
medical care, 66% reported that they didn’t know available. Miscommunications can lead to misdi-
where else to go for their current problem, and agnoses and can impair a patient’s ability to under-
almost half rated the ED better for unscheduled stand his or her medical condition, follow up as
care. Approximately one third of ED have been directed, and comply with recommended treat-
classified as high-safety-net-burden providers (see- ment. One study found that only 52% of non-
ing many uninsured or underinsured patients), English-speaking patients were satisfied with their
with hospitals located in the South more likely ED care compared with 71% of English-speaking
(61%) to have this designation. High-burden EDs patients. Many EDs don’t have translation services
see a higher percentage of nonurgent cases that are available or don’t have services provided in a
primary-care treatable. timely manner. Often, family members (especially
children) are relied on to translate, which can lead
to problems of inaccuracy, conflicts of interest, or
Lack of On-Call Specialists compromised patient confidentiality.
Many specialty physicians do not want to be on
call for EDs because of the difficulty in getting Finances
reimbursed for services with many uninsured
patients presenting to EDs. Also, many specialists Since hospital EDs are required to provide
perceive additional liability risks for working with sophisticated services at all hours, operation costs
ED patients, who may need high-risk procedures are high. Services are not designed for nonurgent
and with whom they don’t have an established care, and increased use for these purposes creates
relationship. Insurance premiums can be higher for unnecessary costs. Additionally, increased use of
specialists who offer on-call services to ED. Being EDs by underinsured patients who cannot pay
on call can be disruptive to the specialists’ personal their bills leads to increased uncompensated care.
lives, and providing night and weekend services in The American Hospital Association (AHA) calcu-
addition to regular practice hours can be physi- lated that the cost for uncompensated care was
cally demanding. Due to these constraints, many $26.9 billion for all community hospitals in 2004.
EDs report a lack of on-call specialists, which Many measures that are being instituted to address
could delay treatment of emergent conditions, ED overcrowding simply expand the EDs’ capaci-
some of which could be life threatening. Of all on- ties to deal with higher volumes of patients but do
call specialists, the services of plastic and hand little to curtail the inappropriate use of EDs.
614 Hospitalists
Possible Solutions Health,” Emergency Medicine Clinics of North

America 24(4): 815–19, November 2006.
The national IOM has outlined several key recom- Kellermann, Arthur L. “Crisis in the Emergency
mendations to improve EDs based on its recent Department,” New England Journal of Medicine
studies. They include the following: (a) create coor- 355(13): 1300–1303, September 28, 2006.
dinated, regionalized, and accountable prehospital Nairn, Stuart, Elaine Whotton, Christine Marshal,
trauma and emergency care systems; (b) create a et al. “The Patient Experience in Emergency
lead agency (based at the Department of Health Departments: A Review of the Literature,”
and Human Services [HHS]); (c) end ED boarding Accidents and Emergency Nursing 12(3): 159–65,
and diversion; (d) increase funding for emergency July 2004.
care; (e) enhance emergency care research; (f) pro- U.S. General Accounting Office. Hospital Emergency
mote EMS workforce standards; and (g) enhance Departments: Crowded Conditions Vary Among
pediatric presence throughout emergency care. Hospitals and Communities. GAO-03–460.
To improve ED efficiency and enhance patient Washington, DC: U.S. General Accounting Office,
flow in order to reduce overcrowding problems, it 2003.
is recommended that hospitals adopt operations
management techniques. Notably, the Centers for
Medicare and Medicaid Services (CMS) and the Web Sites
Joint Commission need to institute standards that American Academy of Emergency Medicine (AAEM):
support moving patients to inpatient beds more http://www.aaem.org
quickly and discouraging boarding. American College of Emergency Physicians (ACEP):
In response to the recent national IOM reports, http://www.acep.org
an Academic Emergency Medicine Panel high- American Hospital Association (AHA): http://www.aha.org
lighted areas warranting attention at academic Emergency Department Practice Management
medical centers. These include (a) strengthening the Association (EDPMA): http://www.edpma.org
education environment in academic EDs, (b) recog- National Center for Health Statistics (NCHS):
nizing the importance of emergency medicine resi- http://www.cdc.gov/nch
dency training and emergency medicine subspecialty
development, (c) using educational loan forgiveness
to encourage rural emergency medicine practice,
and (d) addressing ED crowding and its adverse Hospitalists
effects on quality of care and patient safety.
Stacey Chamberlain Hospitalists are physicians whose primary profes-

sional focus is the general medical care of hospital-
See also Academic Medical Centers; Access to ized patients and who provide continuity of
Healthcare; Emergency Medical Services (EMS); hospital care from admission to discharge, often
Emergency Medical Treatment and Active Labor Act seeing patients in the emergency room and orga-
(EMTALA); Hospitals; Inner-City Healthcare; Patient nizing post-acute care. The term hospitalists was
Dumping; Primary Care first coined in 1996. The recent American hospital-
ist movement continues to grow at a rapid pace.
Further Readings
Background
Burt, Catharine W., and Linda F. McCaig. “Staffing,
Capacity, and Ambulance Diversion in Emergency Hospital-based physicians in Europe and a small
Departments: United States, 2003–04,” Advance Data number of integrated health delivery systems in
376: 1–23, September 27, 2006. the United States, such as Kaiser Permanente, pre-
Hirshon, Jon Mark, and David M. Morris. “Emergency ceded the more general introduction of hospitals
Medicine and the Health of the Public: The Critical to manage inpatient care across the nation.
Role of Emergency Departments in U.S. Public Traditionally, primary-care physicians supervise
Hospitalists 615
inpatient care. Recently, however, some primary- defined by the setting where they provide care—the
care physicians have begun to delegate the respon- hospital. In this sense, hospitalists are akin to inten-
sibility to a hospitalist, thus converging to European sivists, whose focus of specialization is the inten-
practice, where the general practitioner in the sive-care unit of hospitals. Hospitalists, typically
community refers the patient to a consultant for trained as generalists, can be contrasted with the
inpatient care. growing number of ever more narrowly defined
Hospitalists were first introduced in the mid- specialists working within the hospital whose ser-
1990s, and by 2005, survey data from the American vices can no longer be coordinated ad hoc.
Hospital Association (AHA) reported 16,000 hos- Although hospitalists enhance coordination of
pitals in the nation. The association’s survey indi- care within the hospital, some believe that they do
cates that 40% of short-term community hospitals so at the cost of potentially worsening coordina-
have hospitalists on the staff. The Society of tion between the referring physician’s office and
Hospital Medicine (SHM), the professional society the hospital. For this reason, hospitalists can be
for hospitals in the United States, estimates that in viewed as offering different advantages to physi-
2007 there were 20,000 hospitals in the nation. cian groups and to hospitals that are comparing
Most hospitalists are trained internists, family the likely benefits and costs of employing hospital-
practitioners, and pediatricians. ists directly.
The AHA survey also showed that larger hospi-
tals were more likely to use hospitalists than smaller
Hospitals’ Motives to Use Hospitalists
hospitals. General hospitals were more likely than
specialty hospitals, and hospitals with at least 20 In response to the growing regulatory scrutiny and
residents and those affiliated with a medical school advances in medicine, coupled with the increasing
were more than twice as likely as hospitals with less pressures of prospective payment adjustments and
than 20 residents and those not affiliated with a the exhaustion of cost savings through conven-
medical school. Federal government and private tional utilization management, many hospitals
nonprofit hospitals were more likely than local have been turning to hospitalists to cope with these
government and private for-profit hospitals to use operational challenges.
hospitalists. Hospitalists tended to work in hospi- As they work exclusively in the hospital, hospi-
tals that also made available advanced diagnostic talists specialize in coordinating the care of hospi-
and therapeutic medical devices. Hospitals in urban talized patients and thus are often efficient in
and wealthier counties were more likely to use hos- managing throughput. By closely monitoring
pitalists. Hospitalist use was more prevalent in patients and managing the flow of information,
counties with higher managed-care penetration and hospitalists minimize the unproductive intervals
greater competition among health maintenance between successive treatment stages, reduce the
organizations (HMOs). A higher average physician incidence of hospital-borne pathologies, help in
age, an older patient population, and a greater the formulation of and compliance with clinical
share of primary-care physicians in the county practice guidelines, and prevent unnecessary use
where the hospital was located were all associated of diagnostic tests and therapeutic procedures,
with lower adoption rates. thereby limiting utilization of hospital resources
and minimizing the length of stay without com-
promising patient safety or treatment quality.
Duties of Hospitalists
Hospitalists aid in streamlining the administrative
The emergence of hospital medicine as a new medi- processes that govern hospital-based patient care
cal specialty adds a new dimension to the ongoing and mediate between specialist physicians and
specialization process in healthcare along the geo- staff. Given their constant presence in the hospi-
graphic and institutional dimension, namely the tal, their familiarity with the hospital’s resources,
site of care provision. Whereas existing medical and their greater social distance from the patient
specialties are largely defined by disease, organ sys- compared with the patient’s primary-care physi-
tem, patient age, or patient gender, hospitalists are cian, hospitalists are well positioned to manage
616 Hospitalists
the utilization of expensive technologies and pro- Employment Models

cedures. In this sense, hospitalists represent a new
With regard to the employment model for hospi-
generation of utilization management.
talists, in 2003, hospitals using hospitalists
In addition, hospitalists are often tasked with
employed by a hospital or university constituted
managing unassigned patients, who are frequently
the largest group, followed by hospitals whose
admitted through the hospital’s emergency depart-
hospitalists were employed by a hospitalist-only
ment and whose care is not assigned to a specific
group and those whose hospitalists were employed
physician prior to admission. In academic medical
by a physician group. If hospitalists were uni-
centers, hospitalists are also charged with teaching
formly engaged in a specific set of tasks, economic
duties.
theory would predict, all other things being equal,
that the healthcare system would converge to a
single, cost-minimizing employment model. In this
Primary-Care Physicians’ light, the diversity of employment models is puz-
Motives to Use Hospitalists zling to health services researchers and suggests
The infrequency and the higher severity of the that variation in the local characteristics of the
typical hospitalization have lowered the attrac- market for physician services may play a large
tiveness of hospital work for office-based physi- role. The choice of employment model affects the
cians. By delegating the hospital-based portion of extent to which the efficiency gains promised by
care of their patients to hospitalists, office-based proponents of hospitalist use are realized and
primary-care physicians can spend more time on shared by the parties involved.
office visits, need not invest in the knowledge and Apart from teaching duties for hospitalists who
skills specific to hospital-based medical care, and are employed by teaching hospitals, they are
can save commuting time between the office and engaged in the same tasks across all employment
hospitals. As the frequency of patient referrals by models. By employing hospitalists directly, hospi-
office-based primary-care physicians to hospitals tals can potentially reward hospitalists for the cost
has decreased, and as the sophistication of hospi- savings, outcome improvements, and patient satis-
tal-based care has increased, more and more pri- faction ratings that they may achieve and thereby
mary-care physicians are finding it beneficial to align the hospitalists’ objectives with those of the
use hospitalists. hospital. This alignment may be particularly
Primary-care physicians who serve older patient important when the hospital chooses to manage
populations may be worried about the potential costly medical technologies, whose use can be
discontinuity of care that the introduction of hos- monitored and controlled by hospitalists.
pitalists creates at the point of the patient’s transfer Insofar as hospitalists are charged with manag-
from the referring physician to the hospital. This ing unassigned patients, who are disproportion-
handoff may lead to a loss of patient-specific infor- ately uninsured and therefore do not constitute a
mation, such as comorbidities, medical histories, source of separate reimbursement for hospitalists,
and treatment preferences, whose importance typi- direct employment by the hospital may provide
cally increases with patient age. This discontinuity both parties with a convenient solution to the
presents a major challenge to the hospitalist management of unassigned patients.
model. Some primary-care physicians may prefer to
The similar per-episode reimbursement rate for contract with independent provider groups and
hospital-based and office-based care for primary- physician groups if they give them better control
care physicians seems to play a role in reducing over the hospitalists’ priorities in treating the refer-
the reluctance of some physicians to delegate the ring group members’ hospitalized patients.
hospital-based portion of care to hospitalists. Compared with direct employment by the hospi-
More in-depth specialization along the healthcare tal, this arrangement may mitigate the possible loss
continuum is also hampered by the prohibition of knowledge about the patient’s medical history
and prosecution of kickbacks and fee-splitting and treatment preferences, which might be partic-
practices. ularly serious for older patients.
Hospitalists 617
In addition to primary-care groups and hospitals, new yardstick for payers, who will likely internal-
hospitalists may choose to organize themselves as ize the new standards and lower their effective
freestanding practice groups. Hospitalist-only payments accordingly. As a result, more pressure
groups are free to serve multiple primary-care physi- may be put on hospitalists to come up with even
cian groups, as well as multiple hospitals, and there- better ways to decrease length of stay further.
fore may be in a position to diversify across different Another driver of the hospitalist movement is the
patient groups that are associated with individual pay-for-performance model of reimbursement. A
primary-care physician groups and hospitals. growing number of hospitalist programs have
Which employment model prevails in the long quality-based incentives, often matching the pay-
term will depend on the number of physicians for-performance targets of the hospital.
prepared to work as hospitalists relative to the The future course of the diffusion of the hospi-
demand for them. If demand outpaces the supply, talist model is unclear. If the principal barrier to
hospitalists will likely choose to organize in the further diffusion of the hospitalist model is a lack
form that allows them to capture most of the gains of information among nonadopting hospitals, a
and addresses their personal needs best. continued process of learning will encourage more
Fraud and abuse laws, as well as ethical consid- hospitals to adopt and thereby help contain cost
erations and increasing scrutiny, make it difficult further. While initially raising hospital profits, phy-
to share any potential gains from using hospital- sician wages, or insurance profits, rate-setting enti-
ists, unless the party employs them directly. By tlement programs may eventually reduce hospital
developing vertically integrated working struc- reimbursement rates, which should then be passed
tures, in which physicians are salaried by the hos- on to consumers in the form of lower insurance
pital, the incentives of physicians and hospitals are premiums and taxes. On the other hand, if the prin-
more closely aligned. As bona fide employment cipal barrier to further diffusion lies in the small
relationships are one salient exception to the anti- size of benefits compared with the cost of adoption,
kickback statute, vertical integration allows hospi- additional diffusion will be minimal and the effi-
tals to control costs by supervising physicians ciency gains may have been already exhausted.
through utilization management techniques, clini-
cal practice guidelines, and other care protocols. Lorens A. Helmchen and Guy David
See also American Hospital Association (AHA);

American Medical Association (AMA); Fraud and
Future Implications Abuse; Hospital Emergency Departments; Hospitals;
The use of hospitalists has emerged partly in Physicians; Primary-Care Physicians; Quality of
Healthcare
response to regulatory pressure, such as the switch
to a prospective payment system and the passage
of the federal Balanced Budget Act of 1997. In Further Readings
particular, the widely adopted practice of payment
David, Guy, and Lorens A. Helmchen. “The Choice of
per Diagnosis Related Group (DRG) has encour- Employment Arrangement in the Market for
aged hospitals to find new ways to cut the length Hospitalist Services,” Southern Economic Journal
of stay without jeopardizing quality of care. While 73(3): 604–22, January 2007.
the role of hospitalists in reducing average length Everett, George, Nizam Uddiv, and Beth Rudloff.
of stay seems well established, it remains debat- “Comparison of Hospital Costs and Length of Stay
able whether this effect was a by-product of or the for Community Internists, Hospitalists, and
principal reason for their emerging prominence. It Academicians,” Journal of General Internal Medicine
is also not clear whether hospitals will be able to 22(5): 662–67, May 2007.
continue to appropriate the efficiency gains from Lindenauer, Peter K., Michael B. Rothberg, Penelope S.
lower hospitalization stays in the long run. The Pekow, et al. “Outcomes of Care by Hospitalists,
new type of practical knowledge and evidence- General Internists, and Family Physicians,” New
based medicine that hospitalists have been helping England Journal of Medicine 357(25): 2589–2600,
to develop and propagate will eventually lead to a December 20, 2007.
618 Hospitals
Meltzer, David O. “Hospitalists and the Doctor-Patient (a) has at least six inpatient beds that are continu-
Relationship,” Journal of Legal Studies 30: 589–606, ously available for care; (b) is constructed to ensure
June 2001. patient safety; (c) has an identifiable governing
Wachter, Robert M. “Reflections: The Hospitalist authority responsible for running it, a chief execu-
Movement a Decade Later,” Journal of Hospital tive who reports to the authority, a medical staff
Medicine 1(4): 248–52, July 2006. with licensed physicians, and at least one registered
nurse supervisor and continuous nursing services;
(d) admits patients only by a member of the orga-
Web Sites nization’s medical staff; (e) maintains medical
American Hospital Association (AHA): records; and (f) provides pharmacy services and
http://www.aha.org patient food services, including special diets.
American Medical Association (AMA): The National Center for Health Statistics
http://www.ama-assn.org (NCHS) defines a hospital, for the purpose of its
Center for Studying Health System Change (HSC): surveys, as an organization with an average length
http://www.hschange.com of inpatient stay of less than 30 days (short stay)
Society of Hospital Medicine (SHM): whose specialty is general (medical or surgical)
http://www.hospitalmedicine.org services or that provides general medical care for
children. NCHS excludes federal hospitals, hospi-
tal units of institutions, and hospitals with fewer
than six beds staffed for patient use.
Hospitals
Classifications
Hospitals are the centerpiece of U.S. healthcare.
Hospitals are multipurpose healthcare institu- Hospitals are classified in many ways, such as by
tions. They provide a place for physicians and their ownership, the services they provide, whether
other clinicians to treat patients, for special diag- they are community hospitals, and whether they
nostic and treatment services, and for emergency are members of a multihospital healthcare system.
care services. They are important resources in In terms of ownership, hospitals are classified as
times of crises, for aggregating healthcare assets being nongovernment not-for-profit institutions
to benefit the community, and major sources of (i.e., church operated, or other), investor-owned
employment and other economic benefits. (for profit) institutions, or government-owned
Hospitals also often serve as focal points for the institutions (i.e., federal, state, or local).
coalescing of people’s efforts to address the health- In terms of the services they provide, hospitals
care needs of communities. are classified as being general institutions (provid-
ing a wide array of patient services, diagnostic and
therapeutic, for a variety of medical conditions),
Definitions
special institutions (providing services for patients
Hospitals are increasingly defined by the various with specific medical conditions), rehabilitation
organizations that license, regulate, and accredit and chronic-disease institutions (providing services
them. As such, the technical definition of a hospi- to handicapped or disabled individuals requiring
tal may vary widely across nations, states, and restorative treatment), or psychiatric institutions
programs. (providing services for patients with psychiatric
The World Health Organization (WHO), for illnesses).
example, broadly defines a hospital as an organi- A very important distinction is whether an insti-
zation that is permanently staffed by at least one tution is a community hospital or not. The AHA
physician, can offer inpatient accommodations, defines community hospitals as all nonfederal,
and can provide active medical and nursing care. short-term (having an average length of inpatient
The American Hospital Association (AHA) more stay of less than 30 days), general and other special
narrowly defines a hospital as an organization that hospitals (e.g., children’s hospitals, obstetrics and
Hospitals 619
gynecology, rehabilitation hospitals) whose facili- rights; (d) patient privacy guidelines; (e) state and
ties and services are available to the public. federal tax-exempt requirements (for not-for-profit
Hospitals can also be classified by whether they hospitals); and (f) federal and state rules regarding
are members of a multihospital healthcare system assured access to emergency medical care.
(two or more hospitals owned, leased, sponsored, The most direct independent force in molding
or contract managed by a central organization) or the structure of contemporary hospitals has been
a single stand-alone institution. the Joint Commission. The Joint Commission sets
standards through which almost all nongovern-
mental hospitals and many other healthcare orga-
Hospitals in the United States
nizations are measured to attain accreditation
In 2006, there were a total of 5,747 hospitals reg- approval. This accreditation is not only a means of
istered with the AHA in the United States. Of the asserting a quality status to the public at large but
total, the majority, 4,927, were community hospi- also serves as the surrogate approval mechanism
tals (85.7%). Most of the nation’s community for many other regulatory agencies and other state
hospitals were nongovernment not-for-profit insti- and federal certification. Approval may also be the
tutions (2,919 hospitals, or 59.2%), followed by key to being accepted by payers such as Medicare,
state and local government institutions (1,119 hos- Medicaid, and Blue Cross. While the accreditation
pitals, or 22.7%) and investor-owned institutions process is voluntary, and hospitals are required to
(889 hospitals, or 18.0%). Most community hos- pay for participation, the link to certification,
pitals, 2,926 (59.4%), were located in urban areas, licensure, and payment makes it all but mandatory.
while 2,001 (40.6%) were in rural areas. And Its impact on the structure of hospital medical staff
most community hospitals (2,755 or 55.9%) were is, as a result, unavoidable.
members of a multihospital healthcare system.
In terms of noncommunity hospitals, there were
History
221 federal hospitals (e.g., Veterans Affairs, Public
Health Service, and Department of Justice hospi- Specially organized places where individuals
tals), 451 nonfederal psychiatric hospitals, 129 sought relief from illness or injury, places to
nonfederal long-term care hospitals, and 19 hospi- receive care in the process of dying, and places to
tal units of institutions (e.g., prison hospitals and go for birthing have existed in many forms for
college infirmaries). thousands of years. The ancient Greeks, Egyptians,
There were a total of 947,412 staffed hospital and Romans established temples where rites were
beds in the nation, with community hospitals performed to cure the sick.
accounting for 802,658 beds (84.7%). There were Perhaps the oldest highly organized institution
a total of 37,188,775 admissions to all hospitals, specifically dedicated to the care of the sick was
with 35,377,659 admissions to community hospi- established in Mihintale, Sri Lanka, sometime
tals (95.1%). The total expenses for all hospitals around the 4th century BCE. Archeological evi-
were $607,355,354,000, with community hospi- dence appears to show that the well-constructed
tals accounting for $551,835,328,000 (90.8%). hospital had a waiting room, a dispensary, examin-
ing rooms, residential rooms for patients, and a
bath where patients would be immersed in medici-
Licensure, Regulation, and Accreditation
nal herbal water or oil.
Hospitals must meet the myriad standards created In Europe, hospitals were typically created by
by various government regulatory bodies. Such various religious orders. Hospitals were also estab-
standards include, among others, (a) state and local lished as hospices along the major pilgrimage
licensure requirements; (b) conditions of participa- routes. The name hospital comes from the Latin
tion for federally funded payment programs (i.e., hospes, referring to either a visitor or the host who
Medicare, Medicaid, and TRICARE, the Military receives the visitor. From hospes came the Latin
Health System); (c) rules governing research, the use hospitalia, an apartment for strangers or guests,
of controlled drugs, radiation safety, and patient and the Medieval Latin hospitale and the Old
620 Hospitals
French hospital. In England, in the 15th century, surgeons lacked anesthesia, they had to operate
the name shifted to mean a home for the elderly or quickly, patients suffered great pain and torture,
infirm or a home for the down-and-out. Hospital and postoperative infection rates were high and
only took on its modern meaning as an institution often deadly. It was not until the mid-19th cen-
where the sick or injured are given medical or sur- tury with the introduction of anesthesia, such as
gical care in the 16th century. Other terms related nitrous oxide, ether, and chloroform, making
to hospital include hospice, hospitality, hospitable, possible the systematic application of surgery,
host, hostel, and hotel. that the growth of hospital services began. As a
In the New World, the Spanish conquistador result, surgeons became the professional leader-
Hernando Cortez built the first hospital in 1524 in ship in the formalization of hospital organiza-
Mexico City. The Hospital of the Immaculate tions well into the 20th century.
Conception (which in 1663 became the Hospital In the mid-19th century, individuals such as
of Jesus of Nazareth) is today the oldest continu- Oliver Wendell Holmes, Ignatz Semmelweis, Louis
ously operating hospital in America. Throughout Pasteur, Joseph Lister, Robert Koch, and others
the Spanish settlement of America, various Catholic advanced the germ theory of disease and demon-
orders established a number of hospitals. strated effective measures that could reduce the
As other Europeans settled in what would rate of disease, methods of immunization, and
become the United States, they also established ways to prevent the raging infectious disease
hospitals. As the population of the new country death rates in hospitals. With the reduction of
expanded, more hospitals were created. Specifically, diseases such as puerperal fever, a deadly disease
hospitals were established for a number of reasons. of women giving birth, the public no longer
Religious orders created hospitals in response to viewed the hospital as a place to die; instead, it
local needs. Some communities created hospitals was a place to be cured. New antisepsis techniques
to expand their almshouses and prisons in order to developed by Lister lowered the infection rates
house the insane, the poor, and others who did not from surgery. Previously, almost all wounds
have a home in which to receive care, whereas became infected, and mortality rates from surgery
other communities created hospitals to contain were as high as 90%.
patients who were contagious or who were in Today, technologic innovations and medical
some other way undesirable. Physicians also cre- advances continue to take place in hospitals.
ated hospitals to have a place to support patient For example, recent surgical innovations include
care. Some communities built hospitals as a place minimally invasive surgery, various endoscopic
to support training of physicians and other profes- procedures, and the use of surgical robots that
sionals to meet their healthcare needs and/or as a allow delicate microprocedures to be performed.
place to support research and the development of In addition, advances in physiology and the
new medical technology. In addition, individuals monitoring technology of anesthesia have
and corporations created hospitals as profit-mak- extended surgical procedures to older and
ing ventures to fill specific market niches. sicker patients. Interventional instruments such
as the laparoscope and balloon catheters con-
tinue to radically change hospital care, while
Technology and the Modern Hospital
advances in the development of radiation ther-
Today’s modern hospital emerged in the latter half apy have expanded the treatment options for
of the 19th century. Although a number of factors many diseases. New imaging instruments such
were responsible for its emergence, arguably, the as ultrasonography equipment, thermal imag-
two most important factors were the development ing equipment, high-speed computerized tomog-
of anesthesia and the germ theory of disease and raphy (CT) scanners, magnetic resonance
antisepsis techniques. imaging (MRI) equipment, and positron emis-
While American surgeons had much of the sion tomography (PET) scanners are opening a
knowledge needed to conduct major surgical new world of early and noninvasive diagnostic
procedures by the 19th century, because the techniques.
Hospitals 621
The Hospital Medical Staff glue that held them together, and the choices made
in that mutuality would benefit the patient, whose
As hospitals evolved through the 19th century, the best interest was served by the increasing availabil-
role of physicians remained as that of independent ity of medical services.
caregivers and entrepreneurs. Their relationship This was convenient and economically produc-
with the hospitals of their time was as individuals tive at a time when the majority of care was on a
and, for the most part, was neither organizational fee-for-service basis. The economic basis for this
nor economic. The concept of mutual benefit had exclusivity was also the basis for attacks on it by
mostly to do with the perceived need for a place excluded physicians.
to keep those patients who could not be treated at While the courts in the 1970s and 1980s forced
home. The physicians performed surgery and hospital medical staff to become less exclusive and
attended to their patients, but there was little opened staff privileges to any qualified physician, the
demonstration of an organized role in the gover- legitimate need to control access to staff had to be
nance or oversight of medical care as a whole. recognized and a new way had to be found to serve
However, it was in this period that the func- that need. There was, in part, as a response, a sig-
tional and economic basis for cooperation among nificant increase in externally imposed regulation on
physicians grew. Acceptance by a group of col- the hospital. This created many more complex
leagues, willingness by those colleagues to refer responsibilities for the medical staff and its elected
patients to the member for service, and willingness officers. Organizing and monitoring to ensure the
to see a colleague’s patients when he or she was not quality of care became a substantial task. Later, there
available were all valuable resources for a physi- emerged complex reimbursement methodologies that
cian. As these benefits became more important, the required even more staff involvement in oversight,
notion of limiting who could join the medical staff regulation, and assurance of fairness to the patient.
of the hospital and share its benefits became more
important. Being selective about who may join the
hospital medical staff has been a powerful tool for Hospital Management
improving and maintaining healthcare quality, but Over the course of the past century, as hospitals
it also has been responsive to economic incentives. increased in size and complexity, and the financing
The role of gatekeeper has sometimes been an of care moved from self-pay to a third-party reim-
appropriate one for the hospital medical staff, and bursement system, healthcare administration as a
sometimes it has been abused. In addition to help- profession evolved to meet these new challenges.
ing staff focus on maintaining quality, it has also Early hospital administrators were called superin-
been closely related to economic factors and the tendents, and they typically had little formal educa-
success of the staff physicians. tional training for their jobs—many were nurses
Today’s hospital/hospital medical staff partner- who had taken on administrative responsibilities.
ship is constructed in an environment of regulation For example, more than half of the superintendents
more intense than at any other time. But these rec- who were members of the AHA in 1916 were
ommendations and requirements have emerged graduate nurses. Other hospital superintendents
slowly, over a period of many years, as the con- were physicians, laypersons, and Catholic nuns.
cepts of clinical science, technology, and ethical The first degree-granting program in hospital
responsibility have grown more complex. administration was established at Marquette
Hospital medical staffs originally began as University in Wisconsin. In 1927, two students,
social organizations that facilitated an orderly both women, received their degrees, but in 1928,
referral of patients from one member to another, the program, with no other graduates, failed.
controlled the growth of the medical staff, and In 1934, Michael M. Davis, a pioneer researcher
helped nurture the addition of new members in the economics, quality, and organization of
deemed desirable. The mutuality of operating and medical care, developed the first graduate program
economic interest among staff members and the in hospital administration at the University of
hospital in which they operated was the powerful Chicago. Davis recognized that most hospital
622 Hospitals
superintendents of the time lacked proper training medical technology and practice make managing
in business. The new program was placed in the hospitals a complex and challenging task.
university’s business school. Davis developed the
curriculum, which included 1 year of academic Benn J. Greenspan
course work in accounting, statistics, and manage- See also Academic Medical Centers; Access to
ment and a hospital residency. With the success of Healthcare; American College of Healthcare
the program, other universities established hospital Executives (ACHE); American Hospital Association
administration programs based on Davis’s model. (AHA); Health Insurance; Hospital Closures; Joint
Before the founding of the first graduate pro- Commission; Multihospital Healthcare Systems
gram in hospital administration, a group of prac-
ticing hospital superintendents came together in
1933 and formed the American College of Hospital Further Readings
Administrators (now the American College of American Hospital Association. AHA Guide: United
Healthcare Executives [ACHE]), the first profes- States Hospitals, Health Care Systems, Networks,
sional association for hospital administrators. And Alliances, Health Organizations, Agencies, Providers.
while both clinically trained and lay administra- Chicago: American Hospital Association, 2008.
tors could join the college, the emphasis was American Hospital Association. Hospital Statistics.
clearly on the lay administrator. Among the 106 Chicago: American Hospital Association, 2008.
charter fellows of the college, only 32 were physi- Griffin, Don, and I. Donald Snook. Hospitals: What
cians. Over the years, the college has grown; and They Are and How They Work. 3d ed. Sudbury, MA:
today it is an international professional society of Jones and Bartlett, 2006.
more than 30,000 healthcare administrators who Henderson, John, Peregrine Horden, and Alessandro
lead hospitals, healthcare systems, and other Pastore, eds. The Impact of Hospitals, 300–2000.
healthcare organizations. New York: Oxford University Press, 2007.
While hospitals have continued to evolve, the Howell, Joel D. Technology in the Hospital: Transforming
field of healthcare administration continues to sus- Patient Care in the Early Twentieth Century.
tain three primary objectives. First, healthcare Baltimore: Johns Hopkins University Press, 1996.
administrators are responsible for the business and Risse, Guenter B. Mending Bodies, Saving Souls: A
History of Hospitals. New York: Oxford University
financial aspects of hospitals, clinics, and other
Press, 1999.
health services organizations, and they are focused
Rosenberg, Charles E. The Care of Strangers: The Rise
on increasing efficiency and financial stability.
of America’s Hospital System. New York: Basic
Their roles include human resources management,
Books, 1987.
financial management, cost accounting, data col- Stevens, Rosemary. In Sickness and in Wealth: American
lection and analysis, strategic planning, marketing, Hospitals in the Twentieth Century. Baltimore: Johns
and the various maintenance functions of the orga- Hopkins University Press, 1999.
nization. Second, healthcare administrators are
responsible for providing the most basic social
service: the care of dependent people at the most Web Sites
vulnerable points in their lives. Third, healthcare
administrators are responsible for maintaining the http://www.ache.org
moral and social order of their organizations, serv- American Hospital Association (AHA):
ing as advocates for patients, arbitrators in situa- http://www.aha.org
tions where there are competing values, and Center for Studying Health System Change (HSC):
intermediaries for the various professional groups http://www.hschange.com
that practice within the organization. Centers for Medicare and Medicaid Services (CMS):
The challenges faced by the healthcare adminis- http://www.cms.hhs.gov
trators of hospitals are many. Shortages of nurses Healthcare Financial Management Association (HFMA):
and other healthcare workers, concerns for the http://www.hfma.org
safety and quality of healthcare services, rising Joint Commission: http://www.jointcommission.org
costs, the growing number of uninsured Americans, National Center for Health Statistics (NCHS):
an aging population, and the rapidly changing http://www.cdc.gov/nchs
I
event-reporting system. After the IOM report, the
Iatrogenic Disease Joint Commission created a set of national patient
safety goals that were incorporated into the
Iatrogenic disease commonly refers to a physician- accreditation process to reduce medical errors.
induced disease and more generally to a disease The most obvious example of iatrogenic disease
state caused by the commission of acts by the phy- is medical errors. Common medical errors include
sician rather than the omission of needed treat- performing an operation on the wrong body part
ment. The word iatrogenic comes from the root or dispensing the wrong medicine due to negli-
iatro, the Greek word for physician, or more gen- gence; however, this is only a small part of iatro-
erally a healer, and the word genic, meaning to genic disease. The greatest amount of iatrogenic
come from or be created by. Thus, iatrogenic dis- disease is caused by the unintended side effects or
ease literally means a disease state that is brought adverse effects caused by drug interactions. These
forth by those who intend to heal. More broadly, adverse effects may range from mild disease states,
however, the term iatrogenic disease has been such as impaired sleep or indigestion, to severe
referred to any adverse event that is associated consequences, such as heart failure, stroke, and
with a healthcare provider, including a nurse or death. Sometimes, the adverse effects are known
medical technician, or treatment. Iatrogenic dis- and accepted by the patient because the positive
ease poses itself as a risk to patients, and it can be effects of the treatment outweigh the adverse
the result of several factors including negligence, effects. In these cases, while the resulting disease
medical error, and/or the adverse effect of treat- state is in fact iatrogenic, the term is often not
ments. It is estimated that iatrogenic disease is the applied because iatrogenic disease is generally used
third leading cause of death in the United States. pejoratively.
Iatrogenic disease may also result in hospitalized
patients acquiring nosocomial infections. For
Overview
example, hospital staff may unintentionally trans-
Iatrogenic disease has been cited as a widespread mit microbes during the routine patient encounter
national problem. In 2000, the national Institute because of improperly sterilized medical equip-
of Medicine (IOM) released a report titled To Err ment and through the use of unclean or ungloved
Is Human: Building a Safer Health System. This hands.
landmark report estimated that between 44,000 Another example of iatrogenic disease derives
and 98,000 deaths occur each year in the nation’s from interventions that are done or not done as
hospitals from medical errors. An earlier report a result of financial incentives. For example,
about medical errors in New York hospitals when a healthcare provider decides to use a cer-
spurred the Joint Commission to create a sentinel tain medication because of its association with a
623
624 Iatrogenic Disease
pharmaceutical company, any disease state that Future Implications

results from choosing the particular medicine over
Iatrogenic disease is a consequence of modern
a more effective alternative is considered to be an
medicine; however, much of this burden can be
iatrogenic disease. Thus, the referral for an inter-
reduced through a number of changes. For
vention for the purpose of profit rather than for
instance, medical errors are being tackled through
the best interest of the patient also results in iatro-
error reduction strategies—a technique that has
genic disease. Many studies of physician behavior
been successfully used in the aeronautics industry.
have documented that financial incentives change
Furthermore, the National Institutes of Health
practice patterns.
(NIH) funds large RCTs on many important treat-
Physicians also change their behavior in response
ment modalities, including alternative medicine.
to potential litigation, which can be brought on by
Additionally, many organizations have imple-
medical negligence, an action punishable in the
mented incentives to improve healthcare quality,
U.S. judicial system. This practice, often referred
which are now being considered by Medicare.
to as defensive medicine, may have positive out-
With new safety-oriented procedures, financial
comes because the behavior of the provider changes
incentives geared toward patient safety and qual-
to try to avoid negligence. However, this behavior
ity, tort reform, and emerging scientific evidence,
may also lead to unnecessary tests, procedures,
iatrogenic disease can be overcome.
and treatments, which ultimately result in iatro-
genic disease. Gregory Vachon
A more complicated example of iatrogenic dis-
ease is the use of unproven diagnostic and thera- See also Adverse Drug Events; Evidence-Based Medicine
peutic modalities. Many practice patterns in (EBM); Joint Commission; Malpractice; Medical
modern medicine are not definitively proven to be Errors; National Patient Safety Goals; Patient Safety;
Quality of Healthcare
beneficial. The recently debunked routine practice
of prescribing estrogen replacement therapy at
menopause for women is a case in point. In this
Further Readings
instance, a substantial amount of basic science
data, as well as data from observational studies in Caplan, Ruth B., and Gerald Caplan. Helping the
women, strongly suggested that postmenopausal Helpers Not to Harm: Iatrogenic Damage and
estrogen protected against heart attacks. However, Community Mental Health. New York: Brunner-
the results from a randomized controlled trial Routledge, 2001.
(RCT), considered the gold standard of evidence- Farley, Donna O., Sally C. Morton, Cheryl L. Damberg,
based medicine, showed that hormone replace- et al. Assessment of the National Patient Safety
ment therapy actually caused myocardial Initiative: Context and Baseline Evaluation Report 1.
Santa Monica, CA: RAND Corporation, 2005.
infarctions. As a result, many women were having
Kohn, Linda T., Janet M. Corrigan, and Molla S.
iatrogenic heart attacks for decades because of
Donaldson, eds. To Err Is Human: Building a Safer
poor-quality data. Similarly, the currently accepted
Health System. Washington, DC: National Academy
protocol for prostate cancer screening and treat-
Press, 2000.
ment in men has been studied, and the findings Madeira, Sofia, Miguel Melo, João Porto, et al. “The
suggest that these processes may lead to iatrogenic Diseases We Cause: Iatrogenic Illness in a Department
disease. To prevent this type of large-scale iatro- of Internal Medicine,” European Journal of Internal
genic disease, modern medicine needs the right Medicine 18(5): 391–99, September 2007.
kind of evidence to guide its actions. Raje. R. Ravindra, and Priscilla D. Wong. Iatrogenic
Iatrogenic disease is not limited to conventional Diseases. Westbury, NY: PJD, 1999.
medical practices, however. Alternative-medicine Sage, William M. “Principles, Pragmatism, and Medical
practitioners can also cause iatrogenic disease. For Injury,” Journal of the American Medical Association
example, ephedrine, an active ingredient in many 286(2): 226–28, July 11, 2001.
alternative weight loss products, was withdrawn Webster, Craig S. “The Iatrogenic-Harm Cost Equation
from the market because it was shown to cause and New Technology,” Anaesthesia 60(9): 843–46,
strokes. September 2005.
Indian Health Service (IHS) 625
Web Sites 1.9 million of an estimated 3.3 million American

American Iatrogenic Association: http://www.iatrogenic.org Indian and Alaska Native population.
Association for Professionals in Infection Control and More than half of the IHS’s budget is handled
Epidemiology (APIC): http://www.apic.org directly by the tribes. In turn, the IHS helps the
Hospital Infection Society (HIS): http://www.his.org.uk tribes develop their health programs and coordi-
International Federation of Infection Control (IFIC): nate their health planning using federal, state, and
http://www.theific.org local resources. However, many of the tribes lack
the necessary resources to manage their own pro-
grams. There is also a growing interest among
managed-care organizations to contract with the
tribes for clinical services. Some American Indian
Indian Health Service (IHS) and Alaska Native leaders worry that these trends
may undermine the federal government’s responsi-
The Indian Health Service (IHS), an agency of the bility to the tribes.
U.S. Department of Health and Human Services
(HHS), is the principal healthcare provider to
American Indians and Alaska Natives (AI/AN) Health Disparities
and acts as their health advocate. The mission of While the overall health status of American Indians
the IHS is to provide quality healthcare services to and Alaska Natives has improved in the past few
the 562 federally recognized tribes of American decades, important disparities still exist between
Indians and Alaska Natives. Its goal is to ensure the American Indian and Alaska Native popula-
comprehensive, culturally acceptable personal and tion and the general population in terms of mortal-
public health services and to ensure that these ser- ity, disease rates, costs, and access to healthcare.
vices are available and accessible to those who are The five leading causes of American Indian
eligible. Since its inception, the IHS has been deaths in 2004 were heart disease, cancer, acci-
working with various tribes, urban Indian pro- dents (unintentional injuries), diabetes mellitus,
grams, and other Indian organizations to achieve and stroke (cerebrovascular diseases). In contrast,
these goals. the five leading causes of deaths for the entire
population of the nation were heart disease, can-
cer, stroke, chronic lower respiratory diseases, and
Background
accidents.
The federal government has the responsibility Life expectancy for American Indians and Alaska
of meeting the health needs of American Indians Natives is lower than for all other races in the
and Alaska Natives, as promulgated by the nation. The median age of American Indians and
Snyder Act of 1921; the Indian Health Care Alaska Natives is 28.0 due to high-mortality rates
Improvement Act (IHCIA), as amended; and the in early life. For example, the infant death rate is
Indian Self Determination and Education 10 per 1,000 live births compared with 7 per 1,000
Assistance Act (ISDEAA). The Snyder Act and the for the entire U.S. population (2001–2003 rates).
IHCIA have provided the authority for the fed- Compared with the nation’s population,
eral government programs to deliver health ser- American Indians and Alaska Natives more
vices, while the ISDEAA promotes the tribal frequently die from tuberculosis (750% higher),
administration of federal Indian programs, includ- alcoholism (550%), diabetes (190%), accidents
ing healthcare. (150%), homicides (100%), and suicides (70%).
Established on July 1, 1955, the IHS works in They also tend to suffer from higher rates of infec-
partnership with American Indians and Alaska tious diseases, likely the result of waste disposal
Natives to honor its goal of providing optimal and sanitation problems. American Indians and
care and to promote the physical, mental, emo- Alaska Natives have the third highest rate of HIV/
tional, and spiritual health of American Indians AIDS diagnoses in the nation, and they are more
and Alaska Natives, along with protecting their likely to seek and receive treatment in the later
sovereign rights. The IHS serves approximately stages of illness, thus resulting is shorter life spans.
626 Indian Health Service (IHS)
American Indians and Alaska Natives have the service units. The basic organizational element of
highest rate of Type II diabetes in the world. The the healthcare program is the service unit usually
IHS healthcare expense per American Indian/ serving the local community, and it is often hospi-
Alaska Native is $2,158 compared with $5,921 for tal based.
the U.S. population. The American Diabetes The IHS has its own roster of physicians, nurses,
Association estimates that the average cost of dia- aides, pharmacists, and dentists and is predomi-
betes care is more than $13,000 per diabetic nantly staffed by American Indians and Alaska
patient per year, largely due to the cost of pharma- Natives. The IHS operates 33 hospitals, 52 health
ceuticals. In the past, the emphasis of the IHS had centers, and 38 health stations. Tribal hospitals
been on the clinical care of diabetes and the pre- number 15, with 220 health centers and 116
vention of complications rather than on the pre- health stations. There are 34 urban programs in
vention of the disease itself, but that is changing. existence, including community health and com-
Needed services are often rationed due to lack prehensive primary healthcare services.
of funding. Funds are not distributed proportion-
ally, and additional funds are not available should
Future Implications
more money be needed for health services. The
tribes may offer funds but often not enough to The costs of the IHS are increasing as a result of
cover the shortfalls. Many facilities have negoti- the overall increasing costs of healthcare and
ated discounts for contract care. Most hospitals because of increases in the size of the American
have been willing to discount, but many physicians Indian and Alaska Native population. The eligible
are not always as willing. population was estimated to increase by 1.6% in
Availability of services depends on accessibility 2007, or an additional 30,000 people, which
to IHS-funded facilities. However, not all IHS means more healthcare demands for services now
facilities offer the same services. And there is often and in the future.
a long waiting time between the call for an However, for FY2009, the IHS will receive fed-
appointment and the actual service. eral funding of $3.3 billion, a $21.3 million cut.
Some services cannot be provided on-site because Given the rising costs and insufficient funding, along
of the growing complexity of medical care, which with a growing trend toward managed care, the IHS
is beyond the scope of current IHS clinics and faces a challenging future in fulfilling its mission.
health centers. Sometimes, patients are forced to
use contract care or to travel great distances to a Patricia R. Meyers
discounted hospital or an IHS facility. See also Access to Healthcare; Cultural Competency;
This presents a challenge to the private sector, Diabetes; Ethnic and Racial Barriers to Healthcare;
having to deal with the social, cultural, and other Health Disparities; Public Health; Rural Health;
characteristics that divide this population from Vulnerable Populations
other populations. American Indians and Alaska
Natives are a very diverse group, and they cannot
be all grouped together because of differences in Further Readings
language skills and customs. Allison, Michael T., Patrick A. Rivers, and Myron D.
Fottler. “Future Public Health Delivery Models for
Organization Native American Tribes,” Public Health 121(4):
296–307, April 2007.
The IHS is a complex organization, with myriad U.S. Department of Health and Human Services, Indian
programs operating under varying circumstances Health Service. Caring and Curing: The First 50
across geographic areas. Years of the Indian Health Service. Rockville,
Its main headquarters is located in Rockland, MD:Indian Health Service, 2005.
Maryland. It also has 12 area offices covering 35 Kunitz, Stephen J. “Ethics in Public Health Research:
states, most states being in the western portion of Changing Patterns of Mortality Among American
the country. Services are administered through Indians,” American Journal of Public Health 98(3):
these offices and 163 IHS- and tribally operated 404–11, March 2008.
Infectious Diseases 627
Rhoades, Everett, ed. American Indian Health: healthy host are termed primary pathogens. Their
Innovations in Health Care, Promotion, and virulence or capacity to cause disease depends on
Policy. Baltimore: Johns Hopkins University the number of organisms transmitted and their
Press, 2000. ability to enter tissues, evade the host’s defenses
U.S. Government Accountability Office. Indian Health and multiply, or produce extracellular products
Service: Health Care Services Are Not Always such as toxins. Organisms that invade and cause
Available to Native Americans. GAO-05–789. disease in a host with altered resistance are termed
Washington, DC: U.S. Government Accountability opportunistic pathogens. These organisms are
Office, 2005.
often part of the host’s normal flora, residing
Westmoreland, Timothy M., and Kathryn R. Watson.
within the gastrointestinal or respiratory tracts, or
“Redeeming Hollow Promises: The Case for
may be acquired from the host’s environment.
Mandatory Spending on Health Care for American
They take advantage of the host’s altered defenses,
Indians and Alaska Natives,” American Journal of
Public Health 96(4): 600–605, April 2006.
due to, for instance, genetic defects, immunosup-
pressive therapy, cancer chemotherapy, or changes
in the antimicrobial flora due to exposure to an
Web Sites
antimicrobial drug.
Indian Health Service (IHS): http://www.ihs.gov

Indian Health Service (IHS) Fact Sheets: http://info.ihs.gov Transmission
An exogenous disease, such as malaria, is caused
by a microorganism whose natural environmental
reservoir is outside the body. Other infections,
Infectious Diseases such as appendicitis, are caused by a constituent
of the indigenous microbial flora and designated
Microorganisms are everywhere. They are found as endogenous diseases. Organisms may be trans-
throughout the environment and by the billions mitted to the host by several different mechanisms
on the skin and in the gastrointestinal and respira- including direct or indirect contact, which includes
tory tracts. Most are quiescent, colonizing the hand contact or a sneeze; contaminated food or
host without producing disease or prevented from water; contact with a contaminated inanimate
doing so by the body’s normal defenses. Intact object; or the bite of an insect vector. Entry thus
skin and mucosal surfaces, as well as specialized may be by inhalation, ingestion, injection, or
elements of the immune system, serve to limit the direct implantation.
host-microbe interaction. However, when circum- Once transmitted, the organism colonizes the
stances change and this delicate balance is dis- host’s tissue at the site or portal of entry before
rupted, such as when a burn destroys intact skin, undergoing a period of multiplication, leading to
antibiotic therapy alters normal microbial flora, subsequent invasion of tissue and/or production
or surgery disturbs the normal anatomic barriers, of disease-causing toxins. An infectious disease
microorganisms gain access to the host and create becomes clinically evident when the microbe
an opportunity for an infection to occur. An infec- invades locally and/or disseminates throughout the
tious disease then is a clinically evident disease body and produces tissue injury or organ dysfunc-
affecting the host due to a microorganism or one tion. Injury may be a direct effect of the organism
of its products. or its toxins. In some cases, it may be due to the
host’s own inflammatory or immune response.
Some organisms grow only at a specific body site,
Microbial Factors
while others disseminate widely. The host and/or
The variety of microorganisms capable of infect- microbe determine the factors accounting for this
ing humans is broad and includes bacteria, viruses, tissue tropism. Some microbes are obligate intrac-
fungi, protozoa, helminthes, arthropods, and, ellular parasites and must invade cells for their
rarely, proteinaceous substances called prions. survival; malaria spreads in this way. They often
Organisms that invade or damage tissue in a have surface molecules that facilitate entry into
628 Infectious Diseases
their target cells. Other microbes use the host’s smallpox, rubella, and measles were high. As
own scavenger cells but resist the normal killing exposure continued, levels of immunity in the
mechanisms to survive, proliferate, and cause an population rose, and resistance increased, leading
infectious disease, such as tuberculosis. to lower prevalence, reduced mortality, and more
predictable patterns of occurrence.
The Greek physician, Hippocrates, the father of
Host Immunity
Western medicine, was one of the first to describe
Fortunately, most infections in the normal host diseases such as malaria, tuberculosis, mumps,
are self-limited due to a series of immune mecha- diphtheria, and probably influenza in enough
nisms that have evolved over time. Innate immu- detail to make them recognizable today. Epidemics
nity is not influenced by repeated infections, while of measles and smallpox occurred in ancient
adaptive immunity follows repeated exposure to Greece and Rome. The Black Plague, which
an organism or its products. Innate mechanisms hit Europe in the Middle Ages, killed an estimated
constitute the first line of defense. Mechanical 25 million people, or 25% to 50% of the European
barriers, such as skin and mucosal membranes, population at the time.
and normal secretions, such as tears, saliva, and The European settlement of the Americas in the
urine, make entry into the body difficult. The 15th and 16th centuries introduced smallpox,
indigenous microbial flora discourages pathogenic measles, and typhus into New World populations
colonization by competing for binding sites and with no immunity to these diseases. From 1511 to
nutrients or producing inhibitory chemicals called 1560, the population of Mexico declined from
bacteriocins. Invasion of the host produces a series about 20 million to 3 million and then to 1.6 mil-
of acute-phase responses manifested by mediator lion by the turn of the 17th century. The coloniza-
molecules such as interleukin-1 and the completion of the New World by Europeans was
ment system. These reactions initiate the host’s accomplished more by the pathogens they brought
response to limit the spread of the pathogen. than by their traditional weapons.
Adaptive or specific immunity has two major Epidemics continue to unfold across the world
coordinated components. The B-lymphocyte sys- due to both old pathogens and new ones. The
tem produces specific immunoglobulins, or anti- Spanish flu pandemic of 1918 to 1919 killed 25 to
bodies against the pathogen. The T-lymphocyte 50 million people worldwide. Two other less viru-
system activates the killer cells to attack intracel- lent influenza pandemics occurred in the 20th
lular microbes or produce cytokines, chemicals century, and new strains of the influenza virus are
that stimulate other scavenger cells or macrophages, continually emerging. According to many experts,
which then may limit the infection. another pandemic is inevitable.
The ability to control many of these pathogens
has made great strides in the past several centuries.
History
Edward Jenner developed the first vaccine for
Microbes have populated the earth longer than smallpox in 1786, which eventually led to its con-
man has existed, and infections have undoubtedly trol. It became the first and only infectious disease
played a role in his survival. Plagues are noted in to ever be managed and eliminated worldwide.
the Old Testament and occurred as man began The work of Robert Koch and Louis Pasteur and
forming aggregate groups large enough to sustain the introduction of the germ theory of disease
epidemics of new or evolving pathogens that made the control of infectious diseases possible.
could be transmitted from person to person. The Isolation and identification of microbial agents led
origin of many infectious agents remains a mys- to descriptions of the epidemiology and natural
tery, but man became the established reservoir for history of many infectious diseases. By the end of
many of these microbes. Infected animals and con- the 19th century, water purification treatment,
taminated food and water were additional sources vector control, and rodent reduction programs
of other organisms. As there was little previous were beginning to make strides in the control of
exposure to these microbes, the level of immunity many pathogenic microbes. The 20th century saw
was low, and mortality rates for infections such as major public health strides in vaccine development
and usage for the control of polio, measles, mumps, responses. The Centers for Disease Control and
diphtheria, and tetanus. These achievements have Prevention (CDC), in partnership with federal,
truly been one of the public health success stories state, and local agencies, foreign governments, the
throughout the developed world, and public health World Health Organization (WHO), and many
measures to control infectious diseases are having groups in private industry, formulated plans to
similar success, where implemented, in develop address these emerging infectious disease threats.
ing countries. Furthermore, such measures are In the United States, some success has been
extremely cost-effective. For example, every $1 achieved with the reduction of childhood bacterial
spent on a vaccine against measles, mumps, and meningitis, group B streptococcal infections in
rubella (MMR) saves $21, while every $1 spent on infants, and bloodborne diseases such as hepatitis
a vaccine against diphtheria, pertussis, and tetanus B and human immunodeficiency virus (HIV). Still,
(DPT) saves $29. However, these diseases have not worldwide epidemics of tuberculosis, malaria, and
disappeared. If effective vaccination campaigns are AIDS continue. Tuberculosis infects up to one third
not continued until these microorganisms are of the world’s population and causes 2 million
eradicated everywhere, their reemergence is likely. deaths per year; drug-resistant malaria kills 1 mil-
The serendipitous discovery of penicillin by lion children in sub-Saharan Africa each year and
Alexander Fleming in 1929 heralded a new age of has crept into new habitats; and AIDS has infected
the treatment of infectious diseases. For the first more than 40 million people to date and continues
time, effective therapy for bacterial infections was to spread throughout the developed and the devel-
possible. The post–World War II era brought the oping world. Despite a century of scientific prog-
discovery and/or synthesis of many new antibiotics, ress, infectious diseases still cause tremendous
leading to treatment of common infections of the human suffering, deplete scarce resources, impede
lung, skin, and urinary tract and ever-increasing social and economic development, and contribute
control of life-threatening bacterial infections such to global instability. Much more work needs to be
as tuberculosis and typhoid fever. Antimicrobials done before the control of these major pathogens
to treat various viruses, fungi, and parasites have becomes a reality.
also been developed. With the success of the new
antibiotics, some physicians even predicted the end
Infectious Diseases and Healthcare Today
of infectious diseases—an optimistic view that was
soon proven false. Unfortunately, microorganisms Healthcare today is delivered in many venues,
replicate rapidly, and within a few years of the including physicians’ offices, immediate-care clin-
development of antibiotics, resistance began to ics, specialty centers, long-term care facilities,
emerge. The last three decades of the 20th century emergency departments, and hospitals. The sick-
brought a resurgence of resistant sexually transmit- est and most vulnerable patients are hospitalized,
ted diseases; increasing antibiotic resistance in undergoing the most procedures and interventions
common bacteria; as well as the identification of and receiving the most medications. They are at
new infections such as legionnaire’s disease, toxic risk for a variety of healthcare-associated infec-
shock syndrome, lyme disease, and acquired immu- tions. The national Institute of Medicine’s (IOM)
nodeficiency syndrome (AIDS). report To Err Is Human: Building a Safer Health
In 1992, the national Institute of Medicine System estimated that hospital-related adverse
(IOM) issued a report, Emerging Infections: events in the nation, including hospital-associated
Microbial Threats to Health in the United States, infections (HAIs), cause an estimated 44,000 to
which emphasized the global nature of emerging 98,000 deaths annually at a cost of $30 billion.
pathogens. The landmark report outlines modern HAIs may affect as many as 5 to 15 per 100 hos-
demographic, environmental, and behavioral pitalized patients, with associated complications
changes leading to diseases of infectious origin in 25% to 50% of patients in intensive care.
whose incidence in humans has increased or Attempts to prevent hospital infections began
threatens to increase in the near future. with Ignaz Semmelweis’s introduction of hand
Strategies for preventing these infections washing with chlorinated lime solution to prevent
demanded both national and international maternal mortality at the Maternity Clinic in
630 Infectious Diseases
Vienna in 1847. These efforts were continued with (MDROs) are replacing older more susceptible
Florence Nightingale’s Notes on Hospitals in ones. Today, this is one of the major problems
1863, in which she reported mortality rates for the confronting the control of infections, particularly
main hospitals in the United Kingdom and noted in vulnerable populations in hospitals and long-
the relationship between the lack of sanitary con- term care facilities. The pharmaceutical cost of the
ditions and postoperative complications. In the development and approval of new antibiotics to
United States and elsewhere, surveillance and the successfully combat these new threats continues to
systematic collection, analysis, and interpretation escalate, and the incentives for a return on invest-
of data form the basis of infection control essential ment are diminishing. In the past decade, far fewer
for the evaluation and subsequent intervention to new antibiotics have been developed than needed,
control infection risk in hospitals and other health- with only four developed between 2003 and 2007.
care settings. The CDC in the 1970s began the Of these, only one was a novel drug. Hospitals are
Study of the Efficacy of Nosocomial Infection currently having to deal with an increasing num-
Control (SENIC) Project to evaluate the effects of ber of patients with infections due to resistant
surveillance and reporting on hospital infection staphylococci, Escherichia. coli, and Candida spe-
rates, and it found that 35% to 50% of all hospital cies. Most of the hospital-acquired infections in
infections were associated with just a few patient intensive-care units are due to these and similarly
care practices: (a) the use and care of intravenous resistant organisms. Unsuspected resistance can
and urinary catheters, (b) surgical procedures, (c) lead to treatment with an inappropriate antimi-
mechanical support of lung function, (d) hand crobial, one in which the microorganism is not
hygiene, and (e) the use of isolation precautions. susceptible. Treatment courses are longer, hos-
During the past four decades, it has become clear pitalization is prolonged, and mortality rates
that hospital-associated infections are good indica- are higher in those infections due to resistant
tors of the quality of patient care. Interhospital organisms. Controlling these infections in the
comparisons, however, have been difficult due to hospital depends on early detection, hand
differences in the severity of illness in patients and hygiene, implementation of isolation precau-
lack of standardization of methods of measure- tions, and appropriate use of available antibiot-
ment. To reduce infections associated with these ics, all of which increase hospital costs in days
interventions, standardized guidelines and preven- of decreasing reimbursement. Other healthcare
tion programs have been introduced in most hos- settings, especially long-term care facilities and
pitals, and they have proven to be cost-effective. hospital emergency departments, are facing
Prevention of the transfer of organisms from one similar problems.
patient to another via the hands of healthcare per- Effective therapy depends not only on the sus-
sonnel is one of the most important interventions ceptibility of the organism to the antimicrobial but
to control HAIs. Hand hygiene, including hand also on host factors, the virulence of the organism,
washing and/or the use of alcohol-based hand anti- and the pharmacology of the drugs. Ideally, the
septics, remains a major compliance problem that choice of an appropriate antimicrobial should
is being addressed aggressively in most healthcare strive for maximal efficacy, with minimal toxicity,
settings. Guidelines have been revised, and cam- at the lowest cost, and with the smallest risk of
paigns including education, compliance monitor- inducing further resistance. To maintain the effi-
ing, and feedback are becoming the norm. cacy of the antimicrobials in use today, several
strategies have been instituted or are needed.
These approaches include the following: (a) cam-
Antimicrobial Resistance
paigns to educate physicians and the general pub-
The control of healthcare-associated infections has lic to avoid using antimicrobials for common
become complicated with the rise of microorgan- infections such as viral upper-respiratory infec-
isms resistant to many commonly used antibiotics. tions in children or acute bronchitis in otherwise
The promise that bacterial infections would disap- healthy adults; (b) new government regulations
pear or be easily controlled with antibiotics has limiting the use of antimicrobials in animal feed,
disappeared. New multidrug-resistant organisms which drives the development of resistance in
human pathogens; (c) optimal development and Disease; International Classification of Diseases
use of vaccines to prevent common diseases such (ICD); Public Health
as ear infections and pneumonia in children; and
(d) appropriate funding for public health programs
to monitor and control emerging and reemerging Further Readings
pathogens. Ali, S. Harris, and Roger Keil, eds. Networked Diseases:
Unless Americans become better stewards of Emerging Infections in the Global City. Malden, MA:
current antimicrobials and encourage research and Blackwell, 2008.
development of new ones, the ability to treat even Brachman, Philip S. “Infectious Diseases: Past, Present,
common infections will diminish. Infectious dis- and Future,” International Journal of Epidemiology
eases may return as the most common cause of 32(5): 684–86, October 2003.
death in the nation. Chamberlain, Neal R. The Big Picture: Medical
The impact of the national IOM’s To Err Is Microbiology. New York: McGraw-Hill, 2009.
Human: Building a Safer Health System, which Institute of Medicine. Emerging Infections: Microbial
included healthcare-associated infections, in Threats to Health in the United States. Washington,
terms of morbidity, mortality, and costs sparked DC: Institute of Medicine, 1992.
organizations such as the Institute for Healthcare Kohn, Linda T., Janet M. Corrigan, and Molla S.
Improvement (IHI) to develop several new pro- Donaldson, eds. To Err Is Human: Building a Safer
grams, guidelines, and standards for patient care Health System. Washington, DC: National Academy
and safety within healthcare systems. The Five Press, 2000.
Million Lives Campaign, started in 2007, tar- Mayer, Kenneth H., and Hank F. Pizer, eds. The Social
gets, among other goals, reduction from harm Ecology of Infectious Diseases. Boston: Elsevier
Academic Press, 2008.
caused by surgical-site infections and infections
Sattenspiel, Lisa, and Alun Lloyd. The Geographic Spread
caused by the multidrug-resistant Staphylococcus
of Infectious Diseases: Models and Applications.
aureus. Furthermore, several state legislatures
Princeton, NJ: Princeton University Press, 2009.
are contemplating new laws for screening of
Shetty, Nandini, Julian W. Tang, and Julie Andrews.
patients on entry into the hospital to limit the Infectious Disease: Pathogenesis, Prevention, and
spread of multidrug-resistant organisms in an Case Studies. Hoboken, NJ: Wiley, 2009.
effort to address quality-of-care issues. Whether Southwick, Frederick S. Infectious Diseases: A Clinical
these costly programs will have a lasting impact Short Course. 2d ed. New York: McGraw-Hill, 2008.
in today’s healthcare milieu remains an open Webber, Roger. Communicable Disease Epidemiology
question. and Control: A Global Perspective. 3d ed.
Cambridge, MA: CABI, 2009.
Future Implications Zacher, Mark W., and Tania J. Keefe. The Politics of
Global Health Governance: United by Contagion.
The past several decades have witnessed the emer- New York: Macmillan, 2008.
gence of new infectious diseases and the resur-
gence of infectious diseases once considered
vanquished. Today, many microorganisms are Web Sites
resistant to antibiotics, and treatment of infectious
Association for Professionals in Infection Control and
diseases is becoming more complex and expen-
Epidemiology (APIC): http://www.apic.org//AM/
sive. New antibiotics and antiviral agents need to
Template.cfm?Section=Home1
be developed, as well as new molecular techniques Centers for Disease Control and Prevention (CDC):
to better detect and trace the spread of microor- http://www.cdc.gov
ganisms rapidly and globally. Infectious Diseases Society of America (IDSA):
Gary D. Rifkin http://www.idsociety.org
Institute for Healthcare Improvement (IHI):
See also Acute and Chronic Diseases; Continuity of http://www.ihi.org
Health Service Operations During Pandemics; Society for Healthcare Epidemiology of America (SHEA):
Disease; Emerging Diseases; Epidemiology; Iatrogenic http://www.shea-online.org
632 Inflation in Healthcare
and geographic region of residence. Older people

Inflation in Healthcare have a higher prevalence of chronic health condi-
tions and use more healthcare resources than
Inflation in healthcare is the continued increase in younger people. As the nation’s population ages,
the price of healthcare goods and services. Inflation per capita healthcare spending also increases.
in healthcare is reported in several ways. First, the Changes in health insurance coverage influence
rate of growth in per capita healthcare spending is healthcare inflation by changing the consumer
often compared with the rate of growth in the per demand for healthcare. Increases in health insur-
capita gross domestic product (GDP) to measure ance coverage, through more comprehensive cover-
whether healthcare spending is growing faster or age or reductions in consumer cost sharing, reduce
slower than the overall economy. Second, national prices to the individual consumer and increase
health expenditures as a percentage of GDP are demand for healthcare. When managed-care orga-
used to determine whether healthcare spending as nizations increase provider choice by broadening
a proportion of overall spending is growing over networks and reducing referral restrictions, per-
time. National health expenditures as a percent- enrollee spending may also increase. Conversely,
age of GDP have steadily increased in the United shifting more costs to the individual consumer
States from 7.0% in 1970 to 16% in 2007. through higher copayments or deductibles, for
Another important measure of inflation in example, decreases the demand for healthcare.
healthcare in the nation is the consumer price Although considered as a small component, the
index (CPI). The CPI is an overall measure of aver- health status of the population is another driver of
age retail price changes over time. Medical care is healthcare inflation. Behavioral factors such as
included as two components of the CPI, measuring obesity, smoking, and a general sedentary lifestyle
medical-care services, including professional medi- increase healthcare spending. As a population
cal services, hospital and related services, and becomes less healthy, per capita healthcare spend-
health insurance, and medical-care commodities, ing also increases.
including prescription drugs and nonprescription Finally, growth in personal income may also
drugs and medical supplies. Since the CPI mea- drive demand for healthcare. Healthcare is a normal
sures inflation for goods and services purchased at good, meaning that as a consumer’s income increases,
the retail level, it is limited to out-of-pocket spend- he or she demands more healthcare services.
ing for medical care by consumers and excludes,
for example, payments for health insurance cover-
Supply-Side Factors
age by employers and the government.
Supply-side factors related to escalating health-
care spending include provider supply, changes
Factors Driving Inflation in provider operating costs, changes in provider
Inflation in healthcare can be caused by factors payment mechanisms, and advancements in
that are related to either the demand or the supply technology.
of a healthcare good or service. Changes in the overall provider supply and a
mix of the types of providers is one supply-side
driver of inflation. Specialists have been shown
Demand-Side Factors
to use more expensive technology and resources,
Demand-side factors associated with escalating while midlevel providers, such as nurse practitio-
healthcare spending include changes in the demo- ners and physician assistants, may be lower-cost
graphic composition of the population, changes in alternatives.
health insurance coverage, changes in the health Provider operating costs, including wages,
status of the population, and general economic medical malpractice premiums, and other operat-
conditions (e.g., growth in personal incomes, pro- ing expenses, can influence inflation. Continued
portion of the population living in poverty). increases in medical malpractice premiums increase
Demographics can influence healthcare infla- operating costs and also encourage increases in
tion through changes in age, gender, ethnicity/race, defensive medicine, liability-induced changes in
Inflation in Healthcare 633
healthcare goods and services provided to an indi- waned in recent years. In response to a backlash
vidual patient as a way of reducing the likelihood by providers and consumers to the stringent con-
of incurring a lawsuit. Malpractice litigation trols used by many managed-care organizations,
accounts for some of the differences in healthcare incentives to control healthcare spending have
inflation between nations that are more versus less shifted to the individual consumer. High-deductible
litigious. Furthermore, shortages in specific labor health plans coupled with health saving accounts
markets, such as the nurse labor market, also have been touted by both the federal government
increase inflation by driving up provider operating and employers as a mechanism to reduce rates of
costs. healthcare spending growth by shifting more costs
Provider payment mechanisms may also influ- to the individual consumer. It seems likely that
ence inflation. Fee-for-service payment mechanisms such plans will greatly increase in the future.
encourage overutilization, while capitation-based
payment mechanisms encourage more cost- Tricia J. Johnson
effective utilization. See also Competition in Healthcare; Cost of Healthcare;
Technological innovations and improvements, Healthcare Financial Management; Health Economics;
such as new equipment, new medical and surgical Health Insurance; Malpractice; Payment Mechanisms;
procedures, and new pharmaceutical drugs, are Technology Assessment
another driver of healthcare inflation. New tech-
nologies may create demand for care that did not
previously exist, may increase demand for treat- Further Readings
ments that are less invasive or have an improved
Glabman, Maureen. “Bare Bones. As the Cost of
prognosis over older treatments, and may be more
Malpractice Insurance Skyrockets, Doctors, Hospitals
expensive per treatment.
and Patients Suffer,” Trustee 56(3): 8–13, March
2003.
Solutions to Mitigate Inflation Jones, Cheryl Bland. “Revisiting Nurse Turnover Costs:
Adjusting for Inflation,” Journal of Nursing
Both supply-side and demand-side interventions Administration 38(1): 11–18, January 2008.
have been used to mitigate the continued increases Moser, James W. “Trends in the Consumer Price Index,”
in healthcare prices. In the United States, price Journal of Medical Practice Management 23(2):
controls have been implemented for both hospi- 94–96, September–October 2007.
tals and physicians in an effort to reduce price Pentecost, Michael J. “Health Care Inflation and High-
increases. Medicare uses a prospective payment Tech Medicine: A New Look,” Journal of the
system (PPS) based on Diagnosis Related Groups American College of Radiology 1(12): 901–903,
(DRGs) to control hospital costs and uses the December 2004.
National Physician Fee Schedule to reimburse Shireman, Theresa I., Jean P. Hall, Sally K. Rigler, et al.
physicians for professional services. Many private “Medicaid’s Expenditures for Newer
payers also use variations of Medicare’s PPS and Pharmacotherapies for Adults With Disabilities,”
physician fee schedule. Managed care has been Health Care Financing Review 28(4): 31–41, Summer
used as a mechanism to reduce healthcare spend- 2007.
ing primarily through supply-side incentives such
as capitation; primary-care gatekeeper physicians;
prospective, concurrent, and retrospective utiliza- Web Sites
tion review; second-opinion examinations; and Bureau of Labor Statistics (BLS): http://www.bls.gov
prior authorization requirements. Healthcare Financial Management Association (HFMA):
http://www.hfma.org
Health Inflation News: http://www.healthinflation.com
Future Implications
Strong supply-side incentives to mitigate health- http://www.kaiserfamilyfoundation.org
care spending increases, such as those provided by National Coalition on Health Care (NCHC):
health maintenance organizations (HMOs), have http://www.nchc.org
634 Informed Consent
legally authorized patient representative is avail-

Informed Consent able, (3) if the patient declines the right to know
the information, and (4) if the provider determines
Informed consent is the process by which a pro- that disclosing the information to the patient
vider and patient discuss the merits of a proposed would actually cause greater harm. The fourth
therapeutic intervention, and it serves as a signifi- exception, often called therapeutic knowledge, is
cant component of the provider-patient relation- discouraged in most healthcare institutions, but it
ship. Informed consent is neither a signature on is applied on a regular basis under the guise of
a consent form nor a tool to avoid a lawsuit, paternalistic medicine. This entry highlights the
but rather, it is a communication process. The experiences and challenges of the informed-
informed-consent process typically includes a dis- consent process in the United States, the United
cussion between the provider and the patient to Kingdom, Canada, and Australia.
help guide the patient’s decision to undergo or
forgo a specific treatment or intervention. The
informed-consent process is an ethically and legally
Overview
required discussion that is tailored to the particu- Informed consent is based on the contemporary
lar needs of the patient and to the specific medical perception of autonomy, or self-determination,
circumstances. Informed consent occurs prior to which arose from 17th-century political and legal
and separate from documentation of any form. philosophy. The concept of autonomy in the
During the informed-consent process, patients also Australian, Canadian, British, and American med-
have the opportunity to ask questions so that they ical fields, however, did not surface until major
have a better understanding of the proposed course social changes took place in the mid 20th century.
of treatment and therefore are able to make an The American, Australian, Canadian, and British
informed decision based on all the risks, benefits, medical societies finally officially recognized
and alternatives. The informed-consent process is patient autonomy in the 1980s. Despite the British
a distinct, identifiable, and essential factor of medical community’s acknowledgment of a
patient care in procedurally based specialties such patient’s right to autonomy, the British legal sys-
as surgery. In specialties that are not procedurally tem remains disproportionately paternalistic com-
based, such as internal medicine, the informed- pared with that of the United States, Australia,
consent process happens naturally during the pro- and Canada.
vider-patient discussion; it is, however, no less Recent technological advancements have made
essential to building a trusting relationship. information more readily available and accessible.
Informed consent should not be coerced, manip- As a result, the widespread dissemination of medi-
ulated, threatened, or induced by fraud. The per- cal information, written in nontechnical language
son with the requisite knowledge and experience to be easily understood by those who are not
to perform the therapeutic intervention and explain medically trained, has led to a change in patients’
the critical elements is required to disclose to the overall attitudes toward providers. It has also
patient the diagnosis, the proposed therapy and influenced patients’ willingness to accept provid-
the rationale for recommending it, the associated ers’ diagnostic and therapeutic decisions and
risks and anticipated benefits, the available alter- patients’ requests for specific medicinal or proce-
natives, and the consequences of refusing treat- dural interventions. Nonetheless, providers still
ment. A competent patient retains the right to must provide patients with accurate information
refuse appropriate treatment. A strong treatment and facts to help them make appropriate health-
recommendation by a provider is not, however, care decisions; without the expertise of medical
considered coercion as long as the recommenda- professionals, individuals may base decisions on
tion is made to the decision maker. marketing and promotion campaigns. Medicine
There are four exceptions to the informed- itself has significantly changed because of these
consent disclosure: (1) in emergent situations when scientific advancements. The general use of anes-
life and/or limb are immediately at risk, (2) if the thesia, for example, makes it impossible to obtain
patient is unconscious or incompetent and no a patient’s consent to change a surgical plan at the
Informed Consent 635
exact time a surgeon is legally required to obtain used solely by the Australian judiciary. Canada
it. Providers are able to diagnose seriously ill uses the professional standard with regard to
patients before the patients themselves know it or diagnosis only and the reasonable-person stan-
feel sick, and the number of therapeutic options to dard for disclosure of material information. The
select from has increased exponentially. Thus, United States also uses both the professional stan-
proper informed consent in this rapidly changing dard and the reasonable-person standard. Judicial
environment is paramount. preference in the United States, however, is clearly
for the reasonable-person standard. Successful
lobbying by the medical profession resulted in 25
Legal Dimensions of Informed Consent
state legislatures enacting professional-standard
The advancement of the idea of self-determination statutes.
forms the legal foundation for informed consent. Defenders of the professional standard, inde-
The legal causes of action related to informed con- pendent of country, argue that the standard is
sent are battery and negligence. For example, if a consistent with a provider’s obligation to provide
provider touches a patient without that patient’s care in the patient’s best interest by providing him
explicit consent, then the provider is considered to or her with the latitude to decide what informa-
have committed an act of battery even if the pro- tion to share. The provider, because of his or her
vider believed that the action was in the best inter- medical knowledge and training, is more qualified
est of the patient. If, however, the provider touched to make medical decisions for the patient and to
the patient in the exact way in which the patient determine what information will only serve to
had consented but failed to provide the patient confuse or scare the patient. Proponents of the
with pertinent information that the patient consid- reasonable-person standard, however, argue that
ers necessary to decide whether to consent, then this other standard reconciles the tension between
the provider is considered to have committed an a provider’s duty to disclose information and a
act of negligence. patient’s right to make an informed decision with
The United Kingdom and the United States have regard to his or her healthcare. The patient can-
long recognized the legal and ethical obligation for not make an informed decision without the pro-
informed consent. Comparatively, in Canada and vider at least providing a modicum of material
Australia, informed consent is a relatively new information. Patients look to providers for guid-
concept. Battery was the leading cause of action in ance, advice, and information that they feel is
the United States and United Kingdom until 1957, necessary to decide whether to trust the provider
when jurists began to hold that negligence was the enough to voluntarily agree to consent to the
appropriate cause of action for an alleged breach therapeutic intervention. Many have argued that
of a physician’s duty to care, specifically the duty the professional standard is no longer viable and
to disclose information to patients. However, that the reasonable-person standard better serves
Canada and Australia base the causes of action on patients’ needs.
the premise of negligence. Australia and Canada have based their stan-
Two legal standards exist for disclosure of dards for disclosure and causes of action on the
information to patients: the professional standard legal precedence set in the United States and the
and the reasonable-person standard. The profes- United Kingdom. Although there is some indica-
sional standard states that a provider must dis- tion that Australian, Canadian, and U.S. legal deci-
close information that is usually made available sions are influencing the beliefs of the British
by the medical profession. British courts have judiciary, currently the English system remains
exclusively used the professional standard. On the steadfastly wedded to the professional standard
other hand, the reasonable-person standard states for disclosure.
that a provider must disclose information as to
what a reasonable person in the patient’s position
Impact of Healthcare Delivery and Cost
would want to know in order to decide whether
to undergo or forgo a therapeutic procedure or From a delivery-of-care and healthcare systems
intervention. The reasonable-person standard is perspective, engaging in the informed-consent
636 Informed Consent
process requires financial resources and organiza- Future Implications

tional oversight. In the United Kingdom, Australia,
As greater emphasis is placed on patient auton-
and Canada, the healthcare system bears the cost
omy, providers must find a method of reconciling
of the provider’s time devoted to informing
the ethos of paternalism with the patient’s right to
patients. In the United States, the ethical and legal
self-determination. The medical community, not
obligation to engage in the informed-consent pro-
jurisprudence, must take responsibility for devel-
cess approximates to an unfunded mandate as
oping an informed-consent doctrine that acknowl-
both patients and providers bear the cost. The
edges and respects patient autonomy while
major healthcare insurance plans do not allow
simultaneously supporting the authority of the
providers to bill for informed-consent discussions,
provider in diagnosis and treatment. This goal
leaving providers to incorporate the discussion
can be accomplished through shared decision
into other billable procedures. This practice often
making and acknowledging the limits of scientific
causes the discussion to be rushed and/or incom-
knowledge.
plete. It also means that a provider may delegate
Understanding the degree and accuracy of infor-
the obligation to obtain informed consent to an
mation communicated during the informed-
individual who does not possess the same amount
consent discussion and enhancing the process will
of knowledge of and experience with the thera-
benefit both public health and patient care. By
peutic intervention, resulting in the patient receiv-
viewing informed consent as a therapeutic compo-
ing inadequate or incorrect information.
nent of patient care, the provider shows respect
As with financial resources, the United
for the patient, engages the patient as an active
Kingdom, Australia, and Canada have a central-
participant in healthcare decisions, improves the
ized process for making decisions regarding
patient’s understanding of the risks associated
informed consent. Administrators and providers
with certain behaviors, and increases compliance
collaborate to decide on the minimum amount of
with suggested medical therapies. This partnership
information that must be disclosed to the patient.
enables the provider to address the patient’s con-
In the United States, however, the process is
cerns at the appropriate time and to build a foun-
decentralized. It is left to the individual organiza-
dation of trust. The trend toward an increased
tion or provider to discern which standard for
deference for patient autonomy is growing in the
disclosure to follow in order to provide the legally
United States, Canada, Australia, and even the
required minimum amount of information to
United Kingdom.
patients.
Heather Sherman
Impact on Public Health
See also Adverse Drug Events; Ethics; Health Literacy;
Informed consent not only affects the individual Malpractice; Medical Errors; Physicians; Randomized
patient, but it also has profound effects on public Controlled Trials (RCTs); Vulnerable Populations
health. Through informed consent, providers can
engage patients in discussions to prevent and man-
age chronic diseases and help patients understand Further Readings
the consequences that these diseases have on their Berg, Jessica W., Paul S. Appelbaum, Charles W. Lidz,
health and lifestyles. Providers can also protect the et al. Informed Consent: Legal Theory and Clinical
spread or reemergence of infectious disease by Practice. 2d ed. New York: Oxford University Press,
reminding patients of the cost of complacency 2001.
about vaccination. They can also help patients Clarke, Steve, and Justin Oakley, eds. Informed Consent
avoid resistance to medications, as well as prevent and Clinical Accountability: The Ethics of Report
early mortality, by taking joint responsibility for Cards on Surgical Performance. New York:
patient compliance. Finally, providers can rebuild Cambridge University Press, 2007.
and strengthen the social contract that the medical Corrigan, Donagh, ed. The Limits of Consent: A Socio-
profession has with the community and with the Ethical Approach to Human Subject Research in
individual patient. Medicine. New York: Oxford University Press, 2008.
Inner-City Healthcare 637
Manson, Neil C., and Onora O’Neill. Rethinking area can also exacerbate the health conditions of
Informed Consent in Bioethics. New York: the inner city by not providing adequate housing,
Cambridge University Press, 2007. social welfare, and access to healthcare. It has been
Rozovsky, Fay Adrienne. Consent to Treatment: A posited that the health problems that evolve in the
Practical Guide. 4th ed. Austin, TX: Aspen, 2007. inner city may also spread to other urban, subur-
Wu, Helen W. Improving Patient Safety Through ban, and even rural areas. As a result of these
Consent for Patients With Limited Health Literacy: consequences, a multifaceted approach is needed
An Implementation Report. Washington, DC: to improve the overall health status of inner-city
National Quality Forum, 2005.
residents.
Web Sites Overview

American Medical Association (AMA): The issue of poverty is at the crux of the poor state
http://www.ama-assn.org/ama/pub/category/4608.html of health of the inner city. The link between socio-
Foundation for Informed Medical Decision Making economic status and health has been previously
(FIMDM): http://www.informedmedicaldecisions.org demonstrated. Poverty is related to poor health,
National Cancer Institute (NCI): by the barriers created in accessing preventive
http://www.cancer.govClinicalTrials/ healthcare, proper nutrition, and housing, as well
AGuidetoUnderstandingInformedConsent/Page2 as to higher mortality rates. Poverty has also been
associated with higher rates of violence, child
abuse, and familial and community deterioration.
There is also some emerging evidence to suggest
Inner-City Healthcare that the disparity in the distribution of income
within states has adverse effects on health, and
Almost half of the world’s population resides in therefore the distribution of income may be a pre-
an urban area, where some of the most pressing dictor of the health status of a society.
social problems include poverty and pollution. The phenomenon of an urban health penalty
The rapid urbanization of regions has resulted in has been used by the American College of Physicians
the need to address a variety of social issues, rang- (ACP) to describe the situation when healthier and
ing from poverty, sanitation, and healthcare to more affluent residents leave a city and the resi-
education, housing, and family planning. dents who remain encounter serious health prob-
The inner city is generally characterized as an lems that interact with the physical and economic
area of a city where there are a disproportionate decline of a city. Generally speaking, dispropor-
number of unemployed or low-pay individuals, tionate numbers of racial and ethnic minorities
single parents, and sick or disabled persons living inhabit these inner-city areas, which are character-
in poor housing conditions. Inner-city healthcare is ized by economic decay and a multitude of health
a multifaceted issue that relates to the health dis- problems. The issues related to urban health are
parities that exist within the poorer and more the consequence of a complex set of interactions
densely populated areas of a city. Individuals who between behavioral, socioeconomic, and environ-
reside within the inner city often experience mental factors.
inequalities in health due to lower socioeconomic Inner cities are challenged by the issues of cost,
status, job loss, and various health problems. The quality, and access to healthcare, much like the
health issues of the inner city involve a complex larger U.S. healthcare system. These issues, how-
and myriad set of interactions between socioeco- ever, are magnified in inner-city areas because of
nomic, behavioral, and environmental factors that scarce resources and stresses on the system. Because
relate to race and ethnicity. Some of the most of this, inequalities and injustices in the health of
prevalent public health threats in the inner city inner-city residents are readily apparent. The
include homelessness, substance abuse, mental ill- health problems of the inner city include a range of
ness, HIV/AIDS and tuberculosis transmission, chronic and acute illnesses, such as substance
violence, and pollution. The public policies of an abuse, violence, teenage pregnancies, HIV/AIDS,
638 Inner-City Healthcare
sexually transmitted diseases (STDs), mental ill- Individuals who engage in violent acts are more
ness, infant mortality, asthma, tuberculosis, and likely to be of a lower socioeconomic status and
diabetes. The determinants associated with these have been physically abused. Violence can have an
health problems are poverty, poor nutrition, lack adverse effect on the mental health of young indi-
of adequate housing, violence, and the dearth of viduals residing in the inner city and may result in
social services. The lack of access to appropriate suicidal ideation, posttraumatic stress disorder,
healthcare facilities also exacerbates the problems and depression.
in these areas. Studies have found that there are
differences in preventable hospital admissions
Mental Illness
between high- and low-income areas throughout
the United States. Furthermore, even individuals Mental illness is one of the major health problems
with universal access to healthcare from Medicare confronting the inner city. One study by P. Koegel
still experience differences in health outcomes. A and colleagues estimated that 28% of homeless
study by Marian Gornick and colleagues compar- individuals in Los Angeles’s Skid Row were
ing Whites and Blacks found that Blacks and chronically mentally ill. Compared with a house-
lower-income individuals received fewer preven- hold sample, the rates of major mental illnesses in
tive services, such as immunizations and screen- this cohort were disproportionately high for every
ings, and experienced higher mortality rates. mental disorder examined. Additionally, the rates
Another study by C. McCord and H. P. Freeman of substance abuse and schizophrenia were higher
found that the mortality rate in Harlem, New among those who were repeatedly homeless or
York, is higher than that of the developing country were homeless for longer periods of time.
of Bangladesh, which is characterized as having
one of the lowest incomes in the world. Additionally,
Asthma
this study found that the survival rate of males
beyond the age of 40 is lower in Harlem than in Residents who are poor and reside in certain
Bangladesh. The reasons cited as the cause of the urban areas and are predominantly racial/ethnic
higher mortality rate in Harlem include cardiovas- minorities are at greatest risk of developing
cular disease, diabetes, influenza, homicide, and asthma. The association between living in certain
drug dependency. urban neighborhoods and a disproportionate risk
Even in egalitarian countries such as Canada, of developing asthma has only recently been rec-
where it is assumed that disparities are nonexistent ognized. Studies have highlighted the geographic
because of universal access to healthcare, inequali- variation in asthma deaths in the United States
ties in health outcomes still remain. A study by and found that children and young adults who
David Alter and colleagues found that residents reside in urban areas have significantly higher
in Ontario from the wealthiest neighborhoods death rates. On closer examination, it has been
received 23% more coronary angiograms and had found that the death rates from asthma in urban
45% shorter waiting time to receive an angiogram areas are concentrated within the inner-city areas,
than those from the poorest neighborhoods. The where poverty is also high. Blacks are reported to
authors also found an inverse relationship between have higher rates of asthma at all ages than
mortality 1 year after myocardial infarction and Whites. A strong correlation is indicated between
income. socioeconomic status and prevalence of asthma.
Studies have shown that socioeconomic status is a
major factor in the disproportionate burden of
Violence
inner-city asthma. The living environment, which
Violence has been cited as a major cause of mor- is highly correlated with socioeconomic status,
bidity and mortality among young adults and plays a large role in asthma prevalence. Exposure
adolescents. Studies have shown that youths in the to pollutants in the living environment may result
inner city are often exposed to violence. Violence in the onset of asthma. Family structure and dys-
in these communities can lead to the destruction function may also have a role in asthma morbidity
of social relationships and cause social disarray. and management.
Inner-City Healthcare 639
HIV/AIDS developing effective interventions. The problems

common to all the URCs included institutional
HIV is another public health concern in the inner
racism, time constraints, and distribution of
city. A variety of risk factors and the lack of
resources. Despite these challenges, the work of
healthcare facilities contribute to the high preva-
the URCs resulted in collaborative partnerships,
lence of HIV in these areas. The use of alcohol and
public health programs, and institutional capacity
cocaine, particularly crack, has been linked to the
to carry out community-based participatory
spread of STDs and HIV in the inner city. Crack
research in urban areas.
use is thought to contribute to the heterosexual
transmission of HIV. Injection drug users are also
at risk for HIV transmission by sharing contami- Short-Term Solutions
nated needles. Men who have sex with men and
Addressing the widespread health problems of
commercial sex workers also present themselves
the inner city poses many formidable challenges
as potential risk factors for HIV transmission.
and requires a multifaceted and broadly sweep-
Given these numerous risk factors, HIV preva-
ing approach, from primary prevention to spe-
lence remains high in the inner city.
cialized and acute care. Changing urban policy to
address the root cause of poverty is necessary to
Nutrition mitigate the health problems faced by these com-
The lack of access to fresh food and produce inter- munities. As a first step, the link between socio-
twined with the issue of poverty in the inner city economic factors and health status must be
results in the poor nutritional status of inner-city recognized to improve the health of inner-city
residents. Research on an elderly inner-city popula- residents. Furthermore, the healthcare delivery
tion found that these residents are at high nutri- system in these areas must be improved by
tional risk and lacked resources to pay for food, addressing the issues of coverage, providers, and
had poor food intake, and were unable to prepare public health. Adequate healthcare coverage must
food. Furthermore, childhood obesity is becoming be made available for inner-city residents to
a major problem among inner-city children. The access the healthcare system. The Medicaid safety
lack of physical activity and lack of nutritious foods net is an important part of securing access to
have been cited as the cause of this condition. healthcare for the low-income and vulnerable
populations.
Primary-care providers are also an essential
Research in the Inner City
component in delivering healthcare to inner-city
Participation by community members is essential residents. One of the biggest shortcomings of the
to build lasting public health interventions in the healthcare system is the limited number of pri-
inner city. In 1995, the U.S. Centers for Disease mary-care providers who practice and deliver care
Control and Prevention (CDC) established three to the urban poor and the decline of office-based
urban research centers (URCs) to improve the primary care in these underserved areas.
health and quality of life of urban residents in The inner city is also plagued by some of the
New York, Detroit, and Seattle. The aim of this most pressing public health problems, including
project was to develop collaborative partnerships tobacco use, substance abuse of alcohol and drugs,
among researchers, academics, private and public teenage pregnancies, and violence. The most effec-
partners, and community members to create sus- tive solutions to addressing these problems go well
tainable and effective interventions through com- beyond the biomedical model, and it must include
munity-based participatory research. Through its the public health approach of primary prevention
preliminary work, the URCs established research and education. The environmental context of the
priorities, acquired core funding, and raised their inner city, including housing, unemployment,
ability to conduct community-based research. pollution, and violence, must also be properly
Some of the initial challenges experienced by the addressed. These initiatives require collaboration
URCs included gaining the trust of the commu- among the government, healthcare providers, com-
nity, balancing power, acquiring resources, and munities, and individuals.
640 Institute for Healthcare Improvement (IHI)
The reform and changes to the Medicaid pro- Knowledge Network on Urban Settings. Our Cities, Our
gram in the late 1990s have also made it more Health, Our Future: Acting on Social Determinants
difficult for the neediest citizens, particularly those for Health Equity in Urban Settings. Kobe, Japan:
who live in the inner cities, to receive needed World Health Organization, 2008.
healthcare. Medicaid managed care and the restric- Koegel, P., M. A. Burnam, and R. K. Farr. “The
tion of providers who can participate in the pro- Prevalence of Specific Psychiatric Disorders Among
gram have proved to be a challenge. Furthermore, Homeless Individuals in the Inner City of Los
the welfare reform bill, Temporary Assistance for Angeles,” Archives of General Psychiatry 45(12):
1085–1092, December 1988.
Needy Families (TANF), has made it more cum-
LaVeist, Thomas A. Minority Populations and Health:
bersome for needy individuals to receive welfare
An Introduction to Health Disparities in the United
assistance and food stamps. Nutrition programs
States. San Francisco: Jossey-Bass, 2005.
are a vital component of the safety net for the
McCord, C., and H. P. Freeman. “Excess Mortality in
urban poor, especially children. Harlem,” New England Journal of Medicine 322(3):
173–77, January 18, 1990.
Metzler, Marilyn M., Donna L. Higgins, Carolyn G.
Future Implications
Beeker, et al. “Addressing Urban Health in Detroit,
The United States has the most advanced medical New York City, and Seattle Through Community-
technologies available, yet the health of its inner- Based Participatory Research Partnerships,” American
city residents remains poor. Healthcare reform Journal of Public Health 93(5): 803–11, May 2003.
has been tremendously difficult to achieve, and Prewitt, Elizabeth. “Inner-City Health Care,” Annals of
programs targeting the underserved, including the Internal Medicine 126(6): 485–90, March 15, 1997.
urban poor, have been minimal. As the federal Wasylenki, Donald A. “Inner City Health,” Canadian
government continues to reduce funding, the Medical Association Journal 164(2): 214–15, January
states will have greater responsibility for caring 23, 2001.
for their most marginalized citizens living in the
inner city. It is likely that initiatives targeting the Web Sites
health of inner-city residents will continue to be
advocated in the years to come. American College of Physicians (ACP):
http://www.acponline.org
Jared Lane K. Maeda American Public Health Association (APHA):
http://www.apha.org
See also Access to Healthcare; Centers for Disease Control Centers for Disease Control and Prevention (CDC):
and Prevention (CDC): Community-Based Participatory http://www.cdc.gov
Research (CBPR); Ethnic and Racial Barriers to International Conference on Urban Health (ICUH):
Healthcare; Health Disparities; Medicaid; Medicare
http://www.icuh2008.com
International Society for Urban Health (ISUH):
http://www.isuh.org
Further Readings
Alter, David A., David Naylor, Peter Austin, et al.
“Effects of Socioeconomic Status on Access to
Invasive Cardiac Procedures and on Mortality After Institute for Healthcare
Acute Myocardial Infarction,” New England Journal
of Medicine 341(18): 1359–67, October 28, 1999.
Improvement (IHI)
Gornick, Marian E., Paul W. Eggers, Thomas W. Reilly,
et al. “Effects of Race and Income on Mortality and The Institute for Healthcare Improvement (IHI) is
Use of Services Among Medicare Beneficiaries,” New an independent, nonprofit organization helping
England Journal of Medicine 335(11): 791–99, to lead the improvement of healthcare through-
September 12, 1996. out the world. Founded in 1991 and based in
Hwang, Stephen. “Homelessness and Health,” Canadian Cambridge, Massachusetts, the IHI works to
Medical Association Journal 164(2): 229–33, January accelerate improvements by building the will for
23, 2001. change, cultivating promising concepts for
Institute for Healthcare Improvement (IHI) 641
improving patient care, and helping healthcare Learning System

systems put those ideas into action. Employing a
The IHI’s programs and activities connect people
staff of approximately 100 individuals and main-
from across the world in an ever-evolving learning
taining partnerships with hundreds of faculty
system, based on a philosophy of “all teach, all
members, the IHI offers comprehensive programs
learn.” This system enables committed individuals
that aim to improve the lives of patients, the
and organizations to collaborate on improving
health of communities, and the joy of the health-
healthcare—because it is far easier to improve
care workforce.
together than it is to do it alone. The system
includes four components: (1) innovation,
(2) strategic relationships, (3) learning opportuni-
Background
ties, and (4) knowledge of the world.
Healthcare is a highly complex system, vastly
underperforming its potential. The gap between Innovation
what healthcare achieves today and what it could
achieve at the same or lower cost is so large that At the center of the institute’s work is the cre-
the National Academy of Sciences, Institute of ation and testing of new ideas—novel concepts for
Medicine (IOM), declares it a “chasm.” Crossing improving patient care. The IHI collaborates with
this chasm will require massive change. There are a handful of cutting-edge organizations, on a proj-
examples of excellence—organizations that have ect basis, to test new solutions on old problems
overcome obstacles and redesigned patient care. through research and development that drive the
The challenge is to make these examples the rule, organization’s work.
not the exception, so that all patients reliably
receive the best care possible. Strategic Relationships
The IHI was formed to help healthcare cross the
Once a promising change concept has been suc-
quality chasm—to shepherd a growing movement
cessfully developed in one setting, it needs to be
of healthcare leaders trying to find alternatives to
fully vetted and piloted in other settings. The IHI
the status quo.
maintains a variety of closely aligned strategic rela-
tionships, with dozens of organizations, that test
and deploy these changes. The most common types
Organizational Goals
of relationships are strategic partnerships, the
Improving healthcare is the IHI’s fundamental International Management Package for Adminis
mission and daily work. The institute has tration of Clinical Trials (IMPACT), and learning
adapted its goals from the IOM’s six improve- and innovation communities.
ment aims for the healthcare system: care that is Strategic partnerships are high-level relation-
(1) safe, (2) effective, (3) patient centered, (4) ships focused on transforming entire systems of
timely, (5) efficient, and (6) equitable. The IHI care by concentrating on strategic objectives and
calls this the No Needless List, which includes system-level improvement. In addition to working
the following: no needless deaths, no needless closely with several major healthcare systems in
pain or suffering, no helplessness in those served the United States, the IHI is also involved in stra-
or serving, no unwanted waiting, no waste, and tegic-level efforts with providers in the United
no one left out. Kingdom, Sweden, Malawi, and South Africa.
The IHI seeks to accelerate the measurable and IMPACT is the IHI’s membership network for
continued progress of healthcare systems toward change, where healthcare organizations come
these bold objectives, leading to breakthrough together to achieve dramatic improvement results
improvements that are truly meaningful in the lives in clinical outcomes, patient and provider satisfac-
of patients. The institute accomplishes this by tion, and financial performance. More than 200
building the will for change, cultivating innovative quality-minded organizations participate in change
improvement ideas, and helping healthcare sys- initiatives that combine a leadership agenda with a
tems put those ideas into action. focus on frontline improvement and measurement.
642 Institute for Healthcare Improvement (IHI)
Learning and innovation communities are col- between December 2004 and June 2006.
laborative change laboratories focused on frontline Approximately 3,100 hospitals in the nation joined
improvement. Participating organizations work in that effort. Building on this momentum, the insti-
with each other and with IHI faculty to rapidly test tute initiated the “5 Million Lives Campaign,”
and implement meaningful, sustainable change which aimed to help even more hospitals prevent 5
within a specific topic area. Learning and innova- million incidents of medical harm. The campaign
tion communities are the “next-generation” evolu- ran between December 2006 and December 2008.
tion of the Breakthrough Series, the IHI’s traditional The institute’s online resource, www.IHI.org,
methodology for collaborative improvement. contains a wealth of improvement information
and tools—available free of charge to anyone, any-
where, whose aim is to improve healthcare.
Learning Opportunities
Through the institute’s Health Professions
The IHI offers a wide variety of opportunities Education Collaborative (HPEC), academic lead-
for healthcare professionals to learn from expert ers from dozens of schools of medicine, nursing,
faculty and experienced colleagues across the world. pharmacy, and health administration work together
Some of its learning opportunities include the fol- to integrate quality improvement into their curri-
lowing: conferences and seminars, Web-based pro- cula, so that tomorrow’s health professionals are
grams, and professional development programs. better prepared to drive this agenda forward.
The IHI’s annual National Forum is widely Last, the IHI’s fellowship programs help equip
viewed as the premier meeting place for people healthcare leaders with the drive, skills, and expe-
committed to the mission of healthcare improve- rience to spread improvements in the United States
ment. The institute also presents an annual confer- and globally. The fellowship programs are spon-
ence on clinical office practice improvement and sored by the George W. Merck family, the Health
offers seminars on various quality-related topics. Foundation, and the Commonwealth Fund. Fellows
The institute’s Web programs create opportuni- spend 1 year at IHI, creating a custom-designed
ties for organizations and individuals to learn and education plan and participating in a variety of
implement best-practice ideas through a series of strategic initiatives.
Web seminars. A variety of online presentations
and teaching modules are also available on the Jonathan Small
IHI’s Web site.
See also Berwick, Donald M.; Disease Management;
The IHI’s professional development programs Medical Errors; Outcomes Movement; Patient Safety;
are designed for leaders who seek to gain a par- Quality Indicators; Quality Management; Quality of
ticular set of skills that are required for an organi- Healthcare
zation to succeed in its improvement agenda.
Programs include training for board members,
patient safety officers, improvement advisors, Further Readings
operations managers, as well as others involved in
Berwick, Donald M. “The Science of Improvement,”
critical roles.
1182–84, March 12, 2008.
Knowledge for the World Berwick, Donald M., Thomas W. Nolan, and John
Whittington. “The Triple Aim: Care, Health, and
The final step in the IHI learning system is the Cost,” Health Affairs 27(3): 759–69, May–June 2008.
broad dissemination of best-practice improvement Griffin, Francis A. “5 Million Lives Campaign: Reducing
knowledge. This is done primarily through various Methicillin-Resistant Staphylococcus Aureus (MRSA)
campaigns, IHI.org, professional education, and Infections,” Joint Commission Journal of Quality and
the institute’s fellowship programs. Patient Safety 33(12): 726–31, December 2007.
In line with many other patient safety programs, Goldmann, Donald. “System Failure Versus Personal
the “100,000 Lives Campaign” was a national ini- Accountability: The Care for Clean Hands,” New
tiative to drive widespread adoption of six impor- England Journal of Medicine 355(2): 121–23, July
tant patient safety practices in U.S. hospitals 13, 2006.
Institute of Medicine (IOM) 643
Web Site The Institute’s Work

Institute for Healthcare Improvement (IHI): The IOM provides health-related policy advice in
http://www.ihi.org several different forms: written reports reflecting
the consensus reached by an expert study commit-
tee, symposia and convocations engaging large
audiences in the discussion of national issues,
Institute of Medicine (IOM) summaries and proceedings from conferences and
workshops, or “white papers” on policy issues of
The 21st century has brought with it a number of special interest. Key activities include consensus
complex health problems, including childhood studies, convening activities, and fellowships.
obesity, the threat of pandemic influenza, limited
healthcare access and quality, and questions
regarding vaccine and drug safety. When devel- Consensus Studies
oping policies and strategies for coping with
The majority of the institute’s work centers on
these challenges, the nation often turns to the
rigorously reviewed consensus studies. Consensus
Institute of Medicine (IOM) of the National
studies are conducted by committees whose mem-
Academies for advice. Since 1970, when it was
bers serve without compensation. Each commit-
created as part of the congressionally chartered
tee’s report is subject to rigorous peer review, and
National Academy of Sciences, the IOM has
all are made public. Consensus studies are man-
functioned as a unique, independent source of
aged by one of eight oversight boards of the insti-
unbiased, evidence-based, and authoritative
tute. Depending on the statement of task for the
information on matters involving medicine and
project, studies may be narrow in scope, designed
public health. Through its work, the IOM serves
to answer very specific and technical questions, or
as an advisor to the nation in its endeavor to
they may be broad-based examinations that span
improve health.
myriad academic disciplines, industries, and even
international borders.
Federal agencies are the primary financial spon-
Background
sors of consensus studies. However, additional
In 1863, President Abraham Lincoln signed the studies are funded by state agencies, foundations,
congressional charter that created the National other private sponsors, and the institute itself. The
Academy of Sciences, a nongovernmental institu- institute provides independent advice; the external
tion with two aims: to honor top scientists through sponsors have no control over the conduct of a
membership and to investigate, examine, experi- study once the statement of task and budget are
ment, and report on any subject of science or finalized. Study committees gather information
technology whenever called on to do so by any from many sources in public meetings, but they
department of the government. carry out their deliberations in private to avoid
Since its inception, the Academy has grown political, special interest or sponsor influence.
to include four distinguished organizations: the Through this careful study process, the IOM
National Academy of Sciences, the National produces approximately 40 reports each year.
Research Council, the National Academy of Many of the reports influence policy decisions;
Engineering, and the IOM. Now known collec- some are instrumental in enabling new research
tively as the National Academies, these four programs; others provide program reviews. The
organizations perform unparalleled public ser- institute may also conduct dissemination work-
vice by bringing together experts in all areas of shops to discuss the conclusions and recommenda-
scientific and technological endeavor. These tions made by certain committees. Recent institute
organizations draw on leading national and studies include examinations of the U.S. Food and
international experts, both elected members Drug Administration’s role in monitoring and
and others, who serve as volunteers without improving drug safety, the recent progress made by
compensation. obesity prevention initiatives, and ways to reduce
644 Institute of Medicine (IOM)
the incidence and cost of medication errors in the The Institute’s Members
nation.
The IOM’s members are elected on the basis of
their professional achievements. By becoming
Convening Activities members, these experts commit to serving the
institute, without compensation, through a num-
In addition to its consensus studies, the institute ber of different avenues, including (a) serving on a
strives to stimulate candid, evidence-based dia- study committee, board, roundtable, or forum; (b)
logue about key issues through workshops, round- participating in a workshop or expert-level meet-
tables, and forums. These convening activities ing; (c) taking part in an interest group; (d) serving
allow government, industry, academic, and other on the institute’s council; or (e) reviewing or coor-
representatives to meet and confer privately on dinating reports.
subject areas of mutual interest. These meetings The bylaws of the institute specify that no more
may inform the members about critical issues or than 65 new members and 5 foreign associates
provide an opportunity to plan formal institute shall be elected annually. The announcement of
committee studies. Examples of forums and round- newly elected members occurs at the institute’s
tables include the National Cancer Policy Forum, annual meeting in October. The number of regular
the Forum on Neuroscience and Nervous System members plus foreign associates and emeritus
Disorders, the Roundtable on Health Literacy, and members is currently about 1,500.
the Roundtable on Environmental Health Sciences, An unusual diversity of talent among institute
Research, and Medicine. members is ensured by the charter stipulation that
at least one quarter of its members be selected
Fellowships from outside the health professions, from fields
such as the natural, social, and behavioral sciences,
The IOM also advances the field of health ser-
as well as law, administration, engineering, and
vices research by hosting three fellowship pro-
the humanities.
grams. The Robert Wood Johnson Health Policy
The IOM is governed by the institute’s council,
Fellowship Program provides an opportunity for
which consists of the council president and 20
outstanding midcareer health professionals to
members elected to 3-year terms. The council pro-
gain an understanding of the health policy pro-
vides policy guidance in addition to approving the
cess, contribute to the formulation of new poli-
annual program plan and fiscal-year budget. All
cies and programs, and develop in their careers as
proposals for new and revised projects are reviewed
leaders in academic health centers and in health
and approved by the 5-member executive commit-
policy.
tee of the council.
The institute’s Anniversary Fellows Program
provides early-career biological, social, and clinical
scientists the opportunity to actively participate in
The Study Process
the institute’s work. During this 2-year fellowship,
the fellows continue their work at their main aca- The consensus reports of the institute are viewed
demic posts while being assigned to a board of the as being valuable and credible because of the insti-
institute. Fellows also participate actively in the tution’s reputation for providing independent,
work of an appropriate expert study committee or objective, and evidence-based advice, with high
roundtable, including contributing to its reports or standards of scientific and technical quality.
other products. Checks and balances are applied at every step in
The Distinguished Nurse Scholar Program aims the process to protect the integrity of the reports
to assist nurses in playing a more prominent role and to maintain public confidence in them.
in health policy at the national level. While in the The study process consists of four major stages:
program, each scholar is asked to produce a pol- (1) defining the study; (2) committee selection and
icy-oriented paper or become actively involved in approval; (3) committee meetings, information
the institute’s work, relevant to his or her area of gathering, deliberations, and drafting of the report;
expertise. and (4) report review.
Institute of Medicine (IOM) 645
Stage 1: Defining the Study All provisional committee members are screened
Before the committee selection process begins, in writing and in a confidential group discussion
the institute’s staff and members of their boards about possible conflicts of interest. For this pur-
work with sponsors to determine the specific set of pose, a conflict of interest means any financial or
questions to be addressed by the study in a formal other interest that conflicts with the service of the
“statement of task,” as well as the duration and individual, because it could significantly impair his
cost of the study. The statement of task defines the or her objectivity or could create an unfair com-
scope of the study, and it serves as the basis for petitive advantage for any person or organization.
determining the expertise and the balance of per- The term conflict of interest means something
spectives needed on the committee. The statement more than just individual bias. There must be an
of task, work plan, and budget must be approved interest, often financial, that could be directly
by the executive committee of the institute’s coun- affected by the work of the committee. Except for
cil and by the governing board of the National those rare situations in which the institute deter-
Research Council. mines that a conflict of interest is unavoidable and
promptly and publicly discloses it, no individual
can be appointed to serve on a committee of the
institute used in the development of reports if the
Stage 2: Committee Selection and Approval
individual has a conflict of interest that is relevant
Selection of appropriate committee members is to the functions to be performed.
essential for the success of a study. All committee Membership in the IOM and previous involve-
members serve as individual experts, not as repre- ment in National Academies studies are taken into
sentatives of organizations or interest groups. account in committee selection. The inclusion of
Each member is expected to contribute to the women, minorities, and young professionals is an
project on the basis of his or her own expertise additional consideration.
and good judgment. A committee is not finally
approved until a thorough balance and conflict-
Stage 3: Information Gathering
of-interest discussion is held at the first meeting
and Drafting of the Report
and any issues raised in that discussion or by the
public are investigated and addressed. Study committees, typically, gather information
Careful steps are taken to convene committees through meetings that are open to the public and
that meet the following criteria: an appropriate announced in advance through the institute’s Web
range of expertise for the task, a balance of per- site, submission of information by outside parties,
spectives, screening for conflicts of interest, and reviews of the scientific literature, and investiga-
other considerations. The committee must include tions of the committee members and staff. In all
experts with the specific expertise and experience cases, efforts are made to solicit input from indi-
needed to address the study’s statement of task. viduals who have been directly involved in or who
One of the strengths of the institute is its tradition have special knowledge of the problem under con-
of bringing together recognized experts from sideration.
diverse disciplines and backgrounds, who might In accordance with federal law and with few
not otherwise have been able to collaborate. These exceptions, information-gathering meetings of the
diverse groups are encouraged to conceive new committee are open to the public, and any written
ways of thinking about a problem. materials provided to the committee by individuals
Merely having the right expertise is not suffi- who are not officials, agents, or employees of the
cient for success. It is also essential to evaluate the institute are maintained in a public access file that
overall composition of the committee in terms of is available for examination.
different experiences and perspectives. The goal is The committee deliberates in meetings, closed
to ensure that the relevant points of view are, in to the public, to develop draft findings and recom-
the institute’s judgment, reasonably balanced, so mendations free from outside influences. The pub-
that the committee can carry out its charge objec- lic is provided with brief summaries of these
tively and credibly. meetings that include the list of committee members
646 Intensive-Care Units
present. All analyses and drafts of the report Committee on Identifying and Preventing Medication
remain confidential. Errors, Philip Aspden, Julie Wolcott, J. Lyle Bootman,
et al., eds. Preventing Medication Errors.
Washington, DC: National Academy Press, 2007.
Stage 4: Report Review Committee on Reviewing Evidence to Identify Highly
As a final check on the quality and objectivity Effective Clinical Services, Jill Eden, Ben Wheatley,
and Barbara McNeil, eds. Knowing What Works in
of the study, all IOM reports—whether products
Health Care: A Roadmap for the Nation.
of studies, summaries of workshop proceedings,
or other documents—must undergo a rigorous,
Committee on the Future Health Care Workforce for
independent external review by experts, whose
Older Americans. Retooling for an Aging America:
comments are provided anonymously to the com- Building the Health Care Workforce. Washington,
mittee members. The institute recruits indepen- DC: National Academies Press, 2008.
dent experts with a range of views and perspectives Institute of Medicine. Informing the Future: Critical
to review and comment on the draft report pre- Issues in Health. 4th ed. Washington, DC: National
pared by the committee. Academies Press, 2007.
The review process is structured to ensure that
each report addresses its approved study charge
and does not go beyond it, that the findings are Web Sites
supported by the scientific evidence and argu-
ments presented, that the exposition and organi- Institute of Medicine (IOM): http://www.iom.edu
National Academies: http://www.nationalacademies.org
zation are effective, and that the report is impartial
National Academies Press: http://www.nap.edu
and objective.
Each committee must respond to, but does not
need to agree with, reviewer comments in a detailed
“response to review.” If the reviewer comments are
not agreed with and incorporated, the committee Intensive-Care Units
must explain clearly its reasons for disagreeing. The
response to review is examined by independent Intensive-care units (ICUs) are specialized units
report review monitors responsible for ensuring that within hospitals that are designed to provide care
the report review criteria have been satisfied. After for critically ill or injured patients. ICUs, typically,
the report has cleared review and all the committee have specialized medical equipment and staff to
members have signed off on the final report, it is provide continuous care to patients 24 hours a
transmitted to the sponsor of the study and is released day, 7 days a week. The units also generally have
to the public. The National Academies retains the the ability to monitor patients’ cardiovascular,
copyright to all its products. Sponsors are not given respiratory, and renal functions as well as neuro-
an opportunity to suggest changes in reports. The logical status. The establishment of ICUs has
names and affiliations of the report reviewers are made care for the sickest patients possible through
made public when the report is released. the use of these advanced medical technologies.
Some hospitals maintain multiple ICUs, each
Bethany Hardy designed to handle specific conditions or age
groups. For example, neonatal intensive-care units
See also Access to Healthcare; Cost of Healthcare;
(NICUs) care for infants, pediatric intensive-care
Medical Errors; Public Health; Public Policy; Quality
units (PICUs) care for children, and cardiac-care
of Healthcare; Uninsured Individuals
units (CCUs) care for heart attack patients. A
burn unit in a hospital is also considered an ICU,
or a critical-care unit. Patients who may benefit
Further Readings from intensive care include heart attack and stroke
Berkowitz, Edward D. To Improve Human Health: A patients, victims of multiple trauma or disasters,
History of the Institute of Medicine. Washington, individuals who require mechanical ventilation,
DC: National Academy Press, 1998. and complicated-surgery patients.
Intensive-Care Units 647
The design of the ICU allows medical staff to additional training and certification in critical care.
monitor their patients closely. Many ICUs are While open ICUs allow for any attending physi-
designed so that physicians and nurses can see the cian with admitting privileges at the hospital to
patients at all times, either with a direct line of sight serve as the physician of record and to direct the
or through the use of video monitors. The floor plans patient’s care, closed ICUs require that an intensiv-
dictate adequate traffic flow and use of workspace. ist serve as the physician of record.
The specialized work that occurs in ICUs saves ICU nurses, known as critical-care nurses, also
many lives each year. Healthcare professionals in play an important role in patient services and the
the ICU possess advanced medical skills that allow delivery of care. Often, two nurses staff a single
them to care for critically ill and injured patients. patient in the ICU. This ratio enables the nurses to
In addition to providing specialized medical care, keep a close watch on patients, and often, they
ICU staff must be prepared to communicate effec- serve as the primary contact with the patient’s
tively with family members and support end-of-life family. Experienced ICU nurses are able to recog-
decisions. nize changes in patient conditions and respond
quickly by alerting the attending physician.
Overview
Medical Equipment
The concept behind ICUs has a long history.
Florence Nightingale (1820–1910), while serving Typical medical equipment found in ICUs includes
as a nurse during the Crimean War, separated out monitors, tubes, and ventilators. Monitors are
the severely injured soldiers from those with designed to measure a patient’s vital functions,
minor injury or illness; this practice of triaging such as heart rate, blood pressure, oxygen satura-
allowed the nurses to monitor the seriously tion, and respiration. Intravenous lines (IVs) pro-
wounded patients more closely. During the polio vide medicine, fluids, and nutrition through a
epidemic in the 1940s and 1950s, patients required patient’s veins; urinary catheters remove urine
continuous surveillance and assistance. As a result, from the patient’s bladder; and nasogastric (NG)
many specialized units were established at hospi- tubes, which can be inserted into the patient’s
tals to provide these patients with the appropriate nostrils and through the back of the throat into
care they needed. William Mosenthal, a surgeon the esophagus and stomach, provide nutrition.
at Mary Hitchcock Memorial Hospital in Lebanon, Respirators, or ventilators, assist a patient’s breath-
New Hampshire, is credited with establishing the ing with the insertion of a tube through the mouth
first ICU in the United States (in 1955) that coor- or nose and into the patient’s windpipe.
dinated nursing care and the use of medical equip-
ment in one place for critically ill patients. Today,
Patients and Medical Conditions
ICUs are the standard of care for patients with
life-threatening diseases and injuries. Patients are usually admitted to the ICU from
other units within the hospital, such as the emer-
gency department or surgical areas. For example,
Medical Team
once trauma patients are stabilized in the emer-
The ICU medical team is composed of clinicians gency department, they are sent to the ICU for
from a variety of disciplines, including physicians, advanced care. Surgical patients may be sent to
nurses, respiratory therapists, pharmacists, and the ICU for care and recovery if an advanced or
other allied health professionals. These staff mem- critical surgery has been performed or if the
bers work together to provide advanced medical patient experiences complications following the
care to patients. The medical team receives operation. Critical illnesses such as heart attacks,
advanced training and possesses specialized skills poisoning, and pneumonia are other examples of
to care for critically ill patients. conditions that may lead to admission to an ICU.
Intensive-care specialists, called intensivists, are Many ICU patients require special assistance
board certified in a specialized area, such as sur- with bodily functions as a result of severe respira-
gery or internal medicine, and they have received tory disease. Conditions such as chronic obstructive
648 Intermediate-Care Facilities (ICFs)
pulmonary disease (COPD) or pneumonia weaken Further Readings

the lungs, and patients admitted with these condi- Curtis, J. Randall, Deborah J. Cook, Richard J. Wall,
tions often require assistance with breathing. et al. “Intensive Care Unit Quality Improvement: A
Once admitted to the ICU, the risk of develop- ‘How-To’ Guide for the Interdisciplinary Team,”
ing other problems increases for the patient. Critical Care Medicine 34(1): 211–18, January 2006.
Infections may develop as the patient’s immune Curtis, J. Randall, Ruth A. Engelberg, Marjorie D.
system may be in a weakened state due to an exist- Wenrich, et al. “Missed Opportunities During Family
ing illness. Common infections in ICU patients Conferences About End-of-Life Care in the Intensive
include blood infections due to IVs and urinary Care Unit,” American Journal of Respiratory and
tract infections (UTIs) due to urinary catheters. Critical Care Medicine 171(8): 844–49, Aprril 15,
Antibiotics and/or the removal of the tubes may be 2005.
necessary to treat these infections. Dasta, Joseph F., Trent P. McLaughlin, Samir H. Mody,
Many patients require sedation so that they do et al. “Daily Cost of an Intensive Care Unit Day: The
not try to remove the tubes or other equipment. Contribution of Mechanical Ventilation,” Critical
Heavy sedation slows a patient’s natural physio- Care Medicine 33(6): 1266–71, June 2005.
logic breathing mechanism and may lead to the use Marino, Paul L., and Kenneth M. Sutin. The ICU Book.
of intubation and ventilators, and may slow the 3d ed. Philadelphia: Lippincott Williams and Wilkins,
patient’s recovery. 2007.
ICU patients are also at risk of organ failure. Sinuff, Tasmin, Neill K. J. Adhikari, Deborah J. Cook,
Patients may be admitted with problems in one et al. “Mortality Predictions in the Intensive Care
Unit: Comparing Physicians With Scoring Systems,”
area of their body, but if recovery is slow, other
Critical Care Medicine 34(3): 878–85, March 2006.
organs and bodily functions may be affected.
Web Sites
Life Support and End-of-Life Issues
American Academy of Emergency Medicine (AAEM):
Decisions about life support and end-of-life issues http://www.aaem.org
are not uncommon for ICU patients and their American Association of Critical Care Nurses (AACN):
families, as patients present with life-threatening http://www.aacn.org
illnesses. Medical teams and families often face Society of Critical Care Medicine (SCCM):
decisions about when to turn off life support. http://www.sccm.org/Pages/default.aspx
End-of-life issues may arise after a long-term
effort to prolong the patient’s life indicates no
hope for recovery, or they can emerge quickly fol-
lowing the rapid deterioration of the patient’s Intermediate-Care
health. Physicians may face ethical decisions about Facilities (ICFs)
ending a patient’s suffering or abiding by the fam-
ily’s wishes.
Intermediate-care facilities (ICFs) are a type of care
ICU staff work within the scope of both cura-
facility for individuals such as the elderly, not
tive care and palliative care. Curative care refers to
acutely ill, mentally ill, or disabled, who are not
the effort to do everything possible to assist the
able to live independently but do not require con-
patient’s recovery. Palliative care refers to the
stant care. Thus, ICFs provide services to patients
effort to make the patient as comfortable as pos-
with health conditions that do not necessarily
sible and allow death to occur naturally.
require hospitalization or skilled nursing care but
Kristin Hartsaw present a need for subacute care. Intermediate care
is generally provided to patients who are medically
See also Acute and Chronic Diseases; Emergency Medical stable but are not stable enough to be treated in
Services (EMS): Hospital Emergency Departments; other healthcare settings such as in a long-term care
Hospitalists; Hospitals; Nightingale, Florence; Nurses; facility, at home, or on an outpatient basis. ICFs are
Physicians generally a location for patient recuperation or
Intermediate-Care Facilities (ICFs) 649
rehabilitation following an acute episode or a place past few decades. These facilities serve residents
for the chronically ill to receive care to avoid inap- with severe mental retardation or developmental
propriate hospitalizations. disabilities, in contrast to clients accessing other
The term intermediate care implies that the care types of residential programs.
is provided on a transitional basis, as if moving ICF/MR facilities must meet specific guidelines
from one level of care to another. Therefore, inter- to receive Medicaid reimbursement and maintain
mediate care may refer to the services provided to their certification. Facilities must be licensed
the patient during the transition stage between according to state and local law, and they must
hospitalization and home and from needing acute maintain specific staff-to-resident ratios, depend-
medical attention to being functionally indepen- ing on the severity of client conditions. Those ICF/
dent. Patients of ICFs generally receive 24-hour MR institutions serving residents with severe
care from a multidisciplinary team of health pro- physical disabilities or clients who exhibit combat-
fessionals. Some ICFs may resemble nursing homes, ive or psychotic behavior must have a staff-to-
providing services in a residential setting, while client ratio of 1 to 3.2. When working with clients
others may also care for the elderly. ICFs may offer who have moderate retardation, the staff-to-client
medical, social, and support services to patients; ratio should be 1 to 4. Guidelines require that the
however, the focus of these facilities is on rehabili- staff-to-client ratio must be 1 to 6.4 for facilities
tating individuals so that they are able to regain that serve clients with mild retardation.
the functions of independent daily living and ICF/MR facilities maintain a safe and therapeu-
return to a home setting. tic environment that allows some client indepen-
Although there are ICFs that treat people with dence, depending on the client’s level of functionality.
various health conditions, including the acutely They offer clients protection against verbal, psy-
and chronically ill, this entry focuses on ICFs for chological, and physical abuse. Facilities also pro-
people with mental illness and developmental vide healthcare and rehabilitation services. Adult
delays. ICFs for the Mentally Retarded (ICF/MR) day care programs, which provide outside services,
in the United States are certified by the Centers for are allowed at facilities as long as the programs
Medicare and Medicaid Services (CMS) and state meet Medicaid requirements and the particular
Medicaid programs. The care provided at these needs of the client.
facilities is an optional benefit for Medicaid clients The Medicaid guidelines for ICF/MR advocate
who qualify. The program was originally estab- respect and dignity for clients. Facilities are required
lished in 1971 as a result of federal legislation. to provide staff training that addresses behavior,
appropriate interventions, and positive reinforce-
ment in delivery of care. Staff must be able to
Overview
safely address unacceptable client behavior.
When a patient is referred to an ICF/MR facility, Professionals from several disciplines serve cli-
the ICF/MR team diagnoses the conditions, man- ents residing in these group settings. This diverse
ages treatment, and offers rehabilitative services for staff is responsible for assessing and evaluating
mentally retarded and developmentally disabled clients and developing interventions that best serve
individuals. The ICF/MR services are provided in a their needs.
safe environment and aim to assist individuals in Medicaid requires that ICF/MR facilities coor-
reaching their full potential. Most of the ICF/MR dinate Active Treatment Services for clients, which
facilities are designed as group homes, serving any- provide skills-based training for residents who
where from 4 to 15 individuals at a time. Originally, demonstrate increased abilities in areas such as
these facilities served larger numbers of clients, communication, household tasks, and other basic
with residential populations of up to 200 or more. skills. Daily supervision is required for individuals
Smaller-sized facilities, however, allow for more receiving Active Treatment Services. This type of
individualized attention and increased quality of treatment is provided on a formal and informal
care. The majority of ICF/MR facilities are pri- basis through the client’s settings and services.
vately operated as state governments have closed Active treatment may also be used with the aging
many publicly operated ICF/MR facilities over the population to address issues such as physical
650 International Classification for Patient Safety (ICPS)
fitness and coordination. It is the defining compo- to clients to meet their needs through an individu-
nent for ICF/MR certification. alized approach.
ICF/MR staff must develop individual program
plans for each client. In addition to completing Kristin Hartsaw
assessments and evaluations, staff may work with See also Acute and Chronic Diseases; Case Management;
other team members and partner agencies to best Disability; Long-Term Care; Medicaid; Mental Health;
meet the needs of the client. Identification of the Nursing Homes; Skilled-Nursing Facilities
clients’ specific diagnoses, developmental strengths,
developmental and behavioral management needs,
and skill deficits contributes to the scope of an Further Readings
individual program plan.
ICF/MR care facilities must also address bench- Carpenter, Ian, John R. F. Gladman, Stuart G. Parker,
marks related to clients’ physical development and et al. “Clinical and Research Challenges of Intermediate
Care,” Age and Ageing 31(2): 97–100, March 2002.
health, nutritional status, motor skills and devel-
Lamb, H. Richard, and Linda E. Weinberger. “One Year
opment, emotional development, speech and lan-
Follow-Up of Persons Discharged From a Locked
guage skills, and hearing. These facilities also must
Intermediate Care Facility,” Psychiatric Services
address problem-solving and social skills with cli-
56(2): 198–201, February 2005.
ents. Other activities include job skills training and Martin, Graham P., Susan M. Peet, Graham J. Hewitt,
independent living. et al. “Diversity in Intermediate Care,” Health and
Medicaid requires that facilities maintain written Social Care in the Community 12(2): 150–54, 2004.
policies, procedures, and guidelines that deal with Melis, René J. F., Marcel G. M. Olde Rikkert, Stuart G.
client and staff interaction and the management of Parker, et al. “What is Intermediate Care?” British
inappropriate client behavior. Staff interactions Medical Journal 329(7462): 360–61, August 14,
with clients should be positive and should contrib- 2004.
ute to the client’s personal growth. Staff communi- Steiner, Andrea. “Intermediate Care: A Good Thing?”
cation should also allow for decision-making skill Age and Ageing 30(Suppl. 3): 33–39, August 2001.
development with the clients. Additionally, the staff Utley, Martin, Steve Gallivan, Katie Davis, et al.
must know how to safely deal with clients that act “Estimating Bed Requirements for an Intermediate
out, teaching residents acceptable and unacceptable Care Facility,” European Journal of Operational
behavior. Written policies must detail all methods Research 150(1): 92–100, October 2003.
of intervention for inappropriate behaviors, starting
with the least intrusive approach. Examples of
interventions include time-out rooms, physical Web Sites
restraints, and medication. Centers for Medicare and Medicaid Services (CMS):
ICF/MR facilities also provide nursing services, http://www.cms.hhs.gov
dental care, and pharmacy services. All services are Henry J. Kaiser Family Foundation (KFF):
documented for quality assurance purposes. http://www.kff.org
Medicaid sends surveyors to certified facilities in
order to ensure compliance with specified stan-
dards and maintain quality of care.
International Classification
Future Implications for Patient Safety (ICPS)
ICFs will likely continue to remain an important
part of the healthcare delivery system for individu- Established by the World Health Organization
als with health conditions that require subacute (WHO), the International Classification for Patient
care. ICFs for the mentally retarded, in particular, Safety (ICPS) strives to improve the quality and
provide ongoing care in a residential setting that safety of healthcare. The ICPS aims to define,
promotes the health and personal development of harmonize, and group patient safety concepts into
its clients. A multidisciplinary approach is offered an internationally agreed-on classification system
International Classification for Patient Safety (ICPS) 651
that strives for maximum comparability on a Members of the drafting group reviewed the lit-
global level. By its design, the ICPS is constantly erature and identified the existing patient safety
changing to incorporate new language and updated classifications to determine whether an existing sys-
classification schemes. Currently, the ICPS is only tem could serve as a starting point for the develop-
available for field-testing purposes, which is being ment of the ICPS. These classifications, however,
conducted by the Joint Commission. This entry were developed to address specific aspects of patient
describes the development and theoretical con- safety, such as medication use; they were not
cepts underlying the ICPS system. designed for the overall domain of patient safety.
Because they evolved using different methodologies
with dissimilar definitions for concepts, the drafting
Background
group determined that these existing methods were
In 2002, the WHO’s World Health Assembly not independently fit for global use. Instead, the
adopted Resolution WHA55.18, which called for group decided to construct a new classification
strengthened efforts to address patient safety and based on sound classificatory theory and the experi-
quality of care. Recognizing that all WHO mem- ences of others, including the WHO’s International
ber states faced similar challenges, the WHO Classification of Diseases; the Joint Commission’s
established the World Alliance for Patient Safety Patient Safety Event Taxonomy, endorsed by the
(World Alliance) in 2004. One of the World National Quality Forum (NQF); and the National
Alliance’s key goals was to develop a standard- Patient Safety Foundation’s National Reporting
ized language for patient safety in order to pro- and Learning System of the United Kingdom’s
vide member states with a common terminology, National Health Service. The Australian Patient
based on universally understood meanings, to Safety Foundation’s Advanced Information
enable them to share and learn from each other’s Management System and the Eindhoven/PRISMA-
experiences. In 2005, the World Alliance brought Medical Classification Model, developed by Eind
together 13 international experts with academic hoven University of Technology and Leiden
and practical experience in patient safety, research University Medical Center in the Netherlands, were
methodology, classification theory, human factors also considered.
engineering, health informatics, medicine, and
consumer advocacy and law, and this drafting
Structure and Theoretical Framework
group was charged with developing the ICPS.
At its inception, the most vital purpose for The ICPS was designed to be a flexible descriptive
developing the ICPS was to enable the evaluation tool that could become a basic foundational ele-
of patient safety from a systems approach and ment for global learning. Therefore, its construc-
enhance learning not only from patient safety inci- tion had to be firmly grounded in classificatory
dents that caused harm to patients but also from theory and its underlying infrastructure stable and
those incidents that did not result in harm. These reliable. The classification concepts, or bearers of
types of incidents are known as adverse events and meaning identified by labels or terms, are arranged
near misses, respectively. Developing strategies into classes or groups based on their similarities to
that reduce the risk of harm depends on identifying express semantic and attribute-type relationships.
the factors that contribute to the occurrence of The concepts and the relationships between and
patient safety incidents and the factors that pre- among them are easily identifiable and separated
vent a near miss from becoming an adverse event. without difficulty for analysis. New concepts can
To accomplish this, information is collected be incorporated as knowledge in the field of
through disparate systems, including reporting patient safety increases, which allows it to be
systems, root cause analyses, medical record applicable across disciplines, boundaries, and
reviews, consumer or patient reporting, coroner’s time. Furthermore, the classification must remain
reports, and medical law cases. These data are then culturally and linguistically sensitive. With this
translated into a standardized classification to per- type of infrastructure, the classification can
mit systematic collection, aggregation, examina- mature, respond to change, maintain predictive
tion, education, and ultimately reduction of risk. capability, and enable learning. To construct a
classification such as this, the ICPS’s structure a system failure; however, latent and active con-
needed a proactive, logical, and relational concep- tributing factors/hazards continuously interact.
tual framework to serve as its foundation. The drafting group referred to this period as an
In March 2006, the drafting group identified 10 opportunity to protect against system failure. Once
concepts that would serve as the fundamental classes the failure has occurred, and although both latent
for the ICPS: (1) incident type, (2) patient outcomes, and active contributing factors/hazards remain,
(3) contributing factors/hazards, (4) patient charac- there is still an opportunity for detection and miti-
teristics, (5) incident characteristics, (6) organiza- gation. If the system defenses or an individual is
tional outcomes, (7) detection, (8) mitigating factors, unable to recover from the error, the patient safety
(9) ameliorating actions, and (10) actions to reduce incident occurs. It is at this point that the opportu-
risk. The drafting group then devised a theoretical nity to protect against harm exists. A patient safety
model of the interrelationships between the classes, incident results in a patient outcome and an orga-
based on the theories underlying James Reason’s nizational outcome and possesses patient charac-
“Swiss cheese model,” to understand how the teristics and incident characteristics (who was
classes influence each other and to determine how involved and what occurred). The patient outcome
the classes should be arranged within the conceptual can be either an adverse event or a near miss. Both
framework to achieve the project’s stated outcome patient outcomes and organizational outcomes
of developing a stable ICPS. require actions to ameliorate circumstances and
According to Reason, there are two types of compensate for any harm after a patient safety
approaches to evaluating the occurrence of a incident. Actions taken to reduce risk serve to
patient safety incident. One is the person approach, lessen, manage, or control the harm or probability
where the incident is the result of an individual of harm associated with the patient safety incident.
person making a mistake. The other is a systems These actions, including proactive and reactive
approach, where the incident is the result of a fail- risk assessment, address the issue that allowed the
ure within the system. Reason argues that because contributing factor/hazard to progress into a
individuals are fallible, the system must contain patient safety incident. They relate directly to con-
multilayered processes, referred to as defenses or tributing factors/hazards, detection, mitigating fac-
barriers, to protect against the occurrence of tors, and ameliorating actions and can be
patient safety incidents. Their purpose is to avert implemented anytime, not only after a patient
or reduce the risk of harm by either being built safety incident has transpired. Thus, the process is
into the system from the start or arising on an ad a continuous learning loop.
hoc basis. Using Swiss cheese as a metaphor, the To illustrate this theoretical model, consider
presence of a hole in any one defensive layer does the following example: a 55-year-old man pre-
not necessarily mean that a patient safety incident sented to a busy, understaffed hospital emergency
will occur; however, when the holes in several department with a fever. Although a resident took
defensive layers align as a result of a combination a brief medical history, during which the patient
of active failures and latent conditions, a contrib- indicated an allergy to penicillin, the allergy to
uting factor/hazard can move, uninhibited, to medication was not documented in the patient’s
become a patient safety incident. Reason postu- chart. This negligence is considered a failure of
lates that latent conditions can be detected and protection. Continuing with this example, the
mitigated before an incident occurs through proac- attending emergency physician reviewed the chart,
tive risk assessment or other error recovery meth- ordered amoxicillin, and administered it for treat-
ods. Being able to proactively identify risks and ment. The patient then experienced a mild allergic
design system approaches to counteract these risks reaction to the medication. This adverse drug
illustrates a system’s ability to be resilient. event is considered a patient safety incident.
Applying Reason’s theory to the ICPS, once the Because the patient experienced only a mild reac-
active failure and latent condition have collided, tion, observation was ordered to monitor for any
the system should have the ability to detect the further complication. After an investigation of the
problem and to institute mitigating factors that patient safety incident, through a root cause
have the potential to stop the progression toward analysis or other investigatory process, hospital
International Classification for Patient Safety (ICPS) 653
Influences Informs
Contributing factors/hazards
Patient Incident
Incident
characteristics characteristics
Incident type
Actions taken to reduce risk
Actions taken to reduce risk

Influences Informs
Detection
Influences Informs
Mitigating factors
Informs Organizational Informs

Patient outcomes
outcomes
Influences Informs
Ameliorating actions
System resilience (proactive and reactive risk assessment)
Clinically meaningful, recognizable categories for incident identification and retrieval
Descriptive information
Figure 1 Conceptual Framework for the International Classification for Patient Safety
Source: The World Health Organization, World Alliance for Patient Safety (http://www.who.int/patientsafety/taxonomy/en),
Geneva, Switzerland.
policy, staffing, and education requirements were the conceptual framework is depicted in a manner
reviewed in an effort to reduce risk. that maintains its stability, flexibility, ability to
The depiction of the ICPS’s conceptual frame- incorporate new concepts, and predictive capacity
work must represent this theoretical flow of ideas while simultaneously enabling the creation of
in a logical and operational manner if it is to easily translational tables to map data fields contained in
map, with relatively low resource expenditure, to the existing reporting systems to those contained in
existing reporting systems, in addition to being a the ICPS. Such a structured approach is a prerequi-
tool to organize patient safety data and informa- site for integrating disparate data and information
tion in a structured classification. Consequently, into a common learning platform. Therefore, the
drafting group purposefully arranged the classes to areas, and learn from experience. The ability to orga-
visually depict the learning cycle resulting from a nize patient safety information through an interna-
patient safety incident (see Figure 1). Solid lines tionally accepted classification system with a solid
indicate the semantic relationships between classes, conceptual framework is essential if patient safety
and dotted lines indicate the flow of information. incident data and information are to be used and dis-
An incident type is a descriptive term for a cat- seminated effectively. A standardized patient safety
egory of incidents of a common nature grouped terminology allows for semantic interoperability,
because of shared features. A patient outcome is making it possible to draw comparisons across
the impact on a patient that is either wholly or sources, disciplines, organizations, borders, cultures,
partially attributable to the incident. Together, and time. This, in turn, enables surveillance and evalu-
these classes group patient safety incidents into ation to identify actual and potential threats to patient
recognizable, clinically meaningful categories. safety. Policymakers can use this evidence-based
Contributing factors/hazards are circumstances, research to revise existing or to introduce new system-
actions, or influences that are thought to have wide solutions, assess the effectiveness of the interven-
played a part in the origin or development of an tions, and communicate the lessons learned globally.
incident or in increasing the risk of an incident.
Patient characteristics are the selected attributes of Heather Sherman, Richard Koss,
a patient, whereas incident characteristics are the Gerard M. Castro, and Jerod Loeb
selected attributes of an incident, and organiza-
See also Adverse Drug Events; Comparing Health Systems;
tional outcomes are the impact on an organization
International Classification of Diseases (ICD); Joint
that are wholly or partially attributable to an inci- Commission; Medical Errors; Patient Safety; Quality of
dent. Data and information pertaining to system Healthcare; World Health Organization (WHO)
resilience, risk reduction, protection against fail-
ure, and protection against harm are captured in
Further Readings
the following classes: (a) detection—defined as an
action or circumstance that results in the discovery Kloss, Linda. “Now’s the Time for ICD-10: Adopting
of an incident; (b) mitigating factors—actions or Updated Classification System is Crucial to Reform,
circumstances that prevent or moderate the pro- Patient Safety,” Modern Healthcare 38(41): 22,
gression of an incident toward harming a patient; October 13, 2008.
(c) ameliorating actions—actions taken or circum- Reason James. “Human Error: Models and Management,”
stances altered to make better or compensate any Western Journal of Medicine 172(6): June 2000.
harm after an incident; and (d) actions to reduce Reason James. Human Error. New York: Cambridge
risk—those actions taken to reduce, manage, or University Press, 2003.
control the harm, or probability of harm, associ- Runciman, W. B., J. A. H. Williamson, A. Deakin, et al.
ated with an incident in order to help reduce risk. “An Integrated Framework for Safety, Quality and
Contributing factors/hazards leading to patient Risk Management: An Information and Incident
Management System Based on a Universal Patient
safety incidents are influenced by and inform
Safety Classification,” Quality and Safety in Health
actions to reduce risk, as do concepts contained in
Care 15(Suppl. 1): i82–i90, December 2006.
the classes detection and mitigating factors. Patient
World Health Organization, Alliance for Patient Safety.
outcomes and organizational outcomes both
The Conceptual Framework for the International
inform actions to reduce risk. Ameliorating actions Classification for Patient Safety. Geneva, Switzerland:
also influence and inform actions to reduce risk. World Health Organization, 2007.

The pragmatic utility of the ICPS is its ability to trans- Joint Commission: http://www.jointcommission.org
late data and information collected in disparate National Patient Safety Foundation (NPSF):
reporting systems into a coded language so that analy- http://www.npsf.org
sis of a single concept or a combination of concepts is WHO World Alliance for Patient Safety:
possible to identify trends, predict potential problem http://www.who.int/patientsafety/taxonomy/en
International Classification of Diseases (ICD) 655
issued the 6th revision (ICD-6), and it has devel-

International Classification oped and published all succeeding revisions. In
of Diseases (ICD) 1955, it published the 7th revision (ICD-7). This
revision was changed in the United States in 1959 to
The International Classification of Diseases (ICD) include various clinical modifications. In 1965, the
is the official coding system used by all the world’s WHO published the 8th revision (ICD-8), which
nations for recording the causes of morbidity and also was modified in the United States in 1968. The
mortality. The ICD is periodically revised, pub- WHO published the 9th revision (ICD-9) in 1977,
lished, and disseminated by the World Health and it also was modified, this time by the National
Organization (WHO). Specifically, the WHO, Center for Health Statistics (NCHS), to include
working with 10 Collaboration Centers, produces more morbidity data and medical procedure codes.
the ICD. The purpose of the ICD is to permit valid This extension resulted in the ICD-9-CM, with the
and reliable comparisons of morbidity and mor- CM standing for clinical modification. The United
tality data across time and nations. The ICD plays States currently requires all the nation’s hospitals to
an important role in reducing the complexities of use ICD-9-CM diagnosis codes for Medicare and
thousands of diagnoses of diseases and medical Medicaid claims. In 1994, the WHO released the
procedures to a smaller, more manageable set of 10th revision of the ICD (ICD-10). This revision has
standardized diagnostic and procedural codes. It is been adopted for reporting mortality by the NCHS
widely used by public health departments, health- and the state and local public health departments;
care organizations, and health services researchers however ICD-9-CM is still used by hospitals and
to analyze the general health of population groups; other healthcare organizations for recording mor-
monitor the incidence and prevalence of diseases; bidity and for billing purposes.
and compare other health problems in relation to
the access, cost, and quality of healthcare. Key Differences Between
ICD-9-CM and ICD-10
History
The ICD-9-CM contains 17 chapters and two
The origins of the ICD can be traced back to the supplementary classifications. The E-Codes clas-
1850s, when William Farr (1807–1883), the sify the external causes of injury and poisoning,
founder of medical statistics, and others devel- and the V-Codes organize factors influencing
oped standardized classifications of diseases for health status and contact with health services.
comparative and statistical purposes. Farr, for These two chapters now form part of the main
example, classified diseases into five broad groups: classification in the 10th revision (ICD-10).
(1) epidemic diseases, (2) constitutional (general) Although the overall content is similar and the
diseases, (3) local diseases arranged according to format and conventions of the classification
anatomical site, (4) developmental diseases, and remain unchanged, the ICD-10 is different from
(5) diseases that are the direct result of violence. its predecessor in many ways.
Although Farr’s structure has been modified over The main axis for cataloging injury has changed
the years, it still forms the basis of the ICD. in the injury and poisoning chapter of ICD-10. In
Over the past 100 years, the ICD has been ICD-10, injuries are catalogued first by type: All
revised 10 times approximately each decade to dislocations are grouped together, as are all open
incorporate changes in medicine. The 1st edition of wounds. In ICD-10, however, the axis of organiza-
the ICD, known as the International List of Causes tion focuses instead on the anatomical site of injury.
of Death, was adopted by the International Statistical Thus, all injuries to the foot, for example, are cata-
Institute in 1893. Until the 5th revision of the ICD, logued together, as are all injuries to the head.
the Government of France convened the interna- The ICD-10 is published as a three-volume set
tional conferences that developed the various revi- compared with ICD-9-CM’s two volumes. The
sions. After World War II, however, the newly ICD-10 has alphanumeric categories rather than
created World Health Organization took over the numeric categories to allow sufficient space for
responsibility for the ICD. In 1948, the WHO future additions and changes without disrupting
656 International Health Economics Association (iHEA)
the codes and to provide a larger coding frame. National Center for Health Statistics (NCHS):
Some chapters have been rearranged. For example, http://www.cdc.gov/nchs
certain disorders of the immune system are included Pan American Health Organization (PAHO):
with diseases of the blood and blood-forming http://www.paho.org
organs, whereas in the ICD-9-CM, they are included World Health Organization (WHO): http://www.who.int
with endocrine, nutritional, and metabolic dis-
eases. Two new chapters have been created for
diseases of the eye and adnexa and diseases of the
ear and mastoid process. Some codes have been International Health
expanded, including those for diabetes, alcohol/ Economics Association (iHEA)
substance abuse, and postoperative complications.
The ICD-10 has a total of 21 chapters and almost The International Health Economics Association
twice as many categories as the ICD-9-CM. (iHEA) is an individual, not-for-profit membership
association consisting of more than 2,500 members
Future Implications from 72 countries. The iHEA focuses on the col-
leagueship and advancement of individual health
Researchers at the WHO and other organizations economics scholars, students, and researchers.
are working on the 11th revision of the International Specifically, the goals of the iHEA are to increase
Classification of Diseases (ICD-11). The first draft communication among health economists across the
of ICD-11 is expected to be completed by 2010. globe, foster a higher standard of debate in the
The final version will likely be published around application of economics to health and to healthcare
2014 and implemented by various nations starting systems, and assist young health economists conduct
in 2015. It seems likely that the United States will high-quality research at the start of their careers.
modify ICD-11 to better suit its unique healthcare
system and needs.
Rima Tawk Background
Although as early as the 1920s economists began
See also Disease; Epidemiology; Farr, William; Health
getting together to review each other’s work in the
Informatics; Morbidity; Mortality; Public Health;
World Health Organization (WHO) area of health and to trade ideas on the subject,
there was no formal field of health economics for
many decades. One of the first organizations in
Further Readings
the field was the Health Economics Study Group
Falen, Thomas J. Learning to Code With ICD-9-CM for (HESG), which was established in the early 1970s
Health Management and Health Services in the United Kingdom. Two prominent health
Administration. Baltimore: Wolters Kluwer Health/ economists, Joseph P. Newhouse in the United
Lippincott Williams and Wilkins, 2008. States and Anthony J. Culyer in the United
Israel, R. A. “The History of the International Kingdom, began the Journal of Health Economics
Classification of Diseases,” Health Bulletin 49(1): in 1981. Thus, by the 1980s, the new field of
62–66, January 1991. health economics was clearly established.
Libicki, Martin C., and Irene Brahmakulam. The Costs Over the years, various regional and national
and Benefits of Moving to the ICD-10 Code Sets. health economics associations were started, many
Santa Monica, CA: RAND Corporation, 2004. of those in Europe and Anglophone countries fol-
Lovaasen, Karla R., and Jennifer Schwerdtfeger. ICD-9-
lowing the HESG model. In the United States, a
Coding: Theory and Practice. St. Louis, MO:
health economics committee was created as part of
Saunders-Elsevier, 2009.
the medical-care section with the American Public
Health Association (APHA), and a sectional affili-
Web Sites ate was established in the American Economic
American Medical Association (AMA): Association (AEA), but neither of these entities
http://www.ama-assn.org grew into membership organizations. There were
International Health Economics Association (iHEA) 657
discussions among health economists about the to its members, including a weekly online newslet-
need for creating an international membership ter; (d) maintaining a world directory of health
society to encourage communication among health economists; and (e) conducting a large biennial
economists, and in 1994, the iHEA was estab- international conference on health economics.
lished. Its founding directors included Thomas E. To be eligible for the association’s annual
Getzen, Charles Hall, Alan Maynard, Michael A. Kenneth J. Arrow Award in Health Economics, a
Morrisey, Joseph P. Newhouse, and Mark V. paper must have been published in a peer-reviewed
Pauly. Getzen was the executive director and journal in English in the year of the award.
served as the association’s first president, followed Members submit nominations and a copy of the
by Newhouse, Maynard, and then Pauly. paper to a reviewing committee, who pick the win-
The association has grown over the years. ning paper.
However, eventually it was recognized that for it to The association provides members with dis-
be truly international in scope and not just repre- counts on six journals: (1) Health Economics,
sentative of developed industrial countries, the (2) Journal of Health Economics, (3) European
iHEA would have to seek external funding for Journal of Health Economics, (4) Economics and
members of developing countries. It also recog- Human Biology, (5) International Journal of
nized that the lack of an active American health Healthcare Finance and Economics, and (6) Journal
economics organization was distorting the mem- of Mental Health Policy and Economics.
bership, and in 2003, the board voted to create the The world directory of health economists
American Society of Health Economics (ASHE) as maintained by the association includes information
a subcommittee of the iHEA to provide a more on about 2,300 individuals. It includes the name of
appropriate venue for North American conferences the individual and his or her e-mail address,
and communications. The ASHE will continue to organization/department, and telephone number.
be a subentity within the iHEA until 2010, and The association’s biennial conference is a major
then it will become an independent organization. international event, and the number of attendees
has steadily grown over time. The first conference,
called the “iHEA Congress,” was held in Vancouver,
Funding and Organizational Structure British Columbia, Canada, in 1996. Subsequent
conferences were held in Rotterdam, Holland, in
The iHEA is largely self-funded through individ-
1999; York, England, in 2001, San Francisco,
ual dues and fees, which helps it to maintain inde-
California, in 2003; Barcelona, Spain, in 2005;
pendence from the specific interests of industry,
and Copenhagen, Denmark, in 2007. The associa-
government agencies, or medical organizations.
tion’s 2009 World Congress will be held in Beijing,
Its organizational structure consists of the fol-
China.
lowing: (a) an executive director; (b) a president,
who is elected by the membership; (c) a secretary/ Thomas E. Getzen
treasurer; (d) a board of directors; (d) program
chairs, for the biennial meeting; and (e) the asso- See also American Society of Health Economists (ASHE);
Arrow, Kenneth J.; Committee on the Costs of
ciation’s operational staff, which consists of three
Medical Care (CCMC); Comparing Health Systems;
individuals. Members of the board of directors
Cost of Healthcare; Health Economics; International
serve 4-year overlapping terms. Health Systems
Main Activities Further Readings

The association’s main activities include (a) present- Fuchs, Victor R. “The Future of Health Economics,”
ing the annual Kenneth J. Arrow Award in Health Journal of Health Economics 19(2): 141–57, March
Economics for the best published paper in health 2000.
economics; (b) distributing health-economics-related Lee, Kelley. “Health Care in the Developing World: The
journals to its members at a discounted price; (c) Role of Economists and Economics,” Social Science
distributing health-economics-related information and Medicine 17(24): 2007–2015, 1983.
658 International Health Systems
Mills, Anne. “Leopard or Chameleon? The Changing German Healthcare System

Character of International Health Economics,”
Tropical Medicine and International Health 2(10): Germany was the first nation to enact compulsory
963–77, October 1997. health insurance legislation in 1883. The law
Savedoff, William D. “40th Anniversary: Kenneth Arrow required employers and employees to make pay-
and the Birth of Health Economics,” Bulletin of the ments to voluntary “sickness funds,” which would
World Health Organization 82(2): 139–40, February pay for the covered employees’ medical care.
2004. Initially, only industrial wage earners with incomes
less than $500 per year were included. However,
the eligible population was extended in later
Web Sites years.
American Society of Health Economists (ASHE):
Today, about 90% of Germans receive their
http://healtheconomics.us health insurance through the mandatory sickness
Health Economists’ Study Group (HESG): funds. There are about 500 of these funds, and the
http://www.hesg.org.uk/index.php majority of individuals remain in one of the funds
International Health Economics Association (iHEA): throughout their life. About 40% of people belong
http://www.healtheconomics.org to funds organized by geographic area. About
27% (primarily families of white-collar workers)
belong to “substitute” funds, 12% belong to the
sickness funds of their companies, and another
12% belong to craft-based funds. About 8% of
International Health Systems Germans (mainly those with higher incomes) choose
private insurance, and another 2% receive medical
Over the past several years, there has been a grow- services as members of the armed forces. Less than
ing interest in comparing the healthcare systems of 0.2% of the population has no coverage.
various nations. This interest is primarily a result The sickness funds are quasi-public/quasi-
of searches by governments and citizens alike for private not-for-profit ventures that collect money
new solutions to offset increasing healthcare costs. from members and members’ employers. Unlike
A key element in comparing various national managed-care organizations in the Unites States,
healthcare systems is how they pay for care. the funds are not allowed to exclude people due to
Nations generally pay for healthcare through indi- illness or to raise contribution rates according to
vidual out-of-pocket payments, individual private age or medical conditions. The funds are required
health insurance, employment-based private health to cover a broad range of benefits, including hos-
insurance, or government financing. In most pital and physician services; prescription drugs;
nations of the world, healthcare is delivered and/ and dental, preventive, and maternity care.
or financed by the public sector. In others, such as Copayments for care are modest, and on retire-
the United States, most people both pay for and ment or loss of a job, people and their families
receive their care through the private sector. The retain membership of their sickness fund.
United States is unique among nations because it German medicine maintains a strict separation
views healthcare not as a public good but rather of ambulatory-care physicians and hospital-based
as a private good that is available to those who physicians. Most ambulatory-care physicians are
can afford to pay for it. prohibited from treating patients in hospitals, and
To put the U.S. healthcare system in an interna- most hospital-based physicians do not have private
tional context, two countries—Germany and offices for treating outpatients. Traditionally,
Canada—are compared. These two countries patients could go directly to an ambulatory-care
exemplify healthcare systems different from the specialist. However, in recent years, referrals from
private model in the United States. That is, the patients’ primary-care physician to ambulatory-
Germany and Canada both provide financial care specialists have become the norm. The German
access to healthcare through government-run or system of dispersed medical-care organization
government-mandated programs. is similar to that in the United States, with little
International Health Systems 659
coordination between ambulatory-care physicians Fifty-five percent of Canadian physicians are

and hospitals. general practitioners or family physicians com-
Controlling healthcare costs has been a problem pared with 35% of similar physicians in the United
in Germany in recent years but not to the extent it States. As in other national healthcare systems,
is in the United States. Negotiations on fees, rates, general practitioners in Canada act as gatekeepers
and prices for care are conducted annually at state, to the medical system. As a rule, Canadians see
regional, and local levels between the sickness their general practitioners, who they are free to
funds, physicians’ associations, and hospitals. choose, for routine medical problems and visit spe-
Today, healthcare costs in Germany are about cialists through referral by their general practitio-
10% of its gross domestic product (GDP). ner. Also, because of the close scientific interchange
To control costs, Germany has accentuated between Canada and the United States, the practice
competition into its insurance system by allowing of medicine is very similar in both countries.
individuals greater flexibility in choosing a sick- Studies of the United States and Canada have
ness fund. The expectation is that individuals will compared how receipt of a variety of services,
seek out lower-cost funds and that this consumer ranging from cardiac surgery to mental healthcare,
choice model will motivate all funds to become may vary according to income in the two nations.
more price competitive. However, Germans have In the United States, the poor receive less care than
shown much allegiance to their sickness funds, and the wealthy populations, while in Canada, the
switching behavior has been limited. Overall, the opposite is the case. The poor, who generally have
German values of social solidarity and fairness worse health outcomes, use healthcare services
have dampened aggressive price competition and more in Canada.
shopping for health plans. In 1970, Canada and the United States spent
about the same proportion of their GDP on health-
care (a little more than 7% each). However, since
Canadian Healthcare System
that time, Canada has done a better job of contain-
In 1947, Saskatchewan was the first Canadian ing healthcare costs. In 1998, Canada spent 9.5%
province to initiate a publicly financed universal of its GDP on healthcare compared with 13.6% in
hospital insurance. Other provinces followed, the United States. Notably, the differences in cost
leading to the Canadian Hospital Insurance Act between the United States and Canada are not the
in 1957 and its full implementation in 1961. result of Canadians receiving fewer services over-
Saskatchewan again took the lead in 1961 by all. For example, elderly Canadians receive 17%
enacting a medical insurance plan for physician more physician services than the elderly in the
services. All Canadian provinces covered physi- United States.
cian services by 1971, giving Canada a province- Canadians, on average, spend more days in the
based, tax-financed, public, single-payer healthcare hospital and see physicians more often than people
system. in the United States. However, Canada has lower
Canada, unlike Germany and the United States, costs than the United States because administrative
has severed the link between employment and costs are lower, hospital costs per day are lower,
health insurance. Wealthy or poor, employed or and physician fees and prescription drug prices are
jobless, retired or under age 18, every Canadian lower.
receives the same health insurance, financed in the
same manner. Furthermore, the benefits provided
Comparing the Performance
by the Canadian provinces are broad, including
of Healthcare Systems
unlimited hospital, physician, and ancillary ser-
vices. Provincial plans also pay for outpatient Healthcare systems are often compared on the
drugs, although most provinces limit eligibility for three criteria of cost, access, and quality of care.
this benefit to elderly and low-income patients. Germany and Canada, as well as all other
The Canadian healthcare is unique in its prohibi- advanced nations, have controlled healthcare
tion of private health insurance for coverage of costs more successfully than has the United States
services included in the provincial health plans. in the past 20 years, though all nations continue
to face challenges in containing their spending. coverage or with limited insurance coverage. In
The United States spends more on its healthcare addition, even Americans with above-average
system than any other nation, about 15% of its incomes find it more difficult than their counter-
GDP. In contrast, healthcare spending as a per- parts in other nations to get care on nights or
centage of GDP in other advanced nations aver- weekends without going to a hospital emergency
ages about 9%. department, and many report having to wait 6
Some have speculated that the higher costs of days or more for an appointment to see their own
healthcare in the United States are due to greater physician.
use of services by its citizens. However, recent stud- The Commonwealth Fund has conducted a
ies show that the use of services in the United States number of studies comparing the U.S. healthcare
is lower than in many other nations, including system with other national systems, using surveys
Germany and Canada. It is now acknowledged of patients and physicians and other data. In 2007,
that the main factors leading to higher costs of it ranked the United States last or next to last com-
healthcare in the United States include high admin- pared with five other nations—Australia, Canada,
istrative, pharmaceutical, and medical technology Germany, New Zealand, and the United Kingdom—
costs; defensive medicine practices; and the high on most measures of performance, including qual-
incomes of healthcare providers. For example, it ity of care and access to it. The Commonwealth
has been estimated that administrative costs repre- Fund study ranked the United States first in pro-
sent from 18% to 33% of all healthcare costs in the viding the “right care” for a given condition, as
United States. This compares with about 3% in defined by standard clinical guidelines, and gave it
Canada. A major cause of the high administrative especially high marks for preventive care, such as
and pharmaceutical costs is the fragmented nature pap smears and mammograms to detect early-
of the U.S. healthcare system. Patients move in and stage breast cancers and blood tests and choles-
out of insurance coverage from year to year, and terol checks for hypertensive patients. But the
this puts tremendous strain on the system in terms United States scored poorly in coordinating
of administrative practices such as billing and pre- the care of chronically ill patients, in protecting the
ventive care. Also, the leverage that insurance com- safety of patients, and in meeting their needs and
panies have in the United States to negotiate lower preferences, which drove the nation’s overall qual-
prices for pharmaceuticals is much less in compari- ity of care rating down to last place. American
son with governments negotiating leverage in other physicians and hospitals experienced more surgical
developed nations. Finally, physicians in the United and medical mistakes than their counterparts in
States get paid on average about twice as much as other industrialized nations. Furthermore, the
their counterparts in other developed nations. United States had the best survival rate for breast
The United States has not fared well on the cancer, second best for cervical cancer and child-
access criterion, being the only developed nation hood leukemia, worst for kidney transplants, and
lacking some form of universal healthcare coverage next to the worst for liver transplants and colorec-
for its citizens. The result has been that about tal cancer.
17%, or 48 million, of Americans are uninsured In another study comparing eight countries, the
and many more millions have poor insurance cov- United States ranked last in years of potential life
erage. All other major industrial nations provide lost to circulatory diseases, respiratory diseases,
universal healthcare coverage, and most of them and diabetes and had the second highest death rate
have comprehensive benefit packages with no cost from bronchitis, asthma, and emphysema. Although
sharing by patients. Although people in the United several factors can affect these results, it seems
States can obtain treatment in a hospital emergency likely that the quality of care delivered was a sig-
department, many studies have shown that people nificant contributor.
without health insurance often postpone treatment Other criteria that Americans are starting to
until a minor illness becomes worse, harming their consider in comparing their health systems with
own health and incurring greater costs. those of other nations include fairness, patient sat-
Barriers in the United States include the costs isfaction, use of information technology, and pub-
facing low-income people without health insurance lic health. Each is discussed below.
International Health Systems 661
Fairness ranked near the bottom in healthy life expectancy

The United States ranks last on almost all mea- at age 60 and 15th among 19 nations in deaths
sures of equity because it has the greatest disparity from a wide range of illnesses that would not have
in the quality of care given to richer and poorer been fatal if treated with timely and effective care.
citizens. This is largely due to the fact that health- In terms of prevention, the United States did a bet-
care is not seen as a public good in the United States ter job than other industrialized nations in reduc-
but a private good that is only available to those ing smoking, but it ranked number one in obesity.
who can afford it. As a result, Americans with
below-average incomes are much less likely than Future Implications
their counterparts in other industrialized nations to
Taken as a whole, the mounting national com-
go to a physician when sick, to fill prescriptions, or
parative evidence has caused many healthcare
to get needed tests and follow-up care.
experts, purchasers, health planners, providers,
and consumers to seriously question the value of
Patient Satisfaction the care that is being provided in the United States.
For example, in 2001, the national Institute of
Many Americans hold negative views of their
Medicine (IOM) identified a chasm between the
healthcare system. In Commonwealth Fund sur-
healthcare the nation had and the care it could
veys of five countries, American attitudes stand out
have. It reported that the nation’s current health-
as the most negative, with a third of the adults sur-
care system cannot do the job, that trying harder
veyed calling for rebuilding the entire healthcare
will not work, and that future health reform
system, compared with only 13% who felt that
efforts must reduce the huge number of uninsured,
way in Britain and 14% in Canada. These results
who are the major reason for the poor standing of
may be due to Americans paying higher out-of-
the United States in health globally. It also identi-
pocket costs than citizens of other nations. They
fied needed improvements in the coordination of
are also less likely to have a long-term physician,
care, the use of computerized records, communica-
less able to see a physician on the same day they are
tions between physicians and patients, and many
sick, and less likely to get their questions answered
other factors that impair the quality of care.
or receive clear instructions from a physician.
The United States spends the greatest amount of
money on healthcare among all the nations and
Use of Information Technology because of that, many believe it should be able to
provide universal access to care and at the same
Despite the wide use of computers, software, time provide the highest quality of care in the
and the Internet, much of the U.S. healthcare sys- world. However, there are many entities, including
tem is still operating with handwritten paper physician organizations, insurance companies,
records. American primary-care physicians lag medical device manufacturers, and pharmaceutical
years behind physicians in other advanced nations companies, with tremendous financial resources
in adopting electronic medical records or prescrib- and political power, that may attempt to block
ing medications electronically. This situation makes national healthcare reform efforts. Yet there are
it difficult to coordinate care, identify medical other market pressures, such as the decline of
errors, and adhere to standard clinical guidelines. employer-based health insurance coverage and a
growing willingness by Americans to shop for
healthcare in other nations, which may increase
Public Health
focus on healthcare reform in the coming years.
In 2000, the World Health Organization (WHO)
ranked the healthcare systems of 191 nations. Blair D. Gifford
France and Italy were ranked at the top, while the See also Access to Healthcare; Comparing Health
United States was ranked 37th. The United States Systems; Cost of Healthcare; Health Services Research
had a high infant mortality rate and ranked last of in Canada; Health Services Research in Germany;
23 advanced nations. The United States also Quality of Healthcare; Satisfaction Surveys
Further Readings Kelley, Ed. “Health, Spending and the Effort to Improve
Quality in OECD Countries: A Review of the Data,”
Anderson, Gerard F., Uwe E. Reinhardt, Peter S. Hussey,
Journal of the Royal Society for the Promotion of
et al. “It’s the Prices, Stupid: Why the U.S. is So
Health 127(2): 64–71, March 2007.
Different From Other Countries,” Health Affairs
National Audit Office. International Health
22(3): 89–105, May-June 2003.
Comparisons: A Compendium of Published
Brown, Lawrence D. “Comparing Health Systems in Four
Information on Healthcare Systems: The
Countries: Lessons for the United States,” American
Provision of Healthcare and Health Achievements
Journal of Public Health 93(1): 52–56, January 2003.
in 10 Countries. London: National Audit
Hussey, Peter, Gerard F. Anderson, Jean-Marie
Office, 2003.
Berthelot, et al. “Trends in Socioeconomic Disparities
in Health Care Quality in Four Countries,”
International Journal for Quality in Health Care
20(1): 53–61, February 2008.
Web Sites
Hussey, Peter, Gerard F. Anderson, Robin Osborn, et al. Commonwealth Fund: http://www.commonwealthfund.org
“How Does the Quality of Care Compare in Five National Audit Office (NAO): http://www.nao.org.uk
Countries?” Health Affairs 23(3): 88–99, May–June 2004. World Health Organization (WHO): http://www.who.int
J
healthcare organization is accredited or certified,
Joint Commission it must reapply for accreditation every 3 years or
for recertification every 2 years.
The Joint Commission, formerly known as the The Joint Commission also awards a certifica-
Joint Commission on Accreditation of Healthcare tion, known as the Disease-Specific Care Certifi
Organizations (JCAHO), is the largest and oldest cation, to health plans, disease management service
accrediting healthcare organization in the United companies, hospitals, and other care delivery set-
States. It accredits and evaluates approximately tings that provide disease management and chronic-
15,000 healthcare organizations and programs in care services.
the nation, including general, psychiatric, chil- The Joint Commission was formerly led by its
dren’s, and rehabilitation hospitals; critical-access longtime president Dennis S. O’Leary and is cur-
hospitals; medical equipment services; hospice rently under the leadership of Mark R. Chassin.
services and other home care organizations; nurs- The Joint Commission is overseen by a Board of
ing homes and other long-term care facilities; Commissioners, which is composed of healthcare
behavioral healthcare organizations and addic- professionals, including nurses, physicians, medi-
tion service; rehabilitation centers and group cal directors, and providers, as well as consumers,
practices; office-based surgeries and other ambu- administrators, employers, a labor representative,
latory care providers; and independent or free- health plan leaders, quality experts, ethicists, a
standing laboratories. health insurance administrator, and educators.
Founded in 1951, the Joint Commission is an The corporate members of the Joint Commission
independent, private, nonprofit organization include the American College of Physicians (ACP),
located in Oakbrook Terrace, Illinois, with a sat- the American College of Surgeons (ACS), the
ellite office based in Washington, D.C. The Joint American Dental Association (ADA), the American
Commission’s mission is to improve the quality Hospital Association (AHA), and the American
and safety of care received by the public through Medical Association (AMA). The Joint Commission
healthcare accreditation and through services that employs more than 1,000 individuals in its sur-
support performance improvement in healthcare veyor workforce.
organizations. The Joint Commission carries Since the Joint Commission was formed, volun-
out its mission by accrediting healthcare organi tary accreditation and quality assurance systems
zations and by providing healthcare performance have been adopted across the globe, by countries
improvement services. It maintains perfor- such as Canada, Australia, and various European
mance-based standards and evaluates healthcare nations.
organizations’ compliance with these standards While the Joint Commission is not able to cite or
in maintaining safety and quality care. Once a fine an organization for not meeting its standards,
663
664 Joint Commission
its accreditation program does carry significant Early History

weight. Under the federal Medicare law, Joint
Commission–accredited hospitals are “deemed” to In 1910, Ernest A. Codman, a Boston surgeon,
have met the requirements for participation in the developed the end-result system of hospital stan-
Medicare program. Similarly, most states have dardization. Under this system, hospitals would
incorporated Joint Commission accreditation stan- track every patient to determine if his or her treat-
dards into their hospital licensure standards. The ment was effective and, if not, to find out how to
failure of an organization to meet the Joint prevent this from happening again in the future.
Commission’s standards can result in the loss of At the urging of Franklin H. Martin, the ACS was
accreditation as well as millions of dollars in founded in 1913, and the end-result system
Medicare and Medicaid funding. became a stated objective of this nascent organiza-
Some of the benefits of Joint Commission tion. In 1917, the ACS formally established the
accreditation include an outside evaluation of an Hospital Standardization Program, and 2 years
organization’s quality and safety of care. Joint later it adopted five official standards, known col-
Commission accreditation also provides knowl- lectively as the Minimum Standards for Hospitals.
edge to the public of whether an organization The adoption of these Minimum Standards formed
meets or exceeds its standards. the foundation for the accreditation process.
Recent criticisms of the Joint Commission have The first on-site hospital inspections took place
included the perceived rigor of its hospital survey in 1918, and at the time, only 89 out of 692 hos-
process in assessing quality care, as the vast major- pitals met this standard. The dismal state of hospi-
ity of hospitals that seek accreditation receive it. A tals demonstrated the urgent need for a national
potential conflict of interest cited by critics is the hospital accreditation program. As the ACS
Joint Commission’s subsidiary (Joint Commission Hospital Accreditation Program’s success grew,
Resources) that provides consultation to hospitals more hospitals sought its approval, and by 1950,
on how to gain accreditation and improve their over half of the hospitals in the United States were
performance. The Joint Commission assuages accredited.
these concerns by noting that there are policies in The ever-increasing complexity of medical care
place (“firewall”) that create a barrier between its and the growth of nonsurgical specialties after
subsidiary and the accreditation division, prevent- World War II required that hospital standards be
ing the sharing of information. Additionally, the reviewed, revised, and updated to reflect these
composition of the Joint Commission’s Board of changes. The Hospital Standardization Program
Commissioners, made up of members from the would therefore need the support of the entire
AHA, AMA, and the ACP, to name a few, raised medical community, and as a result, the ACS
some questions about the Joint Commission’s abil- sought the participation of other national profes-
ity to objectively accredit organizations that it sional organizations to improve the voluntary
oversees. accreditation program.
The Joint Commission has also received a back- In 1951, the ACS joined with the ACP, the AHA,
lash from its constituent members, including the the AMA, and the Canadian Medical Association
AHA and the AMA. Some of these grievances to form the independent, nonprofit organization
include the range of variability in the accreditation the Joint Commission on Accreditation of Hospitals
survey process, the value of Joint Commission ser- (JCAH). The primary purpose of JCAH was to pro-
vices, and the role of the Joint Commission as a vide voluntary accreditation. The following year,
peer review organization. AMA members have JCAH took over the Hospital Standardization
also felt that the Joint Commission’s requirements Program from the ACS, and in 1953, the Standards
had become too burdensome and costly relative to for Hospital Accreditation was published. The
the benefits yielded by its accreditation and that Canadian Medical Association later withdrew from
the Joint Commission was unresponsive to physi- the JCAH in 1959 and created its own accrediting
cian complaints. State hospital associations have body in Canada.
also explored comparable alternatives to the Joint The JCAH perpetuated the traditions of the
Commission accreditation. ACS by providing voluntary accreditation with
Joint Commission 665
standards agreed on by health professionals as forefront of hospital standard setting. The optimal
providing quality care, and the accreditation sur- achievable standard would be later defined as the
vey would still represent a combination of evalua- best that could be achieved, making the healthcare
tion, education, and consultation. All information provided as effective as possible. This impetus
obtained through the survey process would be held resulted in the publication of the 1970 Accreditation
in confidence between the JCAH and its member Manual for Hospitals.
organizations. Beginning in the late 1960s and early 1970s, the
The Joint Commission continued to expand its JCAH greatly began to expand its role in accredit-
program, now called the Hospital Accreditation ing new programs with the growth of other health-
Program, and hired and trained surveyors to focus care organizations. Because of JCAH’s experience
on medical staff and patient care issues. with accrediting hospitals and its widespread
acceptance among the medical community, it was
fitting for it to branch out into these new endeav-
Evolving Role
ors. The JCAH started accrediting organizations
With the passage of the Medicare Act in 1965 that served the developmentally disabled through
(PL 89–97), the role of the JCAH shifted, and it the Accreditation Council for Services for the
became more closely affiliated with the federal Mentally Retarded and Other Developmentally
government. This law provided that hospitals Disabled Persons; psychiatric facilities, substance
accredited by JCAH would be deemed in compli- abuse programs, and community mental health
ance with most of the Medicare Conditions of programs through the Accreditation Council for
Participation for Hospitals and, thus, would be Psychiatric Facilities; long-term care facilities
deemed eligible to participate in the Medicare and through the Accreditation Council for Long Term
Medicaid programs. The Social Security Act (PL Care; and ambulatory healthcare facilities through
92–603), later amended in 1972, required that the the Accreditation Council for Ambulatory Health
Secretary of the U.S. Department of Health and Care. In 1978, the JCAH and the American
Human Services (DHHS) validate JCAH findings College of Pathologists created a collaborative
and include an evaluation of its accreditation agreement for the evaluation of laboratories in
process in the department’s annual report to the hospitals, and in 1983, it began to accredit hospice
U.S. Congress. Today, 39 states and the District of care organizations as well.
Columbia have incorporated the Joint Commission’s During this period of growth, the Joint
hospital accreditation into their licensure pro- Commission established a Professional and Technical
grams. Although hospitals may be accredited, they Advisory Committee. The Committee’s role was to
must also remain in compliance with state hospital advise the Joint Commission on developing stan-
licensing statutes and regulations. dards and survey procedures. Through its Board of
The combination of voluntary, private-sector Commissioners, the Joint Commission is able to
accreditation and government regulation has served have close ties with health professionals and main-
to facilitate the quality assurance process by allowing tain its survey process and standards to reflect cur-
state governments to focus their enforcement efforts rent knowledge and practices.
and limited resources on “problem” facilities. With its expanded scope of endeavors in health-
Again in 1966, the JCAH standards had under- care, the JCAH formally changed its name to the
gone significant revisions to reflect optimal achiev- Joint Commission on Accreditation of Healthcare
able levels of quality rather than the minimum Organizations (JCAHO) in 1987.
levels of quality. The reason for this major decision
was that most hospitals had achieved or main-
Quality Assurance and Patient Safety
tained the minimal standards and were no longer
being challenged. Additionally, with the govern- With the development of the minimum standards
ment’s growing involvement in regulating hospi- by the ACS, for the first time hospitals were evalu-
tals through state licensure and the federal Medicare ated for the quality of care they provided. When
program, JCAH would have to define the optimal the Joint Commission took over hospital accredi-
achievable level of care if it were to remain at the tation, it continued to develop standards that
reviewed and evaluated hospital quality. For the Indicator Measurement System. Although this
most part, however, these evaluations were infor- project never came to fruition, it served as the
mal and often subjective. During this time, research predecessor and impetus for the new ORYX ini-
into more objective and valid criteria and system- tiative. With the growing scope of knowledge, the
atic review procedures for measuring quality were Joint Commission revised its original performance
being developed. This later formed the foundation measures and pursued a collaborative approach in
for the Joint Commission’s retrospective, outcome- the ORYX initiative.
oriented auditing practices that commenced in In 1997, the ORYX initiative for the first time
the 1970s. used performance and outcome measures in the
Standards were developed that evaluated the accreditation process that was applied to hospitals,
quality and appropriateness of care, including long-term care organizations, and healthcare net-
safety management, utilization review, and infec- works. ORYX was later expanded to include behav-
tion control. The Joint Commission also requested ioral healthcare and home care organizations.
that hospitals review the credentials in granting ORYX is a tool used by healthcare organiza-
clinical privileges to its medical staff. tions to evaluate their ongoing healthcare perfor-
While the Joint Commission focused on these mance and to inform them of their continuous
quality assurance efforts, hospital audits became quality improvement efforts. Initial policies called
more of a routine exercise to meet the Joint for accredited healthcare organizations to select
Commission’s standard requirements rather two of the approved measures. This information
than focusing on quality care, and therefore this was to be collected on monthly data points and
failed to meet its intended objective. In 1979, transmitted on a quarterly basis to an approved
the Joint Commission addressed this problem by performance measurement system. In July 2002,
developing a new systematic quality assurance the first ORYX measures on accredited hospitals
process that focused on hospital-wide assess- were collected. Today, hospitals are required to
ment activities, including the monitoring and select three core measure sets in order to satisfy
evaluation of all aspects of patient care and accreditation requirements. To reduce the burden
problem identification. of reporting requirements for hospitals, the Joint
Starting in the early 1990s, the Accreditation Commission worked with the Centers for Medicare
Manual for Hospitals began to be reorganized and Medicaid Services (CMS) and other entities to
around standards that emphasized performance standardize these core measures.
improvement concepts and later shifted to stan- Quality Check was established the same year as
dards that examined an organization’s actual per- ORYX, and it serves as a directory of accredited
formance rather than its capability to perform. organizations and performance reports available
Also during this time, the Joint Commission began for public use on the Joint Commission Web site.
to conduct random, unannounced surveys of 5% In 2004, the debut version of Quality Report
of its accredited organizations. became available to the general public, allowing
A sweeping revision to the accreditation pro- easy access to organization-specific data displayed
cess took place with the 1994 Agenda for Change. against comparative state and national data.
The Agenda for Change had as its centerpiece Aligned with its mission to improve the quality
integrating performance measurement into the of care, the Joint Commission established the
accreditation process to carry out the Joint Sentinel Events Policy in 1996 to review an orga-
Commission’s mission of continuously improving nization’s response to sentinel events during full
patient safety and quality of care. During the accreditation surveys and unannounced random
planning process of the Agenda for Change, the surveys. The Joint Commission defines a sentinel
Joint Commission was involved in the develop- event as an unexpected occurrence that involves
ment, testing, and implementation of standardized death or serious physical or psychological injury to
performance measures. As far back as 1986, the a patient. This policy was later revised to promote
Joint Commission established a set of performance self-reporting of medical errors and to identify the
measures that were to be collected from and trans- causes of these events. The Sentinel Events Policy
mitted to all accredited hospitals, known as the was later further modified so that organizations
Joint Commission 667
could request an on-site review instead of report- Another major part of this change is the Joint
ing the cause of the sentinel event due to litigation Commission’s unannounced surveys. The unan-
concerns. nounced survey of hospitals will occur every 18 to
In 2002, the Joint Commission established the 39 months after an organization’s first unan-
National Patient Safety Goals to promote spe- nounced visit. The Joint Commission will also
cific improvements in patient safety. These goals soon require periodic performance reviews of
represent problematic areas in healthcare. To healthcare organizations that involve conducting a
address these concerns, evidence and expert- self-assessment in between survey visits.
based solutions to these problems have been pre- The Joint Commission continues to evolve and
scribed. Some of the future goals of the Joint revise its standards to reflect changes in technol-
Commission include improved medication safety, ogy and advances in medical knowledge and best
communication by caregivers, and accuracy of practices. Its accreditation has come to be regarded
patient identification; risk reduction in healthcare- as a symbol of quality indicating that a healthcare
associated infections, surgical fires, patient falls, organization meets certain performance stan-
and the occurrence of influenza and pneumococ- dards. A healthcare organization must participate
cal disease in older adults who are institutional- in an on-site accreditation survey at least every 3
ized; prevention of healthcare-associated pressure years to earn and maintain the Gold Seal of
ulcers; organizational identification of safety Approval. The Joint Commission continues to be
risks in the patient population; involvement of at the forefront in developing new standards
patients in their own care; and implementation and initiatives to improve patient safety and
of relevant National Patient Safety Goals. healthcare quality.
Jared Lane K. Maeda
Present and Future Directions
See also Accreditation; Chassin, Mark R.; Codman,
Launched in 2004, “Shared Vision-New Pathways” Ernest Amory; National Patient Safety Goals; O’Leary,
ushered in fundamental revisions to the accredita- Dennis S.; ORYX Performance Measurement System;
tion process. The focus of this new accreditation Patient Safety: Quality of Healthcare
process is on organizational systems involved in
patient care and healthcare quality. The Joint
Commission’s new focus will be on the processes of Further Readings
patient care and the specific issues of a particular
healthcare organization. This is in response to DeLorenzo, Michele. “Shared Visions-New Pathways:
some healthcare organizations’ past practices of What to Expect at Year Next JCAHO Survey,”
Nursing Management 36(3): 26–30, March 2005.
“ramp-up” efforts to meet Joint Commission require
Franko, Frederick P. “The Important Role of the Joint
ments immediately preceding an on-site survey.
Commission,” AORN Journal 75(6): 1179–82, June
The term Shared Vision is the vision that the
2002.
Joint Commission and healthcare organizations
Joint Commission. “Fifty Years of Progress in Health
share on the quality of patient care. The “New
Care Quality and Safety,” Joint Commission
Pathways” are approaches to the accreditation pro- Perspectives 21(11): 1, 4–5, November 2001.
cess to achieve this shared vision. Some of the Joint Commission on Accreditation of Healthcare
modifications under the New Pathways approach Organizations. A History of the Joint Commission
include the consolidation of standards to reduce on Accreditation of Healthcare Organizations.
the amount of paperwork and documentation nec- Old Saybrook, CT: Greenwich Publishing Group,
essary and to focus on patient safety and quality 2001.
care, the transition from performance reports to Joint Commission on Accreditation of Hospitals.
quality reports, the periodic performance review Standards for Hospital Accreditation. Chicago: Joint
(PPR), which will make accreditation more of a Commission on Accreditation of Hospitals, 1953.
continuous and ongoing process, a patient “tracer” Joint Commission on Accreditation of Hospitals. 1970
methodology, and a customized focus of the on-site Accreditation Manual for Hospitals. Chicago: Joint
survey as directed by the priority focus process. Commission on Accreditation of Hospitals, 1971.
O’Leary, Dennis S. “The Joint Commission Looks to the Web Sites

Future,” Journal of the American Medical Association
258(7): 951–52, August 21, 1987. American College of Surgeons (ACS):
Roberts, James, Jack Coale, and Robert Redman. “A http://www.facs.org
History of the Joint Commission on Accreditation of Joint Commission: http://www.jointcommission.org
Hospitals,” Journal of the American Medical Joint Commission Resources (JCR): http://www.jcrinc.com
Association 258(7): 936–40, August 21, 1987. Quality Check: http:// www.qualitycheck.org
K
research-based evidence, and recommendations
Kaiser Family Foundation on various health topics, and it advocates for vul-
nerable populations. Much of its work relates to
The Henry J. Kaiser Family Foundation is a non- medically underserved populations such as low-
profit, private-operating foundation dedicated to income families, minorities, women, and people
providing information and analysis on healthcare living in developing countries.
issues and policy. It is an important source of facts
and analysis for policymakers, the media, the
healthcare community, and the general public.
Health Policy Programs
The foundation was established in 1948 by The Kaiser Family Foundation has six programs
Henry J. Kaiser and his wife, Bess, to meet the addressing U.S. healthcare policy: (1) Kaiser
unmet healthcare needs of the citizens of the Commission on Medicaid and the Uninsured,
United States. Its founder, Henry J. Kaiser, was a (2) Health Care Marketplace Project, (3) HIV
legendary American industrialist who completed Policy Program, (4) Medicare Policy Project,
massive construction projects such as the Hoover (5) Race/Ethnicity and Health Care Program, and
Dam and built Liberty ships during World War II (6) Women’s Health Policy Program.
and automobiles after the war. In healthcare, he Begun in 1991, the Kaiser Commission on
pioneered the idea for the Kaiser Permanente Medicaid and the Uninsured is the largest operat-
HMO, which became the model for health mainte- ing program of the foundation. The commission
nance organizations (HMOs) nationwide. focuses on healthcare policy and research regard-
Headquartered in Menlo Park, California, with ing low-income families. It examines how Medicaid
an additional office in Washington, D.C., the and the State Children’s Health Insurance Program
Kaiser Family Foundation funds its own research (SCHIP) work and the corresponding issues facing
and communication programs, sometimes in part- uninsured individuals and families.
nership with other research organizations or major The Healthcare Marketplace Project examines
media companies. Working with an annual budget the trends and determinants of the nation’s health-
of over $40 million, the foundation operates inde- care economy. The project provides resources for
pendently. This independence allows it to provide employer health programs, including information
information on a nonpartisan basis. about health insurance, the pharmaceutical indus-
Although most of the Kaiser Family Foun try, and healthcare costs.
dation’s work concentrates on healthcare issues The foundation’s HIV Policy Program addresses
in the United States, in recent years, it has the costs of treatment, the effectiveness of preven-
expanded its scope to include global health issues. tion methods, and the political atmosphere sur-
The foundation provides up-to-date information, rounding the disease. The program conducts
669
670 Kaiser Family Foundation
research and shares the most recent information The foundation’s Program for the Study of
about HIV/AIDS, including changes in public Entertainment Media and Health studies the
opinions, policies, and laws. media’s impact on young people. Its work includes
The Medicare Policy Project provides resources, an examination of food advertising to children, sex
statistics, and analysis concerning that federal and violence on television, and how youth in the
healthcare program. As the American public ages, a 21st century use media devices. The analysis of this
growing number of individuals are using Medicare. research is used to develop policy and plan com-
The project offers comparisons of various Medicare munity health education programs. In addition to
plans and descriptions of benefits, including the new studying the media, the foundation often partners
prescription drugs component. The resources pro- with news media organizations on issues related to
vided by the project assist people in understanding health policy. The foundation currently maintains
and navigating this complicated benefits program. partnerships with USA TODAY, The Washington
The Race/Ethnicity and Health Care Program Post, the San Jose Mercury News, and XM satellite
addresses health disparities and the difference in radio.
health status among people of color. The program Through its Public Opinion and Media Research
conducts research on issues related to access to Program, the foundation regularly conducts public
care, especially quality healthcare, and recognizes opinion polls that survey people’s experiences with
that public policy is an influential factor in reduc- the nation’s healthcare system and determines
ing health disparities. their views on specific health topics. Results from
The Women’s Health Policy Program focuses the polls are made available through the founda-
on the complex issues relating to women’s health. tion’s publications and on their Web sites.
It focuses on reproductive health issues, maternal The Kaiser Family Foundation Websites pro-
and child health, and the health needs of uninsured gram attempts to keep people informed through its
women. many Web sites. For example, the Kaiser Network
is a source of information for health news. The
network collects health news stories from around
Media and Public Education Programs
the world and offers daily summaries to consumers
The Kaiser Family Foundation has five media and through e-mail subscriptions and Web sites. These
public education programs: (1) Entertainment daily reports cover topics including health policy,
Media Partnership, (2) Media Fellowship and HIV/AIDS, women’s health policy, and health dis-
Internship Programs, (3) Program for the Study parities. On the Kaiser Network Web site, viewers
of Entertainment Media and Health, (4) Public will find headlines featuring top health stories and
Opinion and Media Research Program, and links to entire articles. The Web site also provides
(5) Kaiser Family Foundation Web sites. comprehensive information on a particular health
Through its Entertainment Media Partnerships, issue in its “Issue Spotlight” section. Viewers may
the foundation conducts several public health also search archives containing 65 years of health
information campaigns. Current campaigns pro- opinion polls. The Kaiser Network also provides
vide messages to young people about HIV/AIDS an archive of HealthCasts. Webcast technology
and other sexually transmitted diseases. Media allows the foundation to broadcast events online
partners involved in these campaigns include and archive the products so that consumers may
MTV, Viacom, BET, Univision, and Fox. In addi- access the resources at a later date. Meetings, con-
tion, the foundation coordinates a public health ferences, workshops, and other professional devel-
information campaign in South Africa. opment events related to health care and health
The foundation’s Media Fellowships and policy are examples of the types of HealthCasts
Internships Programs offer fellowships and intern- available through the Kaiser Network.
ships to journalists interested in health policy The foundation’s State Health Facts Web site
news. These programs help inform and develop provides health statistics and information for each
journalists’ understanding of health policy topics. of the 50 states in the nation. Data provided on
The foundation also offers several resources and this site are collected from a variety of public and
tools for journalists’ professional development. private sources. Information about more than 500
Kane, Robert L. 671
health topics is available on this Web site. Viewers Ross, Donna Cohen, Aleya Horn, and Caryn Marks.
may research health data by individual state or Health Coverage for Children and Families in
make comparisons among states with the resources Medicaid and SCHIP: State Efforts Face New
available on this site. Examples of categories fea- Hurdles. Menlo Park, CA: Henry J. Kaiser Family
tured on the State Health Facts site include state Foundation, 2008.
demographics, economy, health status of the Salganicoff, Alina, Usha R. Ranji, and Roberta Wyn.
population, health coverage and the uninsured, Women and Health Care: A National Profile. Menlo
Medicaid and SCHIP, health costs and budgets, Park, CA: Henry J. Kaiser Family Foundation, 2006.
Medicare, managed care and health insurance,
minority health, women’s health, and HIV/AIDS.
KaiserEDU.org is a foundation initiative that Web Sites
coordinates several resources and tools for stu- Henry J. Kaiser Family Foundation (KFF):
dents, faculty, and others. Information and data http://www.kff.org
about the health topics addressed by the founda- Kaiser EDU: http://www.Kaiseredu.org
tion are provided. University faculty have the Kaiser Network: http://www.kaisernetwork.org
opportunity to share course outlines using the Sylla State Health Facts: http://www.statehealthfacts.org
bus Library function on the Web site. The founda-
tion makes available the Table of Contents of
several major health journals and provides several
research tools. Three online tutorials are available Kane, Robert L.
that provide information about collecting and ana-
lyzing data. The foundation has created a health Robert L. Kane is a highly regarded expert in the
video library through KaiserEDU.org. This online field of aging and long-term care. Kane holds an
library contains links to original producers of endowed chair in long-term care and aging and is
health videos and documentaries. The foundation a professor at the University of Minnesota School
does not loan videos; however, it directs viewers to of Public Health in the Department of Health
the production source so that they may obtain it Policy and Management. He also directs the
on their own. The health video library serves as a Center on Aging and the Minnesota Geriatric
clearinghouse as to what type of information is Education Center and codirects the Clinical
available. Outcomes Research Center at the University of
Minnesota. In addition, he directs an evidence-
Kristin Hartsaw based practice center funded by the Agency for
Healthcare Research and Quality (AHRQ).
See also Altman, Drew E.; Health Insurance; Medicaid;
Medicare; Public Policy; Uninsured Individuals;
Kane has received numerous awards and hon-
Vulnerable Populations; Women’s Health Issues ors throughout his long career, including the
President’s Award from the American Society on
Aging, the Polisher Award from the Gerontological
Further Readings Society America, and the Enrico Greppi Prize from
the Italian Society of Gerontology and Geriatrics.
Cara, James, Megan Thomas, Marsha Lillie-Blanton, et al.
He has conducted numerous studies on the out-
Key Facts: Race, Ethnicity and Medical Care. Menlo
Park, CA: Henry J. Kaiser Family Foundation, 2007.
come of care and the organization of care, with an
Henry J. Kaiser Family Foundation. Health Care Costs: emphasis on the care of the elderly and those need-
A Primer. Menlo Park, CA: Henry J. Kaiser Family ing long-term care. Kane has served on the World
Foundation, 2007. Health Organization’s (WHO’s) Expert Committee
Henry J. Kaiser Family Foundation. Medicare: A Primer. on Aging. He has authored or edited more than 30
Menlo Park, CA: Henry J. Kaiser Family Foundation, books and 350 journal articles and book chapters
2007. on the topics of health services research, geriatrics,
Henry J. Kaiser Family Foundation. The Uninsured: A and long-term care.
Primer. Menlo Park, CA: Henry J. Kaiser Family Kane earned his bachelor’s degree from
Foundation, 2007. Columbia College in 1961 and his medical degree
672 Katz, Sidney
from Harvard Medical School in 1965. He did his Kane, Robert L., Reinhard Priester, and Annette M.
medical internship, followed by a residency in Totten. Meeting the Challenges of Chronic Illness.
community medicine, at the University of Kentucky Baltimore: Johns Hopkins University Press, 2005.
Medical Center. Kane, Robert L., and Joan C. West. It Shouldn’t Be This
He began his career in 1968 as an acting coordi- Way: The Failure of Long-Term Care. Nashville, TN:
nator in the Senior Clerkship Program at the Vanderbilt University Press, 2005.
University of Kentucky in the Department of
Community Medicine. He then went on to serve in
the U.S. Public Health Service (PHS) as a service unit Web Sites
coordinator and as special assistant to the Regional Professionals with Personal Experience in Chronic Care
Health Director. In 1970, Kane was appointed as an (PPECC): http://www.ppecc.org
assistant professor and later as an associate professor University of Minnesota School of Public Health,
in the Department of Family and Community Department of Health Policy & Management Faculty
Medicine at the University of Utah School of Profile: http://www.hpm.umn.edu/People/regular/
Medicine. After leaving the University of Utah in kane_Robert/Kane_Robert.htm
1977, he went to the RAND Corporation as a senior
researcher and later joined the faculty of the University
of California at Los Angeles (UCLA). Following this,
Kane served as dean of the University of Minnesota Katz, Sidney
School of Public Health from 1985 to 1990 and then
in his current position as a professor. Sidney Katz is a Distinguished Scholar at the
Kane’s current research addresses the outcomes Benjamin Rose Institute in Cleveland, Ohio, and
of acute and long-term care with a focus on the Professor Emeritus of Geriatric Medicine and
effects of hospital and posthospital care while Codirector of the Stroud Center on Scientific
examining methods to better deliver chronic care. Studies of Quality of Life at Columbia University
He has published a book, It Shouldn’t Be This in New York City. His background is in medicine,
Way, with his sister, Joan West, about the personal epidemiology, and health services research, with a
difficulties encountered in obtaining long-term focus on rehabilitation, the natural course of
care for their mother. Kane also formed a national aging and chronic disease, long-term care, and
advocacy group, Professionals with Personal quality of life.
Experience in Chronic Care (PPECC), to put long- Katz has made a number of significant contribu-
term care and chronic disease on the political tions to geriatrics and health services research. He
agenda by drawing on the experiences of health- was one of the leading champions of the develop-
care professionals in the field. ment of the field of geriatric care. In addition, he was
one of the earliest proponents of the idea that the
Jared Lane K. Maeda goal of treatment for persons with chronic illness
See also Chronic Care Model; Evidence-Based Medicine was improving their quality of life. In his research,
(EBM); Long-Term Care; Nursing Home Quality; Katz moved away from focusing only on disease
Nursing Homes; Outcomes Movement; Quality of diagnoses to examining the interaction and impact
Healthcare of multiple chronic diseases. Furthermore, he argued
that functional status was a more useful measure of
total disease burden and an important indicator of
Further Readings service quality and quality of life. Moreover, Katz
Kane, Robert L., and Rosalie A. Kane. Assessing Older led the team that developed the first indices of
Persons: Measures, Meaning, and Practical activities of daily living (ADLs) to measure changes
Applications. New York: Oxford University in physical function. His work emphasized the cen-
Press, 2003. trality of physical function in the field of geriatrics
Kane, Robert L., Joseph G. Ouslander, and Itamar B. and health services research and yielded a relatively
Abrass. Essentials of Clinical Geriatrics. 5th ed. New precise, standardized measure of physical function-
York: McGraw-Hill, 2003. ing. The Katz Index of ADLs clarified the hierarchal
Katz, Sidney 673
nature of functional limitations and became pivotal philosophy of OBRA-87, with its focus on resi-
in the development of measures of outcome quality dent-centered care, provided considerable support
in rehabilitative and long-term care. for the current move emphasizing culture change
Born in Cleveland, Ohio, Katz earned a bache- in nursing homes.
lor’s degree in general sciences (1944) and a medi- Katz has been recognized for his service and
cal degree from Case Western Reserve University research in a number of ways, including receiving
(1948). He attended the Walter Reed Army Medical the Bronze Star for his service in a Mobile Army
Service graduate school and received a master’s Surgical Hospital in the Korean War. He is listed in
degree (1984) in medical sciences from Brown Who’s Who in Health Care and has received a
University. Over the course of his long and distin- number of awards and honors, including the
guished career, Katz has been a U.S. Navy corps- Lifetime of Caring Award from the American
man in World War II, a professor in the School of Geriatrics Society’s Foundation for Health and
Medicine at Case Western Reserve University, an Aging. Brown University established an honorary
army physician in Korea, a department chair in the lectureship in his name, Columbia University
College of Medicine at Michigan State University, awarded him its Medal of Excellence in Scholarship
and associate dean of Medicine at Brown University. and an Award for Excellence in Health Policy
In 1986, he founded Brown’s Center for Gerontology Research in Geriatrics and Gerontology, and the
and Health Care Research, which for more than 20 Benjamin Rose Institute established the Katz Policy
years has carried out his vision of emphasizing Institute in his honor. He also has been recognized
multidisciplinary research in training clinicians, by the Gerontological Society of America, receiving
behavioral scientists, and statisticians in health the Maxwell Pollack Award for Productive Aging
services research with an emphasis on geriatrics, for research that directly improved policy or prac-
gerontology, and chronic disease management. tice and the Donald P. Kent Award for exemplify-
Katz has been a champion for improving the ing the highest standards of professional leadership
range and quality of long-term care services avail- in gerontology through teaching and service.
able to older persons in their homes, communities,
and long-term care facilities, and he has been an Catherine Hawes
advisor to national and world leaders. As a mem- See also Activities of Daily Living (ADL) Scale; Long-
ber of the national Institute of Medicine (IOM), he Term Care; Institute of Medicine (IOM); Nursing
has served on many committees aimed at improv- Homes; Nursing-Home Quality
ing healthcare quality, but his most distinguished
service came as chair of the IOM Committee on
Nursing Home Regulation. This Committee’s rec-
Further Readings
ommendations were largely adopted by the U.S.
Congress in the nursing-home reforms contained Committee on Nursing Home Regulation, Institute of
in the Omnibus Budget Reconciliation Act of 1987 Medicine. Improving the Quality of Care in Nursing
(OBRA-87). OBRA-87 was the most fundamental Homes. Washington, DC: National Academies Press,
reform of federal nursing-home standards since the 1986.
passage of the Medicare and Medicaid programs Katz, Sidney, Amasa B. Ford, Roland W. Moskowitz,
and specified a new model of nursing-home care et al. “Studies of Illness in the Aged. The Index of ADL:
that included uniform resident assessment, A Standardized Measure of Biological and Psychosocial
Function,” Journal of the American Medical
increased attention to residents’ rights and quality
Association 185(12): 914–19, September 21, 1963.
of life, a revised process for inspecting nursing
homes, and a range of enforcement remedies. The
IOM committee’s recommendations, as incorpo-
rated in OBRA-87, were resident centered and Web Sites
outcome focused, shifting regulators from atten- Benjamin Rose Institute: http://www.benrose.org
tion to paper compliance with regulations to a Brown University, Center for Gerontology and Health
focus on the real care and quality of life experi- Care Research: http://www.chcr.brown.edu/
enced by nursing-home residents. Furthermore, the postdocFrameset.htm
674 Kellogg Foundation
Background
Kellogg Foundation
By its 25th anniversary in 1955, the Kellogg
The W. K. Kellogg Foundation located in Battle Foundation’s assets stood at $124 million. From
Creek, Michigan, has been funding community- an annual payout of $26,000 in 1930, it was now
based approaches to health and well-being since able to give $4.4 million. In 1980, its 50th anni-
its inception in 1930. Established by Will Keith versary year, the foundation made grants of more
Kellogg (1860–1951), the founder of a global than $52 million. In 2005, its 75th anniversary
ready-to-eat cereal company and one of the year, its assets had grown to $6 billion, and its
world’s largest philanthropists, it was originally annual grant making totaled $243 million. As of
named the W. K. Kellogg Child Welfare Foun August 2007, the foundation’s assets were over
dation and focused its attention on the health $8.4 billion.
needs of children living in Michigan’s rural com- A review of the Kellogg Foundation’s first
munities by providing hearing tests, eye exams, decade sheds light on its operations over history.
immunizations, and school lunches under the Most activities during the 1930s were directed
aegis of its Michigan Community Health Project toward filling the gaps in service resulting from the
(MCHP). Since that time, the foundation has financial hardships and community dislocations
provided seed funding and ongoing support for caused by the Great Depression. Even during these
education, service, and research in public health, early years, the foundation showed its commit-
including food security and health professions ment to innovative solutions to public health prob-
education, as well as agriculture and community lems, most notably by hiring Margarite Wales as
development. In keeping with Kellogg’s intention nursing director. Wales had experience in the land-
to use a portion of his fortune to help people mark Henry Street Settlement House, widely
help themselves, its priorities have consistently regarded as having given birth to the discipline of
leaned toward empowerment strategies and sus- public health nursing while improving neighbor-
tainable development. In recent years, it has hood conditions and the personal health of resi-
diversified its funding, directing more money dents of New York City’s Lower East Side. The
toward projects in the developing world, partic- foundation’s commitment to nursing continues to
ularly Southern Africa (10% of total giving in this day.
2006) and Latin America (8% of total giving in By the middle of its first decade, the foundation
2006). had established its first graduate medical educa-
The Kellogg Foundation’s mission is to help tion program, awarding fellowships to U.S. and
people help themselves through the practical Canadian physicians. Its commitment to health
application of knowledge and resources to professions education was further demonstrated
improve their quality of life and that of future later in the decade, when, in 1939, it made a grant
generations. In 2007, the foundation refined its to the University of Michigan to establish the
mission to focus more closely on vulnerable chil- Institute of Graduate and Post-Graduate Dentistry,
dren. Its operations are rooted in several core designed to provide continuing education for
values, including fidelity to the spirit and intent dentists in the community. In the early 1940s,
of its founder, a belief that individuals have an the Kellogg Foundation, with the Rockefeller
inherent capacity to effect change in their lives, Foundation, helped build the University of
organizations, and communities and that inno- Michigan School of Public Health; this is the first
vativeness in thoughts and action leads to endur- instance of another foundation tradition: using its
ing and positive change in both formal and resources to leverage even greater resources.
informal systems. The foundation operates under In addition to funding health profession educa-
the guiding principles of partnership, empower- tion, in 1938, the Kellogg Foundation began fund-
ment, and community development. Throughout ing Michigan State University to develop and host
its history, this orientation has influenced short agricultural education courses for young
its role in public health and health services people from Michigan’s farm communities. The
research. foundation funds similar programs to this day.
Kellogg Foundation 675
Activities in the spirit of helping people help Pursing Community-Based Approaches

themselves can be traced back to the foundation’s
Many examples of health-related community-
early history. From 1931 to 1948, the foundation
oriented approaches have already been discussed.
supported the Michigan Community Health Project
The foundation’s community-oriented strategy
in seven Michigan counties. This comprehensive
touches other program areas as well. For example,
community development project consolidated rural
in 1997, the Kellogg Foundation launched its Mid-
schools, built hospitals and health departments,
South Delta Initiative connecting 55 counties in
and encouraged volunteers to deliver essential ser-
Arkansas, Louisiana, and Mississippi in commu-
vices. In 1938, the foundation conducted a poll of
nity-based efforts to strengthen regional economic
the counties that were participating in the project to
opportunities. This multifaceted program of techni-
determine if residents found it beneficial and would
cal assistance, business loan guarantees, and home
be willing to be taxed in order to continue it. The
ownership programs positioned the foundation to
answer was a resounding “yes,” which reflected the
make substantial contributions to Hurricane Katrina
popularity of the services and the level of commu-
relief. Katrina-related giving played a major role in
nity commitment and willingness to support it.
foundation programs for several years.
Enduring Themes Employing Empowerment Strategies

These themes—serving underserved communities, The Mid-South Delta Initiative is one of many
pursuing community-based approaches, employ- Kellogg Foundation–funded projects that employed
ing empowerment strategies, enhancing commu- a local empowerment strategy. The foundation
nity-based learning opportunities for health funded the Pathways to Collaboration project,
professionals, financing research on agriculture, organized by the Center for the Advancement of
and funding innovative approaches to recognized Collaborative Strategies in Health at the New
public health problems—guide the foundation to York Academy of Medicine, and provided multi-
this day. year funding for seven partnerships around the
nation to address local issues through community-
Serving Underserved Communities driven collaboration.
Over the past 15 years, the Kellogg Foundation

Enhancing Community-Based Learning
has addressed a number of issues that affect U.S.
Opportunities for Health Professionals
communities experiencing impaired access to
healthcare, disinvestment in public health infra- Investment in health professions education has
structure, and educational disadvantage. In 1998, been a core activity of the foundation. Innovations
responding to the increasing number of Americans include funding National Medical Fellowships,
lacking health insurance, the foundation launched Inc. to develop a pool of qualified students to enter
its Community Voices Initiative: Health Care for health professions education for careers in com-
the Underserved to sustain safety net providers munity-based health services by building partner-
through partnerships with community health and ships with communities. During the 1990s, three
human service providers. Community Voices is multiyear health initiatives—Community Partner
national in scope and is managed by the National ships for Health Professions Education, Graduate
Center for Primary Care (NCPC) at the Morehouse Nursing and Medical Education, and Community-
School of Medicine. In addition to providing fund- Based Public Health—were launched. These three
ing for at-risk safety net providers, the foundation programs shared a strategic interest in helping to
continues to provide direct service in communities make systems more responsive to the needs of
of dire need. As an example, the School-Based people in the community. At the same time, the
Health Care Policy Program, a 5-year effort begun foundation invested in a series of other projects,
in 2004, was designed to provide school-based known as Community Partnerships, to redirect
health throughout the United States using a con- health professions education toward community-
sumer-centered model of quality care. based primary care. Taken together, these projects
676 Kellogg Foundation
provided millions of dollars to health professions Centers for Disease Control and Prevention
schools and their community partners, training (CDC), the national Institute of Medicine (IOM),
many public health professionals and primary-care the American Public Health Association (APHA),
professionals (nurses and physicians) to practice in the National Conference of State Legislatures, the
community-based settings and actively engaging National Association of Local Boards of Health,
their communities in setting priorities toward and the National Association of County and City
achieving healthier communities and individuals. Health Officials (NACCHO). Turning Point
During the same period, the foundation invested in addressed a myriad of issues and responded to the
many of the U.S. Historically Black Colleges and changing priorities after the September 11, 2001,
Universities, allowing them to reshape their curri- terrorist attacks, creating collaborative structures
cula in an effort to increase the number of minority for preparedness, including bioterrorism. During
applicants to graduate education. 1996–2002, the foundation funded 41 local pub-
lic health departments in 14 states to engage in
strategic planning and policy development using
Financing Research on Agriculture
an inclusive, collaborative approach. Most sig-
The Kellogg Foundation invests in primary nificantly, a model public health act was pub-
research on foodstuffs and agricultural practices. lished in 2003 and has been used as a template
Launched in 2000, its Food and Society Initiative for public health law reform efforts in a number
is designed to ensure access to a food supply that of states.
is safe and nutritious and grown in a manner that
protects the environment while adding economic
and social value to rural and urban communities. International Programming
In keeping with its orientation toward investment In 1937, two Montreal physicians were awarded
in the future, it is also funding Iowa State University Kellogg fellowships, beginning the foundation’s
to revise Iowa’s education programs in order to work outside the United States. Upon his retire-
prepare food system professionals to meet the ment in 1938, Kellogg spent a significant amount
emerging needs of the agriculture sector of the of time in Mexico, thus beginning the founda-
economy. The foundation also supports various tion’s interest in Latin America. In 1941, nine
environmental projects, including groundwater physicians from Chile came to Battle Creek, a visit
protection and remediation. In the 1990s, the that resulted in a health professions fellowship
Integrated Farming Systems Initiative funded 18 program that brought over 200 Latin American
projects to build demonstrations of viable agricul- health professionals to the United States between
tural systems that also ensure protection of the 1941 and 1945. The foundation has maintained a
environment. Projects include the central Ohio programmatic focus in Latin America since that
Darby Creek Watershed, a successful collabora- time. Starting in 1985, the foundation funded the
tion between local farmers, environmentalists, and Integrated Health Program at Federal University
the Nature Conservancy. of Ceara in Fortaleza, Brazil. This program cre-
ated a network of hospitals and clinics linked to
the university to improve care in communities and
Funding Innovative Approaches to
broaden the training of health professionals.
Recognized Public Health Problems
Today, the foundation maintains an office in Latin
In 1996, the Kellogg Foundation launched the America and funds health professions education,
Turning Point Initiative to improve public health public health initiatives, and community develop-
nationwide through the development of commu- ment projects in many Latin American countries.
nity-based public-private partnerships. This ambi- In 1985, the Kellogg Foundation began to fund
tious project, undertaken in collaboration with programs in Africa. Since that time, it has funded
the Robert Wood Johnson Foundation, set out to direct service, educational scholarships, health
change the basic framework and infrastructure of professions training, and community partner-
public health through a collaborative process that ships. After the fall of apartheid in South Africa,
engaged a wide-range of partners, including the the foundation decided to refocus its African
Kellogg Foundation 677
priorities. Using the community participatory including strengthening access to healthcare,

approach it has espoused throughout its history, promoting policy development that supports
the foundation conducted a thorough program healthy communities and individuals, and pro-
review, meeting with hundreds of community moting social change at the systems level, require
members, professionals, and policymakers across extensive research and evaluation components. In
southern Africa. Ten demonstration sites were recent years, its efforts to encourage community-
developed in rural areas with a programmatic oriented health professions education have pro-
focus on civic engagement, economic opportu- duced research findings of importance to the
nity, skills and leadership development, and discipline of health services research. The Turning
health and well-being. Today, funding for health Point Initiative has directed funding toward policy
professions education continues, and a regional development, bioterrorism, and preparedness
office, staffed by Africans, currently operates in research at local, county, and state levels. There
South Africa. is every reason to expect the W. K. Kellogg
Foundation to continue to play an important role
in these areas.
Funding Priorities
Judith V. Sayad
Information regarding the foundation’s current
funding priorities is available on the foundation’s See also Access to Healthcare; Association of
Web site. Funding is available through specific University Programs in Health Administration
requests for proposals as well as unsolicited (AUPHA); Community Health; Nurses; Primary
responses to general funding guidelines; most Care; Public Health; Safety Net; Uninsured
Individuals
often, the foundation prefers a short preproposal
when responding to general guidelines. It will con-
sider a wide range of activities that support its
Further Readings
stated mission and goals. Requests can include
funding for research, operational expenses for W. K. Kellogg Foundation. Health Care Partnership:
established programs, capital requests, loans, Meeting the Needs of Underserved Communities
equipment, conferences, media projects, endow- Around the World. Battle Creek, MI: W. K. Kellogg
ments, and development campaigns when these Foundation, 1997.
requests are part of a broader program and/or W. K. Kellogg Foundation. Informing State Policy: Five
funding effort. Program-planning grants and study Communication Strategies for Community Advocates
proposals may also be considered when tied to and Leaders. Battle Creek, MI: W. K. Kellogg
specific projects in line with the foundation’s pri- Foundation, 2000.
W. K. Kellogg Foundation. Changing Heart, Changing
orities. In keeping with its philosophy of helping
Mind: The Social and Economic Determinants of the
people help themselves, provisions to ensure proj-
Public’s Health. Battle Creek, MI: W. K. Kellogg
ect sustainability after funding ends are critical for
Foundation, 2001.
a successful proposal.
W. K. Kellogg Foundation. The Social and Economic
Determinants of the Public’s Health. Battle Creek,
MI: W. K. Kellogg Foundation, 2002.
Impact on Health Services Research W. K. Kellogg Foundation. Exploding Myths, Finding
The Kellogg Foundation’s commitment to health Solutions to the World’s Health Care Crisis. Battle
and well-being has been consistent throughout its Creek, MI: W. K. Kellogg Foundation, 2003.
history. This has included funding for direct ser- W. K. Kellogg Foundation. Restoring the Dream: W. K.
vice, health professions education, and policy ini- Kellogg Foundation 2006 Annual Report. Battle
tiatives. Traditionally, it has supported research Creek, MI: W. K. Kellogg Foundation, 2006.
not as an end in itself but as a vital part of accom-
plishing these other goals; the same can be said
Web Sites
regarding specific medical conditions such as
tuberculosis or HIV. Many of their priorities, W. K. Kellogg Foundation (WKKF): http://www.wkkf.org
678 Kimball, Justin Ford
teachers were enrolled in the plan. Within 5 years,

Kimball, Justin Ford the “Baylor Plan” provided health insurance cov-
erage for some 408 diverse employee groups, total-
Justin Ford Kimball (1872–1956) was an educator ing 23,000 members, eventually covering 3 million
and healthcare insurance pioneer and innovator, people within a decade. By 1933, the American
credited with founding the first health insurance Hospital Association (AHA) started regulating and
plan in the nation, which would ultimately become approving similar prepayment plans, and the Blue
Blue Cross and Blue Shield. Kimball was born on Cross symbol, a blue Geneva cross known as a
a farm near Huntsville, Texas, in 1872. In 1890, universal symbol of healthcare, came into use the
he earned an undergraduate degree from Mount following year. During 1944, the Baylor Plan
Lebanon College in Louisiana, and in 1899, he merged into what would become one of the
received a master’s degree from Baylor University. nation’s Blue Cross and Blue Shield plans.
Kimball undertook postgraduate work at the In 1939, Kimball, who was 67 year old, retired
University of Chicago and attended law school at from Baylor University, but he remained active as
the University of Michigan. He subsequently a lecturer. He served on the Dallas civil service
worked as a teacher, principal, and superinten- commission and from 1949 to 1952 was a member
dent in schools in Louisiana and Texas. Beginning of the Texas State Board of Education. He died at
in 1902, he practiced law but returned to educa- his Dallas home in 1956.
tional leadership in 1905. After his death, the American Hospital Association
Kimball proved to be an exceptional admin- (AHA) established the Justin Ford Kimball
istrator, and in 1914, he became Superintendent Innovators Award in his honor. The award recog-
of Public Schools in Dallas, Texas. He held that nizes individuals who make innovative contribu-
position until 1924, when ill health forced tions in bringing together healthcare delivery and
him to resign. After his resignation, Kimball financing.
remained active as a lecturer and speaker, even-
tually joining the faculty of Southern Methodist David J. Ballard and Robert S. Hopkins, III
University in 1925 as a professor of education.
In 1929, he became vice president of Baylor See also American Hospital Association (AHA); Blue
University, in charge of the Colleges of Medicine Cross and Blue Shield; Health Insurance; Health
and Dentistry, School of Nursing, and the Insurance Coverage
University Hospital in Dallas to provide over-
sight of the university’s medical education and
“to shore up the shaky finances” of Baylor Further Readings
University Hospital.
Kimball found that a large share of Baylor Anderson, Odin W. Blue Cross Since 1929:
Accountability and the Public Trust. Cambridge, MA:
University Hospital’s unpaid bills were from Dallas
Ballinger, 1975.
schoolteachers. In 1929, almost concurrently with
Cunningham, Robert, III, and Robert M. Cunningham
the great stock market crash that sparked the
Jr. The Blues: A History of the Blue Cross and Blue
Great Depression, he developed a not-for-profit
Shield System. De Kalb: Northern Illinois University
insurance plan whereby Dallas schoolteachers Press, 1997.
could prepay, at 50 cents a month, or $6.00 a year,
for 21 days of inpatient care in a semiprivate room
at Baylor Hospital. The plan would take effect
after a patient’s first week in the hospital, with Web Sites
payments being $5.00 a day. On its first day of American Hospital Association (AHA): http://www.aha.org
subscription, 1,356 teachers signed up for the Blue Cross and Blue Shield Association (BCBSA):
plan, and by December 1929, 75% of Dallas http://www.bcbs.com/about/history/1920s.html
L
safety and quality by rewarding hospitals that
Leapfrog Group implemented substantial changes. In 2000, BRT
set aside funding, and the Leapfrog Group was
The Leapfrog Group is an initiative that was officially created.
started by large employers that purchase health- The Leapfrog Group has a growing consortium
care. Leapfrog works to create breakthroughs in that includes many of the nation’s largest corpora-
the safety, quality, and affordability of healthcare. tions and other large purchasers of healthcare that
It is supported through its membership base, as provide benefits to more than 37 million individu-
well as the Business Roundtable (BRT), the Robert als across the country. Member organizations of
Wood Johnson Foundation (RWJF), and others. Leapfrog agree to make their healthcare-purchasing
The mission of the Leapfrog Group is to facilitate decisions with the goal of encouraging quality
enormous leaps forward in the safety, quality, and improvement among the providers and consumers
affordability of healthcare by supporting informed involved. Leapfrog estimates that if all hospitals in
healthcare decisions of purchasers and consumers the nation implemented its first three leaps of rec-
and by promoting healthcare that is high in value ommended safety and quality practices, more than
by realigning incentives and rewards. 65,000 lives could be saved, more than 907,000
medical errors could be prevented, and about
$41.5 billion could be saved annually.
Background
In 1998, a consortium of large employers began to
discuss how they could collaborate and use their
Initiatives
purchasing power to influence the quality and The Leapfrog Group is well-known for its Hospital
affordability of healthcare. These employers real- Quality and Safety Survey, which is conducted
ized that billions of dollars were being spent on annually and completed by hospitals on a volun-
healthcare without any evaluation of its quality or tary basis. The survey measures hospital perfor-
its providers. A 2000 national Institute of Medicine mance on the use of computer physician order
(IOM) report, To Err Is Human: Building a Safer entry, evidence-based hospital referral, intensive
Health System, estimated that as many as 98,000 care unit staffing by physicians experienced in
hospital patients die each year from preventable critical care medicine, and the Leapfrog safe prac-
medical errors. The report recommended that tices score. Leapfrog’s survey goals are based on
large employers could use their market leverage to the following criteria: There is substantial scien-
influence the quality and safety of healthcare. The tific evidence that the safety and quality practices
founders of Leapfrog recognized that significant can significantly reduce preventable medical errors;
“leaps” forward could be taken to improve patient the implementation of these practices is feasible;
679
680 Leapfrog Group
consumers can readily benefit from these practices; hold health plans accountable for implementing
and health plans, purchasers, and consumers can the purchasing principles of Leapfrog; and build
readily distinguish if these practices are present or the support of consultants and brokers to use
absent in selecting their healthcare provider. Leapfrog’s principles with their clients.
In 2008, the survey integrated the first set of To promote these purchasing principles, the
hospital efficiency measures using standardized Leapfrog Hospital Rewards Program, a pay-for-
measures from the Joint Commission. The survey performance program, was launched in 2005 to
also serves as the basis for Leapfrog’s Hospital drive improvements in hospital quality and effi-
Rewards Program, a pay-for-performance pro- ciency for five clinical conditions by rewarding
gram that assesses the value of patient care by hospitals that demonstrated excellence in sustaining
measuring performance along two dimensions— improvements. The five clinical conditions are
the quality of the care hospitals provide and how (1) coronary artery bypass graft, (2) percutaneous
efficiently they deliver it. coronary intervention, (3) acute myocardial infarc-
To fuel the drive toward value-driven health tion, (4) community-acquired pneumonia, and
care, Leapfrog developed the Incentive and Reward (5) deliveries/neonatal care. The efficiency measure
Compendium, a free database that categorizes and applies a regional price adjuster to the average reim-
describes financial programs—such as those that bursement a hospital receives for a given condition.
reward providers with quality bonuses—and non-
financial programs—such as those that reward
Current Issues
providers with public recognition. These programs
aim to affect hospitals, physicians, health plans, Beginning in June 2001, the Leapfrog Group
and/or consumers. began collecting data on hospitals by surveying
Bridges to Excellence and The Leapfrog Group urban and suburban hospitals in six geographic
have also formed a partnership to use the strengths regions, which has now grown to 33 regions. The
of each organization to develop and implement survey of the 33 regions covers more than 1,300
programs that reward healthcare providers. hospitals. These hospitals represent about 58% of
Leapfrog lends its expertise in performance mea- all hospital beds in the nation, and they serve over
sures and public reporting, while Bridges to half of the population of the nation. Free access to
Excellence contributes its knowledge of imple- the ratings of these hospitals can be found at
menting programs that reward healthcare provid- Leapfrog’s Web site.
ers for quality improvement. The Leapfrog Group continues to advocate for
change by improving the quality and safety of
patient care through its member organizations’
Purchasing Principles
purchasing power. Leapfrog’s efforts have become
Leapfrog works to create improvements in the a driving force in transforming the nation’s health-
quality of healthcare by building transparency care system to ensure high-quality care and pur-
through its voluntary survey, providing incentives chasing based on value.
and rewards to hospitals that improve the quality
of care they provide to patients, and creating con- Jared Lane K. Maeda and Kat Song
sistency and leverage for change by collaborating See also Health Report Cards; Joint Commission; Medical
with other organizations to develop quality and Errors; National Quality Forum (NQF); Outcomes
safety initiatives. Leapfrog’s member organiza- Movement; Pay-for-Performance; Quality of
tions agree to follow four principles when making Healthcare; Robert Wood Johnson Foundation (RWJF)
healthcare-purchasing decisions for their employ-
ees: increase awareness and inform enrollees
about healthcare safety, quality, and affordability Further Readings
and the importance of comparing among health- Birckmeyer, John D., and Justin B. Dimick. “Potential
care providers; reward and recognize healthcare Benefits of the New Leapfrog Standards: Effect of
providers for making significant advances in the Process and Outcome Measures,” Surgery 135(6):
safety, quality, and affordability of healthcare; 576–78, June 2004.
Lee, Philip R. 681
Delbanco, Suzanne. “Employers Flex Their Muscles as of Minnesota in 1955. From there, Lee rejoined
Health Care Purchasers,” Surgical Clinics of North the faculty at New York University until he
America 87(4): 883–87, August 2007. returned to Palo Alto in 1956. There, he worked as
Galvin, Robert S., Suzanne Delbanco, Arnold Milstein, an internist at the Palo Alto Medical Clinic, which
et al. “Has the Leapfrog Group Had an Impact on was founded by his father, Russell Lee, in 1930.
the Health Care Market?” Health Affairs 24(1): As a practicing physician during the 1960s, Lee
228–33, January–February 2005. joined a group called the Chowder and Marching
Kohn, Linda T., Janet M. Corrigan, and Molla S. Society, headed by Lester Breslow. The society met
Donaldson, (eds.), Committee on Quality of Health
monthly and presented papers on various health
Care in America. To Err Is Human: Building a Safer
policy topics. Also during this time, Lee was one of
Health System. Washington, DC: National Academy
the founders of the Bay Area Committee for
Press 2000.
Medical Aid for the Aged. Additionally, he became
Milstein, Arnold, Robert S. Galvin, Suzanne Delbanco,
et al. “Improving the Safety of Health Care: The
actively involved in the King-Anderson Bill, which
Leapfrog Initiative,” Effective Clinical Practice 3(6):
later became Medicare Part A. It was during this
313–16, November–December 2000. time that he became interested in governmental
Pronovost, Peter, David A. Thompson, and Christine G. policies and practices.
Holzmueller. “Impact of the Leapfrog Group’s In 1963, Lee left his medical practice and joined
Intensive Care Unit Physician Staffing Standard,” the federal government, becoming the director of
Journal of Critical Care 22(2): 89–96, June 2007. health services in the Office of Technical Cooperation
Sandrick, Karen. “One Giant Leap for Quality. When and Research in the Agency for International
Boards Get Behind Quality Initiatives, Patient Care Development (AID). While in that position, he
Benefits,” Trustee 58(3): 22–24, 26, March 2005. assisted in developing the first federal policies on
family planning, malaria control, environmental
sanitation, medical education, and the Food for
Web Sites Peace program. Additionally, he worked to better
Leapfrog Group: http://www.leapfroggroup.org coordinate AID with the U.S. Public Health
Leapfrog Hospital and Quality and Safety Survey: Service.
http://www.leapfroggroup.org/cp From 1965 to 1969, Lee served as the first assis-
Leapfrog Pay-for-Performance Initiatives: tant secretary in the U.S. Department of Health,
http://www.leapfroggroup.org/for_hospitals/ Education and Welfare (now split into the
fh-incentives_and_rewards Department of Education and the Department of
Health and Human Services) under President
Lyndon B. Johnson. In his position, Lee was
involved in a wide range of policy issues, including
Lee, Philip R. bioethics, biomedical research, environmental
health, family planning, and the education of
Philip R. Lee is an academic who has served as a health professionals. One of his main tasks was to
senior federal health policy official in two admin- implement the Medicare program, which was
istrations. He also is a frequent advisor to federal, passed in 1965.
state, and local health policy makers. From 1969 to 1972, Lee served as the chancel-
Born in San Francisco, Lee grew up in Palo lor of the University of California, San Francisco
Alto, California, and is one of five children, all of (UCSF), where he helped increase the enrollment
whom became practicing physicians. Lee earned a of minority students, particularly in the health pro-
medical degree from Stanford University in 1948. fessions. In 1972, while he was a professor in the
He joined the U.S. Navy and served as a medical School of Medicine, he founded the Institute for
officer from 1949 to 1951. From 1951 to 1956, Health Policy Studies, which was the first of its
Lee was a fellow at the New York University’s kind in the nation. Lee served as the director of the
Medical Center and Goldwater Hospital. He com- institute until 1993, when he retired from UCSF to
pleted a fellowship at Mayo Clinic from 1953 to accept the appointment of Assistant Secretary for
1955 and earned a master’s degree from University Health in the Department of Health and Human
682 Lewin Group
Services under President Bill Clinton from 1993 to Web Sites

1997. Additionally, Lee served in several other Philip R. Lee Institute for Health Policy Studies,
capacities. He was the first president of the San University of California, San Francisco (UCSF):
Francisco Health Commission. He served on the http://ihps.medschool.ucsf.edu
Board of Trustees of the Carnegie Corporation
and the Mayo Foundation. And he headed the
federal Physician Payment Review Commission
(PPRC) from 1986 to 1993. Lewin Group
Lee has been honored for his many accomplish-
ments. He received the David Rogers Award from The Lewin Group is a nationally recognized
the Association of American Medical Colleges healthcare and human services management con-
(AAMC) in 1998, the National Academy of sulting firm. The Lewin Group provides policy-
Sciences, Institute of Medicine’s Gustav O. Lienhard focused empirical research, hands-on technical
Award in 2000, the American Public Health assistance, and evaluation services to federal,
Association’s Sedgwick Medal in 2000, the Henrik state, and local governments, foundations, associ-
Blum Award from the California Public Health ations, hospitals and health systems, insurers and
Association in 2001, and the National Hero health plans, and medical technology companies.
Award in 2002. In 2007, the health policy institute
he founded at the University of California, San
Francisco, was renamed the Philip R. Lee Institute Background
for Health Policy Studies in his honor. Founded by Lawrence S. Lewin in 1970, the Lewin
Lee is the author or coauthor of more than 150 Group, which is located in Falls Church, Virginia,
articles and four books. One of his books, The recently was acquired by Ingenix, Inc., a leading
Nation’s Health, is in its seventh edition. Although health information technology company. Lewin’s
he is retired, Lee is currently working on policy strategic and analytical services aim to help clients
issues such as diversity in medical education, improve policy and expand knowledge of health-
financing national health insurance, and evidence- care through the integration of evidence-based
and population-based healthcare. practices; enact, run, and evaluate programs to
enhance delivery and financing of healthcare and
Amie Lulinski Norris
human services; deal with shifts in healthcare prac-
See also Cohen, Wilbur J.; Diversity in Healthcare tice, technology, and regulation; optimize perfor-
Management; Medicare; Public Health; Public Policy mance, quality, coverage, and health outcomes;
and create strategies for institutions, communities,
governments, and people to make healthcare and
Further Readings human services systems more effective. Lewin’s
consultants are drawn from industry, government,
Boufford, Jo, and Philip R. Lee. Health Policies for the
21st Century: Challenges and Recommendations for
academia, and the health professions. Many are
the U.S. Department of Health and Human Services.
national authorities whose strategies for health and
New York: Milbank Memorial Fund, 2001. human services system improvements come from a
Lee, Philip R., Carroll L. Estes, and Fatima M. personal experience with imperatives for change.
Rodriguez, eds. The Nation’s Health. 7th ed. Lewin’s policy research work includes both
Sudbury, MA: Jones and Bartlett, 2003. long-term studies and quick-turnaround policy
Rockefellar, Nancy M. Interview with Philip R. Lee, analyses. Federal and state clients and others count
M.D. Diversity Series 4A–4B. San Francisco: on the Lewin Group for their in-depth experience
University of California, Department of and innovative, analytic approaches.
Anthropology, History, and Social Medicine, UCSF
Oral History Program, 2006.
Modeling Health Reform
Silverman, Milton, and Philip R. Lee. Pills, Profits,
and Politics. Berkeley: University of California The Lewin Group has been a leader in the health
Press, 1974. reform and coverage arena and is one of the few
Lewin Group 683
independent sources of information on the finan- reduced productivity, permanent disability, and
cial impacts of health coverage expansion and premature mortality.
national and state health reform initiatives. The In addition, Lewin continues to estimate the
Health Benefits Simulation Model (HBSM), devel- economic cost of drug abuse in the United States
oped by The Lewin Group, is a well-vetted, pro- for the Office of National Drug Control Policy.
prietary microsimulation model of the U.S. Lewin has also studied the economic burden of
healthcare system. The model, based on the alcohol abuse for the National Institutes of Health
Medical Expenditures Panel Survey data and sur- (NIH) and is updating these estimates for the
veys of employers and health plans, provides a Centers for Disease Control and Prevention (CDC)
comprehensive representation of public and pri- 2008 report. Other studies being conducted
vate insurance coverage and health spending. include the prevalence and cost of 17 digestive
These data enable The Lewin Group to simulate conditions for the American Gastroenterological
the effect of a wide range of health reform initia- Association; the cost of obesity, alcohol abuse,
tives on major stakeholder groups, including and tobacco use for the U.S. Department of
employers, state and federal governments, fami- Defense/TRICARE Management Activity; the cost
lies, and providers. The model has been used by of skin disease for the Society for Investigative
Republicans and Democrats to analyze a broad Dermatology; and the cost of Chronic Fatigue
range of health reform proposals at both the state Syndrome for the CDC.
and the federal level, including The Lewin Group’s
independent analysis of the Clinton health reform
Long-Term Care
proposal of 1993, comparative analysis of the
proposed health plans of President George W. Lewin’s Center on Long Term Care brings together
Bush and Senator John F. Kerry (D-MA) during experts from across the organization to promote
the 2004 presidential campaign, President Bush’s systems change for individuals who have long-
health insurance proposal of 2007, and the Healthy term care needs due to chronic conditions or dis-
Americans Act introduced by Senator Ron Wyden ability. The Lewin Group’s staff provides policy
(D-OR). The Lewin Group has developed com- development support and technical assistance for
parisons of alternative coverage expansions for the U.S. Administration on Aging’s (AoA) efforts
organizations such as the Robert Wood Johnson to reform the nation’s long-term care system so
Foundation (RWJF) and the Commonwealth that older adults and individuals with disabilities
Fund. Lewin also has modeled a wide range of can live independent lives in their communities.
health reform models for individual states, includ- The organization also assists states and local com-
ing tax credits, the single-payer model, and indi- munities to understand the implications of the
vidual mandate proposals. aging baby boom population and its impact on
the range of government services, from transpor-
tation to housing and healthcare.
Cost-of-Illness Studies
Lewin also recently conducted a study docu-
The Lewin Group’s cost-of-illness studies provide menting the significant number of older adults,
information on both the direct medical costs asso- particularly among the “oldest old” (persons 85
ciated with a disease and the indirect costs, such and older), who have elected to stay in their homes
as lost productivity and premature deaths. These and in residential alternatives rather than move to
costs are estimated from the perspective of society, nursing homes. The findings speculate on the
healthcare payers, and consumers. impact this shift will have on the future demand
Lewin recently completed a study on the national for long-term care. Through the Centers for
cost of diabetes for the American Diabetes Medicare and Medicaid Services (CMS)–sponsored
Association. The study estimated the national eco- National Direct Service Workforce Resource
nomic burden of diabetes at $174 billion in 2007, Center, Lewin additionally supported efforts to
approximately $116 billion in additional health- improve the recruitment and retention of direct-
care expenditures attributed to diabetes and $58 service workers, who help people with disabilities
billion in lost productivity from absenteeism, and older adults to live independently.
684 Licensing
Healthcare Workforce: Supply and Demand Reynolds, Kenneth J., Suzanne D. Vernon, Ellen
Bouchery, et al. “The Economic Impact of Chronic
An adequate supply of healthcare workers is inte- Fatigue Syndrome,” Cost Effectiveness and Resource
gral to achieving the nation’s goal of ensuring Allocation 2(4): 1–9, 2004.
access to quality and affordable healthcare. The Sheils, John, and Randall Haught. “The Cost of Tax-
Lewin Group is helping healthcare stakeholders Exempt Health Benefits in 2004,” Health Affairs Web
understand the implications of demographic Exclusive W4–W106, 2004.
trends; changes in the healthcare operating envi-
ronment; and policies and programs on efforts to
train, recruit, and retain health workers. Lewin Web Sites
uses a quantitative approach to help decision Lewin Group: http://www.lewin.com
makers in the public and private sectors deal
effectively with health worker supply and demand
and related issues, such as workforce manage-
ment and program design. The Lewin Group has Licensing
also worked with the Health Resources and
Services Administration (HRSA), states, profes-
Healthcare professionals are licensed by the gov-
sional associations, health systems, insurers, and
ernment to protect the healthcare consumer and
others to develop models that project supply and
to ensure a minimum standard of quality of care.
demand for physicians, nurses, and other health
Most healthcare professionals cannot practice
workers.
unless they are licensed. The licensing of health-
Lisa Chimento care professionals in the United States is carried
out at the state government level, and it limits
See also Cost of Healthcare; Diabetes; Disability; who can and who cannot provide care. The fed-
Healthcare Reform; Health Insurance Coverage; eral government, however, also plays a role in the
Health Workforce; Long-Term Care; State-Based regulation of healthcare providers by coordinating
Health Insurance Initiatives state licensure programs through a centralized
database known as the National Practitioner Data
Bank (NPDB), which contains disciplinary actions
Further Readings
of providers, and by imposing requirements on
Bureau of Health Professions. Physician Supply and providers who receive federal reimbursement (e.g.,
Demand: Projections to 2020. Rockville, MD: Health Medicare, Medicaid).
Resources and Services Administration, Bureau of
Health Professions, 2006.
Dall, Timothy M., Sarah Edge Mann, Yiduo Zhang, Background
et al. “Economic Costs of Diabetes in the U.S. in The government sanction of medical practice dates
2007,” Diabetes Care 31(3): 1–20, March 2008. back thousands of years in India and China. In the
Dall, Timothy M., Yidue Zhang, Yaozhu J. Chen, et al. Western world, King Henry VIII of England in
“Cost Associated With Being Overweight and With 1518 established a charter to grant licenses to
Obesity, High Alcohol Consumption, and Tobacco
qualified physicians. In the United States, the
Use Within the Military Health System’s TRICARE
American Medical Association (AMA) played a
Prime-Enrolled Population,” American Journal of
pivotal role in the 19th century supporting state
Health Promotion 22(2): 120–39, November 2007.
enactment of licensure laws for physicians. Between
Mark, Tami L., Rosanna M. Coffey, Rita Vandivort-
1874 and 1915, licensing requirements for medical
Warren, et al. “U.S. Spending for Mental Health and
Substance Abuse Treatment, 1991–2001,” Health
practice were passed in all states in the nation.
Affairs Web Exclusive W5–W133, 2005. Often, as one state passed licensing requirements,
Office of National Drug Control Policy. The Economic poor-quality physicians would move to another
Costs of Drug Abuse in the United States: unregulated state to practice. However, eventually,
1992–2002. Washington, DC: Executive Office of the as all states required licensing, many poorly trained
President, 2004. and unqualified physicians left the profession,
Licensing 685
which ultimately resulted in better quality of care appeal board may determine if proper procedures
and increased status of the profession. were followed if a discipline is sanctioned, and the
The push by the AMA for state licensure served provider may appeal to the courts. Although disci-
as a model for the licensing of other healthcare plinary actions are made public, they are usually
professionals. By the 1920s, most states enacted not widely publicized.
licensing programs for dentists, pharmacists,
nurses, and other healthcare providers. Most allied
health professionals, including dental hygienists, Issues of Licensing
physical therapists, and emergency medical techni-
The state licensure of healthcare providers raises
cians, were required to receive licensing by 1960.
several issues. Since licensure is carried out at the
The health professions have generally advocated
state level, there are wide variations in profes-
for state licensure in addition to standardized edu-
sional standards as well as in the enforcement of
cation and training.
those standards. The coordination by states and
the federal government on the NPDB is also pre-
Role of State Licensing Boards carious. Providers with disciplinary action against
them may be able to evade enforcement officials
State licensing boards serve as gatekeepers to con-
and seek licensure to practice in another state.
trol the entry of clinical practice. The role of the
The use of professional peers on state licensing
state boards is to confirm a provider’s training
boards is also an area of contention. Although
and education and to administer a prerequisite
professional peers have the credentials necessary to
examination before allowing providers to engage
evaluate other providers in their profession, seri-
in clinical practice. The state boards issue licenses
ous questions have been raised about the objectiv-
to providers who pass the examinations, renew
ity of such a review process and whether this is
licenses, and enforce the basic standards of the
really a form of professional self-regulation. There
profession. Members of state boards generally
are concerns that professional peer board members
consist of individuals in the profession and some-
may be more interested in maintaining the reputa-
times include consumer representatives. The state
tion of their profession or may impose barriers to
boards may function independently or as part of a
the entry of new providers to control competition.
state’s department of health. State licensing boards
Furthermore, consumer advocates argue that the
operate under statutes and regulations and have
low level of enforcement by state licensing boards
oversight by the state legislature. The boards also
is indicative of the boards serving the interests of
maintain procedural rules.
the profession over those of the public.
The licensing of providers usually entails two
components. First, they must have graduated from
a school that has been certified in the state desired
to practice in as well as pass a state-administered Future Implications
examination. Second, they must also provide the Licensing continues to play an important role as
state board with basic information about them- the cornerstone of ensuring quality in healthcare.
selves. The education requirement has allowed for However, there remain some concerns over
state oversight of education curricula. whether licensing is best carried out at the state
The renewal of a license is generally based on or federal level and whether the professions are
not having any disciplinary action against a pro- able to adequately regulate themselves. Also,
vider since the period of the individual’s last review there are questions over whether patients are bet-
and fulfilling a certain number of continuing- ter protected by government oversight or through
education units. If a provider, however, has had a economic market forces. For the time being,
disciplinary action against it, it must be given due state licensing remains the foundation for regu-
process that entails a fair proceeding to contest the lating the clinical practice of most healthcare
charges before the state board revokes or suspends professionals.
its license. The provider must be properly informed
of the charges and be given a fair hearing. An Jared Lane K. Maeda
686 Life Expectancy
See also American Medical Association (AMA); For example, in 2005, the life expectancy at birth
Malpractice; National Practitioner Data Bank; Nurses; for the total U. S. population was 77.8 years; for
Patient Safety; Physicians; Quality of Healthcare; those 65 years of age, it was 83.7 years; and for
Regulation those 75 years of age, it was 87.0 years.
Health services researchers use life expectancy
as a broad indicator of the overall health of a given
Further Readings population. They often compare the life expec-
American Medical Association. State Medical Licensure tancy and health expenditures of nations with
Requirements and Statistics. Chicago: American various health delivery systems. Although the
Medical Association, 2007. United States has a higher life expectancy than
Ameringer, Carl F. State Medical Boards and the Politics the global average, it is only slightly higher than
of Public Protection. Baltimore: Johns Hopkins the average for developed nations. The United
University Press, 1999. States ranks 48th highest in life expectancy, sur-
Field, Robert I. Health Care Regulation in America: passed by nations such as Japan, Sweden,
Complexity, Confrontation, and Compromise. New Switzerland, Australia, and Canada.
Pawlson, L. Gregory, and Margaret E. O’Kane.
“Professionalism, Regulation, and the Market: Impact History
on Accountability for Quality Care,” Health Affairs The English statistician John Graunt constructed
21(3): 200–207, May–June 2002. the first life table, a statistical table that uses age-
Sacks, Terence J. Careers in Medicine. 3d ed. New York:
specific death rates to determine a group’s average
McGraw-Hill, 2006.
life expectancy. Graunt, who is considered the
Shryock, Richard H. Medical Licensing in America,
founder of the science of demography and vital
1650–1965. Baltimore: Johns Hopkins University
statistics, was interested in studying the effects of
Press, 1967.
epidemics on populations. He analyzed the Bills
of Mortality, which recorded the weekly count of
births and deaths in London parishes. In 1662, he
Web Sites
published the results of his findings in Natural
American Medical Association (AMA): and Political Observations Made Upon the Bills
http://www.ama-assn.org of Mortality.
Council on Licensure, Enforcement and Regulation Edward Wigglesworth constructed the first life
(CLEAR): http://www.clearhq.org table in America in 1793. Wigglesworth used mor-
Federation of State Medical Boards (FSMB): tality data reported in 1789 from Massachusetts,
http://www.fsmb.org Maine, and New Hampshire. He estimated the aver-
National Council of State Boards of Nursing (NCSBN): age life expectancy at birth was about 35 years.
http://www.ncsbn.org
Actuaries have been constructing and using life
National Practitioner Data Bank (NPDB):
tables for decades to determine the premium rates
http://www.npdb-hipdb.hrsa.gov
for life insurance policies based on the average life
expectancy of enrollees. Actuaries at the Social
Security Administration (SSA) also use life tables
to monitor Social Security enrollees. And the
Life Expectancy National Center for Health Statistics (NCHS) uses
life tables to monitor mortality trends in the
Life expectancy is the average number of years nation’s population.
that an individual of a given age is expected to Recently, the concept of life expectancy has
live. Life expectancy may be determined by race, been modified to focus on healthy life expectancy,
gender, or other characteristics using age-specific sometimes called health-adjusted life expectancy
death rates or life tables for the population with (HALE), which extends life expectancy measures
that characteristic. Life expectancy at birth is by accounting for the health states of populations.
often cited, but it can be given for any age group. In 2000, the World Health Organization (WHO)
Life Expectancy 687
reported for the first time healthy life expectancy (black lung) and silicosis have come under better
for its 191 member countries. control.
Engineering improvements in both vehicles and
highways and changes in personal behavior, such
Reasons for Increased Life Expectancy
as the use of safety belts, child safety seats, or
During the 20th century, life expectancy in the motorcycle helmets, and decreased drinking and
United States rose dramatically. In 1900, the aver- driving, has resulted in a large reduction in motor
age life expectancy at birth for the nation’s total vehicle-related deaths.
population was 47.3 years; by 1999, it had The discovery of the major underlying risk fac-
increased to 76.7 years. This increase in lifespan is tors of heart disease and stroke—smoking, diet,
attributable to many advances in the nation’s pub- exercise, and blood pressure control—has resulted
lic health. In 1999, the Centers for Disease Control in smoking cessation and blood pressure control
and Prevention (CDC) identified a number of fac- programs. There was also improved access to early
tors that contributed to the dramatic increase in detection and better medical treatment.
life expectancy, including vaccinations, control of Since the 1964 Surgeon General’s report on the
infectious diseases, safer and healthier foods, health risks of smoking, smoking among adults
healthier mothers and babies, safer workplaces, has decreased, and millions of smoking-related
motor vehicle safety, decline in deaths from coro- deaths have been prevented. Public health anti-
nary heart disease and stroke, and recognition of smoking campaigns have resulted in greater public
tobacco use as a major health hazard. awareness of the major health-related problems
Public health vaccination campaigns in the caused by smoking.
nation have eliminated many deadly diseases.
Because of vaccinations, once common deadly
diseases, such as diphtheria, tetanus, poliomyeli- Future Implications
tis, measles, mumps, and rubella, have been virtu-
While the average life expectancy in the United
ally eliminated. And smallpox has been totally
States has risen to nearly 78 years, it seems
eradicated.
unlikely that it will continue to increase at a fast
Public health efforts led to the establishment of
pace in the future. Much of the past increase in life
local and state health departments across the
expectancy was due to decreases in infant mortal-
nation. These health departments initiated envi-
ity and infectious diseases, and other factors. In
ronmental and sanitation programs, such as clean
the future, any increase in life expectancy will
drinking water, sewage disposal, garbage disposal,
likely be small incremental gains of perhaps a
mosquito control, and educational programs,
month or two per year. Some future years may
which decreased exposure to infectious diseases.
even see a slight decrease in life expectancy due to
Safer and healthier foods were developed. Better
factors such as increased diabetes and obesity.
food processing has resulted in fewer deaths
because of microbial contamination. In addition, Xinjian Du
foods have become more nutritious; many are for-
tified to eliminate major nutritional deficiency See also Acute and Chronic Diseases; Comparing Health
diseases such as rickets, goiter, and pellagra. Systems; Epidemiology; Health Disparities; Mortality;
Mother and infant deaths have been greatly Mortality, Major Causes in the United States; Public
reduced by better hygiene and nutrition programs. Health
In addition, there was greater access to healthcare,
family planning programs, antibiotics, and tech-
nological advances in maternal and neonatal Further Readings
medicine. Carey, James R. Longevity: The Biology and
Work-related deaths, injuries, and health prob- Demography of Life Span. Princeton, NJ: Princeton
lems have greatly declined as a result of more safety University Press, 2003.
measures and greater regulation. Once common Centers for Disease Control and Prevention. “Ten Great
diseases such as coal workers’ pneumoconiosis Public Health Achievements: United States, 1900–
688 Lomas, Jonathan
1999,” Journal of the American Medical Association New England Journal of Medicine in 1989. His
281(16): 1481–84, April 28, 1999. research on administrative and public policy
Day, Peter, Jamie Pearce, and Danny Dorling, “Twelve addressed highly topical policy issues such as the
Worlds: A Geo-Demographic Comparison of Global regionalization of health services delivery in
Inequalities in Mortality,” Journal of Epidemiology Canada. His writing about innovative models for
and Community Health 62(11): 1002–1010, priority setting in health services research (“On
November 2008. Being a Good Listener . . .” Milbank Quarterly,
Perenboom, R. J. M., L. M. van Herten, H. C. 2003) and about conducting research in close part-
Boshuizen, et al. “Life Expectancy Without Chronic
nership with health systems decision makers (“Using
Morbidity: Trends in Gender and Socioeconomic
‘Linkage and Exchange’ to Move Research Into
Disparities,” Public Health Reports 120(1): 46–54,
Policy at a Canadian Foundation,” Health Affairs,
January–February 2005.
2000) has been highly influential among research-
funding organizations.
Under Lomas’s leadership, the CHSRF designed
Web Sites its research programs (i.e., the Capacity for
National Center for Health Statistics (NCHS): Applied and Developmental Research and
http://www.cdc.gov/nchs Evaluation [CADRE] program) to build a critical
National Institute on Aging (NIA): http://www.nia.nih.gov mass of applied health services and nursing
Social Security Online: http://www.ssa.gov/OACT/ researchers in Canada and to create a supportive
STATS/table4c6.html environment for these researchers to engage with
World Health Organization (WHO): http://www.who.int decision makers. It also designed training and sup-
port programs for decision makers, such as the
Executive Training for Research Application
(EXTRA) program, and a widely emulated 1:3:25
rule for organizing research reports. Its program
Lomas, Jonathan designs and “linkage and exchange” philosophy
have served as a point of reference for many large
Jonathan Lomas was a faculty member in the and small organizations seeking to improve the
department of clinical epidemiology and biostatis- use of research in decision making in Canada and
tics at McMaster University in Hamilton, Ontario, internationally.
Canada, from 1982 to 1997; Professor of Health Lomas is also known for cofounding McMaster
Policy Analysis from 1992 to 1997; and inaugural University’s Centre for Health Economics and
Chief Executive Officer of the Canadian Health Policy Analysis, his scholarly work with the
Services Research Foundation (CHSRF) from Population Health Programme of the Canadian
1997 to 2007. Although Lomas’s undergraduate Institute for Advanced Research (1988–2004), and
training was in experimental psychology at Oxford his service contributions in Canada (Federal,
University, his landmark contributions have been Provincial, Territorial Advisory Committee to
as a scholar in the field of health policy analysis Deputy Ministers on Health Services, 1994–1996;
and as an innovator in improving the relevance Ontario Premier’s Council on Health, Well-Being
and use of health services research in health sys- and Social Justice, 1991–1994; Interim Governing
tem decision making. Council and Institute Advisory Board of the
Lomas’s scholarly contributions touched on all Canadian Institute of Health Research, 1999–2004)
three “levels of health policy” (as he called them)— and the United States (member of the board of
clinical policy, administrative/organizational pol- directors of the Association for Health Services
icy, and public policy, but it was his research in the Research and its successor AcademyHealth,
domain of clinical policy that first brought him 1999–2005).
widespread attention. His most widely cited schol- He also made an impact through consultancies
arly article, “Do Practice Guidelines Guide Practice? for the World Health Organization (WHO) and
The Effect of a Consensus Statement on the Practice other international agencies in Australia, Indonesia,
of Physicians,” was published in the prestigious Myanmar, the Philippines, South Korea, Sri Lanka,
Long-Term Care 689
and Thailand. He was a visiting scholar at the

University of Gadjah Mada in Indonesia (1990), Long-Term Care
the University of Sydney and the Department of
Health of the New South Wales Government in Long-term care (LTC) includes a wide variety of
Australia (1996–1997), the Dutch national health and support services that are provided to
research and development agency ZonMw (2004), the frail, the elderly, and individuals with chronic
and the Ministry of Health in New Zealand disease conditions and disabilities. LTC is largely
(2007). In recognition of his scholarly and profes- personal, custodial, and unskilled care provided
sional impact, the University of Montreal awarded to those who cannot care for themselves for
him an honorary doctorate degree in 2005, and he extended periods of time. The majority of those
was elected a fellow of the Royal Society of receiving LTC are the frail elderly who suffer
Canada and the Canadian Academy of Health from multiple chronic diseases. In the United
Sciences in 2006. States, about 60% of all individuals 65 years of
age or older require at least some type of LTC
John N. Lavis services during their lifetime, and over 40% need
care in a nursing home for some period of time.
See also AcademyHealth; Canadian Health Services
Research Foundation (CHSRF); Canadian Institute
In 2006, there were 37.3 million people in the
of Health Services and Policy Research (IHSPR); nation 65 years of age or older, or about one in
Clinical Practice Guidelines; Epidemiology; Health every eight Americans. By 2030, the number is
Services Research in Canada; Public Health; Public expected to grow to 71.5 million people, or
Policy about one in every five Americans. Although the
family is the primary source of LTC, the increas-
ing size of the nation’s older population coupled
Further Readings with decreasing family size and high divorce
rates will invariably increase the demand for
Lomas, J., G. M. Anderson, K. Domnick-Pierre, et al.
paid LTC services.
“Do Practice Guidelines Guide Practice? The Effect of
a Consensus Statement on the Practice of Physicians,”
The need for LTC services for people suffer-
New England Journal of Medicine 321(19):
ing from chronic disabilities is often estimated
1306–1311, November 9, 1989. using the criteria of Activity of Daily Living
Lomas, Jonathan. “Using ‘Linkage and Exchange’ to (ADL) or the Limitations of the Instrumental
Move Research and Policy at a Canadian Activities of Daily Living (IADL). The ADL cri-
Foundation,” Health Affairs 19(3): 236–40, teria include bathing, dressing, getting in or out
May–June, 2000. of bed, getting around inside, toileting, and eat-
Lomas, Jonathan. “Health Services Research: More ing; and the IADL criteria are light housework,
Lessons From Kaiser Permanente and Veterans’ laundry, meal preparation, grocery shopping,
Affairs Healthcare System,” British Medical Journal getting around outside, managing money, tak-
327(7427): 1301–1302, December 6, 2003. ing medications, and telephoning. According
Lomas, Jonathan. “The In-Between World of Knowledge to the National Institute on Aging, in 2006,
Brokering,” British Medical Journal 334(7585): about 20% of all Medicare enrollees, including
129–32, January 20, 2007. 5% who were institutionalized, had limitations
Lomas, Jonathan, Naomi Fulop, Diane Gagnon, et al. in one or more ADLs. However, only about
“On Being a Good Listener: Setting Priorities for half of those individuals were estimated to be
Applied Health Services Research,” Milbank receiving personal care. The majority of those
Quarterly 81(3): 363–88, September 2003. (65%) who received personal care obtained
it from unpaid caregivers (i.e., spouse, adult
children, other family members, and friends),
Web Sites about 26% received personal care from
AcademyHealth: http://www.academyhealth.org both unpaid and paid caregivers, and the remain-
Canadian Health Services Research Foundation ing 8% received personal care from only paid
(CHSRF): http://www.chsrf.ca caregivers.
690 Long-Term Care
Projected Demand for Paid Care Medicare Coverage

The demand for paid LTC services is expected to
Since the implementation of Medicare’s hospital
increase sharply in the future because of the growth
prospective payment system in 1983, which encour-
in the nation’s older population. A simulation
aged the nation’s hospitals to shorten patient
study conducted by the Urban Institute in 2007
length of stays and discharge patients as quickly as
estimates that between 2000 and 2040 the number
possible, nursing homes have seen an increasing
of older adults with chronic disabilities in the
number of individuals requiring post-acute reha-
nation will more than double, increasing from
bilitation. Specifically, Medicare Part A will pay
about 10 million to about 21 million individuals.
for their care at a skilled-nursing facility (SNF)
Although the study projected an overall declining
only if the care occurs within 30 days of a hospi-
rate of old-age disability during the period, the
talization of 3 or more days and is certified as
total number of individuals with disabilities will
medically necessary. Covered services are similar
more than double simply because of the enormous
to those for inpatient hospital stays but also
size of the older population by 2040. This trend is
include rehabilitation services and medical equip-
troubling because at the same time that it will be
ment. However, Medicare does not cover nursing
occurring, family size is likely to decline, and there
facility care if the individual does not require
will be rising divorce rates and an increase in female
skilled nursing or skilled rehabilitation services.
employment rates. As a result, the demand for paid
Although the number of SNF days provided by
LTC services is projected to increase sharply in the
Medicare is limited to 100 days per benefit period,
future. The study estimates that the number of old
the average length of stay in an SNF is usually less
people receiving paid home care will increase from
than 2 weeks. Under Medicare, no copayment is
2.2 million to 5.2 million and the number of
required for up to 20 days; a copayment is required
older nursing home residents will increase from
for Days 21 to 100; and after 100 days, the indi-
1.2 million to 2.7 million individuals.
vidual pays the total cost.
While SNF care may be viewed as an extension
of hospital inpatient care rather than true LTC,
Financing Long-Term Care home health care has increasingly been trans-
Meeting the projected need for LTC will be a formed into a source of long-term personal assis-
daunting task for both the private and the public tance for Medicare beneficiaries, especially those
sectors, considering that LTC services for older with severe functional limitations and cognitive
adults already represent a substantial share of the impairment. Both Medicare Part A and B cover
nation’s total healthcare spending. In 2005, nursing part-time or intermittent skilled nursing care and
home and home health care accounted for slightly home health aide services, and some therapies that
over 10% of national personal health expenditures, are ordered by a physician and provided by a
or about $169 billion. This amount does not Medicare-certified home health agency. Specifi
include care provided by family or friends on an cally, Part A covers the first 100 visits following a
unpaid basis (often called “informal care”). It only 3-day hospital stay or an SNF stay, and Part B
includes the costs of care from paid providers. covers any visits thereafter. Home health care
The largest share, 48%, of the nation’s LTC under Part A and B has no copayment and no
costs are paid for by Medicaid, a jointly funded deductible.
state and federal program; state and local govern- Medicare Part A covers hospice care for indi-
ments pay for 19%; and the private sector (through viduals with a terminal illness, generally individu-
out-of-pocket and insurance premiums) pays 31% als who are not expected to live more than 6
of the total LTC costs. However, the federal gov- months. Although Medicare does not consider
ernment pays for LTC through its portion of the hospice care to be an LTC service, an increasing
Medicaid program and also through the Medicare number of hospice patients are living well beyond
program. These two sources pay for 50% of the 6 months, and hospices are becoming more like
nation’s LTC costs, making the federal govern- an LTC setting for those with terminal illnesses
ment the single largest payer for LTC. who are bed-stricken. Hospice services include
Long-Term Care 691
drugs for symptom control and pain relief, medi- Dual Eligible Beneficiaries
cal and support services from a Medicare-approved
Some Medicare enrollees also are Medicaid
hospice provider, and other services not otherwise
recipients, and they are called dual eligibles. For
covered by Medicare (e.g., grief counseling).
those who are dual eligibles, Medicare covers its
Hospice care is usually provided in a patient’s
set of medical services, while Medicaid pays for the
home (which may include a nursing home if that
individual’s Medicare premiums and cost sharing,
is where the patient lives) or a hospice care facil-
and—for those below certain income and asset
ity. However, Medicare does cover some short-
thresholds—LTC services. The dual eligibles tend
term hospital and inpatient respite care provided
to be older, sicker, poorer, and they use more
to a hospice patient to allow the usual caregiver
expensive medical services. The dual eligibles have
to rest.
an important impact on LTC spending. Since
Medicare covers SNF care, some dual-eligible
Medicaid Coverage patients are discharged from hospitals to SNF for
LTC services. After Medicare stops paying for
Although the number of short stays has
their care, the dual eligibles rely on Medicaid to
increased, the majority of nursing home residents
pay for their LTC services. In some cases, noninsti-
require long-term custodial care. Most nursing
tutional options may have been more appropriate,
home care is paid for by Medicaid and by the resi-
which may have provided better outcomes for the
dent’s own resources. According to the National
individual and lower costs for both Medicare and
Center for Health Statistics 2004 National Nursing
Medicaid. Efforts are now being made to better
Home Survey, Medicaid paid for at least some of
coordinate and integrate LTC services between
their care for 65% of all nursing home residents,
Medicare and Medicaid.
private/other sources paid for 22%, and Medicare
paid for 13%.
Private Coverage
During the past decade, a growing number of
older individuals have opted to reside in commu- Medicare and Medicaid are not ideal provid-
nity residential facilities, such as assisted living ers of LTC. For the most part, Medicare was
facilities, board and care, and continuing-care designed to provide acute care not LTC, and the
retirement communities, instead of being placed Medicaid program was designed to provide
into nursing homes. Currently, an estimated medical care to the deserving poor in certain lim-
1 million individuals live in residential facilities, ited categories, particularly women and children.
largely financed from their own resources. The Specifically, Medicare only pays for medically
public sector has taken note of this trend. States, necessary SNF or home health care. While
which have been concerned about the increasing Medicare pays for about 18% of LTC, it only
number of Medicaid residents in nursing homes, pays under specific circumstances. If the type of
have started using Medicaid to fund those living at care needed does not meet Medicare’s rules, it
home and in the community through Home and does not pay. In terms of Medicaid, individuals
Community-Based Service (HCBS) waiver pro- with assets and financial resources often do not
grams. The primary purpose of such programs is qualify for Medicaid unless they use up their
to keep those at risk of being institutionalized in resources by paying for care and become poor.
nursing homes at home or in the community. The Furthermore, states apply strict preadmission
program provides family members with supple- screening to deter people from being institution-
mentary services including adult day care services alized in nursing homes.
to help them continue to provide care. Some states Because of the many problems associated with
are also trying to relocate nursing home residents Medicare and Medicaid, most people who need
back in the community. As a result of these and LTC end up paying for some or all of their care
other changes, the percentage of total Medicaid using their own assets and financial resources.
spending on nursing homes was reduced to 44% in However, LTC is very expensive. For example,
2006, and the percentage of spending for home based on national averages for 2006, a semiprivate
health and personal care increased to 41%. room in a nursing home costs $171 per day, a pri-
692 Long-Term Care
vate room in a nursing home costs $194 per day, a Deficit Reduction Act of 2005
stay in an assisted living facility (one-bedroom
The Deficit Reduction Act of 2005 refined the
unit) costs $2,691 per month, the use of a home
eligibility requirement for state Medicaid recipi-
health aide service costs $25 per hour, the use of a
ents by tightening standards for citizenship and
homemaker service costs $17 per hour, and a stay
immigration documentation and by changing the
in an adult day healthcare center costs $56 per
rules concerning LTC eligibility. Specifically, the
day.
period for determining community spouse income
To pay the costs of LTC, some people purchase
and assets was lengthened from 36 to 60 months,
LTC insurance. Currently, about 10% of the
individuals whose homes exceeded $500,000 in
nation’s population purchase LTC insurance. The
value were disqualified, and the states were required
average annual premium costs for a policy pur-
to impose partial months of ineligibility. The act
chased in 2005, across all age groups of buyers
also contained a provision allowing for the expan-
and all types of insurance policies, was just over
sion of a National LTC Partnership program to all
$1,900. This represents a comprehensive policy
states. The goal of the program is to encourage
(covering both nursing facilities and at-home care)
individuals to purchase private LTC insurance. In
that provides an average of 5.5 years worth of
the program, individuals who exhaust their LTC
benefits, with a daily benefit payment of $143.
insurance benefits can retain a greater amount of
Most policies purchased also included some form
their assets and still qualify for state Medicaid,
of automatic inflation protection.
without having to “spend down.” Specifically,
Other insurance also pays for some limited LTC
purchasers would be allowed to keep a dollar of
services. Most Medicare enrollees purchase a
assets for every dollar they receive in benefits from
Medicare supplemental insurance plan, or Medigap
the program. The ability to retain additional assets,
insurance, which is sold by private health insur-
yet still use Medicaid as a “safety net” if private
ance companies to cover some of the “gaps” in
coverage does not suffice, is an incentive for more
expenses that are not covered by Medicare. In
individuals to purchase at least a moderate amount
addition to covering some of the costs of Medicare’s
of private coverage.
copayments and deductibles, some Medigap poli-
cies also provide additional benefits such as
at-home recovery care. Older Americans Act of 2001
A reverse mortgage may also be an option for The Older Americans Act of 2001 is one of the
some individuals who need LTC and expect to most significant laws affecting LTC. It changed
live in their current home for several years. A the bias toward institutionalizing LTC. In passing
reverse mortgage is a special type of home the act, the U.S. Congress recognized the family’s
equity loan, where home owners 62 years of age role in providing LTC. The act has the goal of
or older receive a loan against their home that retaining the family as caregivers of the elderly who
does not have to be paid back as long as they desire to be cared for in the home. It provides fund-
live in their home. The home owner receives a ing, through state and local Aging Network agen-
lump-sum payment, a monthly payment, or a cies, to help families and older individuals remain
line of credit against the value of the home with- independent within their communities. While there
out selling it. are no specific financial eligibility criteria for Older
Americans Act services, they are generally targeted
Public Policy: Acts Related at low-income, frail seniors over age 60 and minor-
to Long-Term Care ity elders and seniors living in rural areas.
A number of federal acts are directly related to

Millennium Health Care and Benefits Act of 1999
LTC. Some of the major acts include the Deficit
Reduction Act of 2005, the Older Americans Act The Millennium Health Care and Benefits Act of
of 2001, the Millennium Health Care and Benefits 1999 expanded the Veterans Health Administration’s
Act of 1999, and the Balanced Budget Act of (VHA) programs to increase access to nursing
1997. Each act is discussed below. home care and other extended care services to
Long-Term Care Costs in the United States 693
veterans who do not have service-related disabili- See also Chronic Care Model; Continuum of Care;
ties but who are unable to pay the costs of neces- Disability; Long-Term Care Costs in the United States;
sary care. For those who qualify, the benefits can Medicaid; Medicare; Nursing Homes; Skilled-Nursing
provide financial assistance for some LTC costs. Facilities
Copayments may apply depending on the veteran’s
income level. The VHA also has a Housebound
and Aid and Attendance Allowance Program that Further Readings
provides cash grants to eligible disabled veterans Buelow, Janet R. Listening to the Voices of Long-Term
and surviving spouses in lieu of formally provided Care. Lanham, MD: University Press of America,
homemaker, personal-care, and other services 2007.
needed for assistance in activities of daily living and Gibson, Mary Jo, and Donald L. Redfoot. Comparing
other help at home. Long-Term Care in Germany and the United States:
What Can We Learn From Each Other? Washington,
DC: AARP Public Policy Institute, 2007.
Balanced Budget Act of 1997 Golant, Stephen M., and Joan Hyde, eds. The Assisted
Several provisions of the Balanced Budget Act Living Residence: A Vision for the Future. Baltimore:
of 1997 addressed the explosive growth of Johns Hopkins University Press, 2008.
Medicare’s home health care expenses in the early Jurkowski, Elaine Theresa. Policy and Program Planning
for Older Americans: Realities and Visions. New
1990s. Home health care, which in 1989 accounted
York: Springer, 2008.
for only 2.5% of all Medicare Part A expenditures,
Morris, Michael, and Johnette Hartnett. Disability,
exceeded 15% of the total in 1996. To stem the
Long-Term Care, and Health Care in the 21st
growth, the act moved home health care to a pro-
Century. New York: Nova Science, 2009.
spective payment system, and it discouraged hospi- Presho, Margaret, ed. Managing Long Term Conditions:
tal ownership of home healthcare agencies. The act A Social Model for Community Practice. Hoboken,
dramatically reduced Medicare’s home health care NJ: Wiley-Blackwell, 2008.
expenditures and utilization; expenditures in the Pruchno, Rachael A., and Michael A. Smyer, eds.
following 2 years after the act’s passage declined Challenges of an Aging Society: Ethical Dilemmas,
by 52%, the percentage of Medicare beneficiaries Political Issues. Baltimore: Johns Hopkins University
receiving home health care services for the first Press, 2007.
time declined by about 20%, and the use among Sullivan-Marx, Eileen, and Deanna Gray-Miceli, eds.
those who availed of these services declined by Leadership and Management Skills for Long-Term
39%. Care. New York: Springer, 2008.

The projected future growth in the nation’s older AARP: http://www.aarp.org
population will seriously challenge both the pri- American Society on Aging (ASA): http://www.asaging.org
vate and the public sectors. With declining family National Clearinghouse for Long-Term Care
size and high divorce rates, the need for paid LTC Information: http://www.longtermcare.gov
services will greatly increase in the future. Many National Council on Aging (NCOA): http://www.ncoa.org
future retirees will likely not have the necessary National Institute on Aging (NIA): http://www.nia.nih.gov
financial resources to afford the LTC they need.
The future strain on the Medicare and Medicaid
programs will be enormous. To address these
issues, policymakers must develop new innovative Long-Term Care Costs
ways of financing and providing LTC, which
in the United States
politicians will support and the general public will
accept.
Long-term care (LTC) is often viewed as a service
Kyusuk Chung involving only the elderly. In reality, individuals of
694 Long-Term Care Costs in the United States
all ages, including children, nonelderly adults, as discuss, informal caregivers provide the vast major-
well as older persons, use LTC services. ity of care. Family and friends provide an estimated
Approximately 37% of LTC recipients are under 80% of all LTC. Informal caregivers typically pro-
65 years of age. Individuals in these three age vide many hours of care each week, and the average
groups can be further subdivided into classes, duration of caregiving is over 4 years—and usually
including those individuals facing physical chal- longer for caregivers of persons with Alzheimer’s
lenges, persons with persistent and severe mental disease. Nearly half of these caregivers place their
illness, children with developmental disabilities, own economic status and retirement at risk by
adults with intellectual disabilities, persons with reducing or losing employment and income to pro-
some type of dementia, and individuals with some vide care. The value of unpaid care is difficult to
combination of these challenges. determine, but in 2006, the AARP Policy Institute
In 2005, expenditures in the United States for estimated that the value of unpaid LTC was $354
LTC services such as nursing home care, assisted billion annually, which substantially exceeded the
living, and home health totaled over $200 billion. total expenditures on formal services.
Roughly 72% of those expenditures came from the
public coffers, largely the Medicaid or Medicare
Long-Term Care and the Elderly
programs, with payments from private insurance
(7.2%), other private spending (2.7%), and out- The variety of individuals receiving LTC and the
of-pocket expenditures by individuals accounting variety of settings in which it can be provided
for most of the rest of spending on formal LTC make it difficult to succinctly summarize all
services. aspects of its costs. The remainder of this entry
Indeed, LTC is an area of healthcare where con- focuses on LTC costs for the frail elderly, who
sumers or their families pay a relatively substantial constitute more than 60% of those needing LTC
proportion of the costs of formal care. Historically, services. Special attention is given to the projected
for the health services used by the elderly, only LTC costs associated with aging among the baby
expenditures for prescription medications have boomer generation.
been more heavily funded by out-of-pocket expen- High mortality rates and lower life expectancy
ditures. In 2005, out-of-pocket expenditures for during the 19th and early 20th centuries kept the
LTC financed 18% ($37 billion) of the costs of all issue of LTC off the policy agenda. Life expectancy
LTC services. at birth in 1900 in the United States was only 47
Costs are quite high for those paying for LTC years, and children with profound disabilities and
from personal funds, especially when one consid- individuals with developmental disabilities had an
ers the average income of those frail and vulnerable even more limited life expectancy. The few persons
individuals in need of it. In 2006, the estimated who survived into old age in America were cared
average annual cost of a private room in a nursing for either by their families at home or in the local
home was just over $70,000. For those who could “poor farms” or “almshouses” supported by local
afford it, a private room in an assisted living facil- or county governments or charitable organiza-
ity might cost more than $30,000 a year for room, tions. Many of those with persistent and severe
board, oversight, and basic services, such as medi- mental illness also faced institutional care or rele-
cation assistance, with the potential for substantial gation to poor farms. But, by 2004, life expectancy
additional costs for special services, such as more at birth was almost 78 years, life expectancy for
extensive personal care, medications, and thera- someone aged 65 years had increased to 84, and
pies. With an hourly cost of an estimated $25 per life expectancy for someone at 75 years of age had
hour for a home health aide, an individual receiv- increased to nearly 87.
ing only 4 hours of personal care assistance per In the mid 20th century came the passage of the
day would spend more than $36,000 a year for Medicare and Medicaid programs. That legislation
such help. placed LTC costs firmly on the policy agendas of
While much attention is focused on public the states and the federal government. The Medicaid
expenditures for care, it is important to emphasize program, which is jointly funded by the states and
that no matter which group of LTC recipients we the federal government, pays for the vast majority
Long-Term Care Costs in the United States 695
of LTC costs. In 2005, Medicaid paid just over little interest in paying premiums now for benefits
$100 billion for nursing home and home care ser- that they may need in 30 to 40 years.
vices, almost 49% of the total costs of these ser-
vices, compared with just over $42 billion (20%)
Dealing With the Baby Boomers
paid by Medicare for these same types of services.
A major concern of some policymakers has No discussion of LTC costs in this country can be
been the transfer of assets by the elderly to younger complete without a discussion of what many see
family members to qualify for Medicaid LTC ser- as the looming explosion in LTC needs and
vices. However, the U.S. Government Accountability expenditures as the baby boomer generation ages.
Office (GAO) analysis of the 2002 Health and Baby boomers include those individuals born
Retirement Study data indicated that those elderly between 1946 and 1964. Based on estimates from
most likely to need LTC services had a median the Urban Institute’s simulations, the number of
annual income of less than $14,000 and median older adults with disabilities will increase from 10
nonhousing assets of less than $4,000. Recapture million to 21 million from 2000 to 2040. The
of transferred assets in such a population is not number of elderly receiving paid home care will
likely to have a significant impact on Medicaid increase from 2.2 million to 5.3 million, while the
expenditures for LTC. number of nursing home residents will grow from
One of the current policy debates surrounding 1.2 to 2.7 million. All this will occur at the same
LTC costs is rebalancing. Since the implementa- time that the number of middle-aged or younger
tion of Medicaid, public funding for LTC has individuals who might serve as informal or formal
almost exclusively supported the provision of LTC caregivers will fall because of long-term reduc-
in institutional settings (nursing homes). At the tions in the nation’s birth rate.
same time, almost all consumers would prefer to As the more than 70 million baby boomers age,
receive LTC in a community setting, and public some estimates indicate that Medicaid costs will
funding agencies want to reduce expenditures for grow from 3% of the U.S. gross domestic product
the most expensive type of LTC, nursing homes. (GDP) in 2000 to approximately 11% of GDP by
Rebalancing is typically thought of as requiring an 2080. Some researchers argue relatively persua-
increase in the proportion of funding going to sively that reduced disability in the elderly popula-
community-based care while reducing the proportion could dramatically reduce these projected
tion of funds going to nursing home care. Another expenditure levels.
alternative, of course, is simply expanding expen- These population dynamics and cost projections
ditures for LTC and targeting these additional have raised serious concern among many analysts
funds for use in other forms of residential LTC and and policymakers. The federal government’s
for home- and community-based services. response to these concerns, at this point, has
Rebalancing is currently far from complete. In largely been an attempt to increase individual
2005, almost two thirds of LTC expenditures went responsibility by encouraging the purchase of LTC
to support nursing home care for individuals with insurance and increased personal savings for LTC
severe physical and cognitive impairment. Despite costs. The Centers for Medicare and Medicaid
this, the inadequacy of nursing home reimburse- Services (CMS) informational campaign for
ment is apparent. The majority of nursing homes Medicare recipients, titled “Own Your Own
are understaffed and thus at risk of being unable to Future,” is only one example of this approach.
meet the needs of their residents. As the baby boomers age, the nation will be
Another policy option that many hoped would faced with a series of difficult decisions. How
help reduce the public costs of LTC was LTC much of the cost of LTC is the responsibility of
insurance. However, LTC insurance has not seen society, and how much is the responsibility of the
the growth in the number of policyholders needed individual? What reallocations of social and per-
before it can serve as a substitute for a significant sonal resources will be necessary to meet the chal-
proportion of Medicaid payments to nursing lenges presented by the projected explosion in the
homes. The elderly find it difficult to afford LTC number of frail elders who will need LTC? What is
insurance, and younger individuals have shown an equitable distribution of total LTC spending?
696 Luft, Harold S.
How can we balance spending for the elderly’s National Alliance for Caregiving and AARP. Caregiving
LTC needs with other pressing social priorities? in the U.S. Washington, DC: National Alliance for
However, we might do well to remember that at Caregiving and AARP, 2004.
each stage of its life course the baby boomer gen- U.S. Government Accountability Office. Medicaid:
eration has presented unprecedented challenges to Transfers of Assets by Elderly Individuals to Obtain
our society. First, this generation needed expanded Long-Term Care Coverage. GAO-05–968. Washington,
public school services; then they needed expanded DC: Government Accountability Office, 2005.
higher education; and then they needed jobs. At
each point, our society successfully reallocated or
generated the resources to meet those needs. One Web Sites
can only wonder how this looming challenge will AARP: http://www.aarp.org
differ from those earlier trials. Centers for Medicare and Medicaid Services (CMS):
Charles D. Phillips and Catherine Hawes Congressional Budget Office (CBO): http://www.cbo.gov
Urban Institute (UI): http://www.urban.org
See also Centers for Medicare and Medicaid Services U.S. Government Accountability Office (GAO):
(CMS); Cost of Healthcare; Life Expectancy; Long- http://www.gao.gov
Term Care; Medicaid; Medicare; Nursing Homes;
Payment Mechanisms
Luft, Harold S.
Further Readings
Gibson, Mary Jo, and Ari N. Houser. Valuing the Harold S. Luft is a leading health services
Invaluable: A New Look at the Economic Value of researcher. He is perhaps best known for his work
Family Caregiving. Washington, DC: AARP, 2006. on how health maintenance organizations (HMOs)
Johnson, Richard W., Desmond Toohey, and Joshua M. achieve cost savings compared with fee-for-service
Weiner. Meeting the Long-Term Care Needs of the medicine and his discovery of the volume-quality
Baby Boomers: How Changing Families Will Affect relationship in healthcare—the inverse relation-
Paid Helpers and Institutions. The Retirement ship between the volume of hospital procedures
Project, Discussion Paper 07–04. Washington, DC: performed and in-hospital patient mortality for
Urban Institute, 2007. certain surgeries and medical conditions.
Komisar, Harriet L., and Lee Shirey Thompson. National Luft is the former Caldwell B. Esselstyn Professor
Spending on Long-Term Care. Fact Sheet, Long-Term of Health Policy and Health Economics and direc-
Care Financing Project. Washington DC: Georgetown
tor of the Institute for Health Policy Studies at the
University, 2007.
University of California, San Francisco (UCSF). In
Koitz, Dave, Mellissa D. Bobb, and Ben Page. The
2008, he became the director of the Palo Alto
Looming Budgetary Impact of Society’s Aging.
Medical Foundation Research Institute.
Congressional Budget Office Long-Range Fiscal
Born in 1947 in Newark, New Jersey, Luft
Policy Brief, No. 2. Washington, DC: Congressional
Budget Office, July 3, 2002.
received his bachelor’s degree, master’s degree, and
Manton, Kenneth G., Gene R. Lowrimore, Arthur D. doctorate from Harvard University, where he spe-
Ulian, et al. “Labor Force Participation and Human cialized in health sector economics and public
Capital Increases in an Aging Population and finance. Prior to joining UCSF in 1978, he was an
Implications for U.S. Research Investment,” assistant professor in the Health Services Research
Proceedings of the National Academy of Sciences Program at Stanford University.
104(26): 10802–10807, June 26, 2007. Luft has undertaken research in a variety of
Miller, Edward Allan, and Vincent Mor. Out of the areas, including the applications of cost-benefit
Shadows: Envisioning a Brighter Future for Long- analysis, the relationship between hospital vol-
Term Care in America. Providence, RI: Brown umes and patient outcomes, the regionalization of
University, Center for Gerontology and Health Care hospital services, HMOs, risk assessment and risk
Research, 2006. adjustment, quality and outcomes of care, and
Luft, Harold S. 697
healthcare reform in various states and communi- Luft has also been pivotally involved in multi-
ties. He also has studied the role of large databases disciplinary postdoctoral training for more than
and informatics tools to improve healthcare. 35 years. He served as the codirector or associate
Throughout his long career, Luft has authored director for three training programs sponsored
or coauthored five books and almost 200 scientific jointly by UCSF and the University of California,
journal articles. His most recent book, Total Cure: Berkeley.
Rebuilding the American Healthcare System, pro-
poses a fundamental restructuring of the nation’s Ross M. Mullner
financing and delivery of healthcare. He also has
See also Health Economics; Health Maintenance
served on many editorial boards, including the Organizations (HMO); Managed Care; National
journal Inquiry, and was the coeditor-in-chief of Health Insurance; Public Policy; Quality of Healthcare;
Health Services Research from 1997 to 2006. Volume-Outcome Relationship
Luft has received many awards and recognitions
for his outstanding contributions to the field. He
was awarded the Investigator Award in Health
Policy Research from the Robert Wood Johnson Further Readings
Foundation (RWJF) in 2004; the Distinguished Luft, Harold S. “Assessing the Evidence on HMO
Investigator Award from the Association of Health Performance,” Milbank Memorial Fund Quarterly
Services Research in 1999; and the William B. 58(4): 501–36, 1980.
Graham Prize for Health Services Research, spon- Luft, Harold S. “Health Maintenance Organizations and
sored by the Association of University Programs in the Rationing of Medical Care,” Milbank Memorial
Health Administration (AUPHA) and the Baxter Fund Quarterly 60(2): 268–306, 1982.
Allegiance Foundation, in 1998. He also was a fel- Luft, Harold S. Total Cure: Rebuilding the American
low of the Center for Advanced Study in Behavioral Healthcare System. Cambridge, MA: Harvard
Sciences, the National Science Foundation, and the University Press, 2008.
Carnegie Foundation and a Graduate Prize Fellow Luft, Harold S. “Universal Health Care Coverage: A
at Harvard University. Potential Hybrid Solution,” Journal of the American
Luft is a member of the National Academy of Medical Association 297(10): 1115–18, March 14,
2007.
Sciences, Institute of Medicine (IOM). He was a
Luft Harold S., John P. Bunker, and Alain C. Enthoven.
member of and chaired the National Advisory
“Should Operations Be Regionalized? The Empirical
Council of the Agency for Health Care Policy and
Relation Between Surgical Volume and Mortality,”
Research (now the Agency for Healthcare Research
and Quality). He is a research associate at the December 20, 1979.
National Bureau of Economic Research (NBER). In Luft, Harold S., Sandra S. Hunt, and Susan C. Maerki.
addition, Luft has served on the board of “The Volume-Outcome Relationship: Practice-Makes-
AcademyHealth. And he also has been a consultant Perfect or Selective-Referral Patterns?” Health
to a number of federal agencies, including the Health Services Research 22(2): 157–82, June 1987.
Care Financing Administration (HCFA) (now the
Centers for Medicare and Medicaid Services [CMS]),
the National Institute of Mental Health (NIMH),
Web Sites
the U.S Commission on Civil Rights, and the U.S.
General Accounting Office (GAO) (now the U.S. Palo Alto Medical Foundation (PAMF) Research
General Accountability Office). Institute: http://www.pamf.org/research
M
doubt,” in civil actions such as malpractice, the
Malpractice standard of proof is “the preponderance of evi-
dence, which means more likely than not,” or 51
Malpractice is defined as professional negligence on a scale of 100.
that results in injury or harm to an individual.
Although the term malpractice can be applied to
other professions, the most common reference is Duty
in the area of medicine or healthcare. The Joint The duty of care is a legal obligation that
Commission defines malpractice as “improper or requires that an individual adhere to a reasonable
unethical conduct or unreasonable lack of skill by standard of care when performing acts that could
a holder of a professional or official position.” cause harm to another. Although the law does not
Malpractice arises from the branch of law called necessarily define the duty of care, its meaning may
tort law or civil law, where a remedy can be pro- develop through common law or local customs.
vided for the action. This is different from crimi- For example, physicians generally are said to have
nal law or penal law, where causes of action lead a duty of care by virtue of the physician–patient
to prosecution. When malpractice occurs in health- relationship. This relationship may be established
care delivery, it is referred to as medical malprac- when a patient first makes an appointment to
tice, although it can involve any healthcare receive care and treatment, or it may be established
provider or facility. when a physician is consulted to render emergency
This entry focuses first on the elements neces- care and treatment. Hospital or other healthcare
sary to establish a claim of medical malpractice. facility personnel are said to have a duty of care
Then, it discusses the incidence of malpractice. because they are either employees or contractors
Last, this entry addresses the limitations that may for an agent that agrees to deliver services to a
occur as a result of medical malpractice claims. patient. Pharmacists also have a duty of care when
they can reasonably foresee that their actions or
inactions could reasonably cause harm to clients.
Elements of Malpractice
Although all healthcare employees generally are
To make a claim that medical malpractice has expected to honor the duty of care for patients
occurred, a claimant must establish four elements: under their care, there have been cases where
(1) duty, (2) breach of duty, (3) causation, and employees have successfully argued that they did
(4) damages. All four of these elements must exist not have a duty of care because provision of care
and must be proven for a medical malpractice would have violated their own ethical principles.
claim to be satisfied. Unlike criminal actions, In healthcare, the duty a professional owes to
where the standard is “beyond a reasonable an individual under his or her care is based on
699
700 Malpractice
standards of care. Standards of care address the possess the knowledge and training to carry out a
reasonableness of care and hold a professional specific role. This can occur, for example, when
accountable to deliver care as would a reasonable advanced-practice nurses, physician’s assistants, or
person with similar training and skills in similar other similarly credentialed individuals perform
circumstances. This is known as the reasonable- functions that had previously been only in the
person standard. scope of physician practice. In these cases, the
Standards of care may be defined in a number other professionals will be held to the same stan-
of ways. For an individual holding a license to dard as that expected of the physician.
practice a profession, the standard may be defined
through the elements articulated in a scope of pro-
Breach of Duty
fessional practice. This is generally one of the ways
by which standards of care can be established for A breach of duty occurs when the care rendered
physicians, dentists, nurses, physical and occupa- is unreasonable or fails to meet the reasonable-
tional therapists, and other similarly credentialed person standard of care previously described. In
individuals. Standards of care also may be estab- medical malpractice, an expert witness is generally
lished by state laws, by accrediting and profes- called upon to help establish the applicable stan-
sional associations, and through organizational dard of care and then to testify as to whether the
policies and procedures that govern how care is to healthcare professional met or breached the stan-
be rendered. dard established.
Depending on the locale, standards of care may There are three common legal terms that relate
follow national standards or be based on local to the manner in which a professional might fail to
customs and practices. If a national standard is meet the applicable standard: (1) nonfeasance, (2)
applied, this means that the reasonable-person misfeasance, and (3) malfeasance. Nonfeasance
standard would be based on what similarly trained refers to the failure to do something that was
individuals with similar skills would do under the expected. For example, if the applicable standard
same conditions anywhere in the United States. On of care for a particular hospital indicates that a
the other hand, if a local standard is applied, the medical patient’s vital signs are to be taken every 4
standard would reflect what similarly trained indi- hours, failure to take them at that interval as a
viduals would be expected to do in communities minimum would constitute nonfeasance. Similarly,
that have the characteristics of the community if a patient had laboratory tests ordered and the
where the care was rendered. Since most health- laboratory, although able, failed to collect the nec-
care professionals are expected to be educated to essary specimens, that would also be considered
deliver care anywhere, it is more common to find nonfeasance. Nonfeasance is also referred to as an
a national standard of care applied. error of omission. Failure to act or nonfeasance, in
In determining the applicable standard of care for itself, however, does not constitute malpractice.
specific actions of a professional, there is an expecta- Misfeasance occurs when there are errors due to
tion that if a professional carries out a task requiring mistakes or carelessness. Medical errors such as
special knowledge and skill, she or he will be evalu- wrong-site surgery, administration of medication or
ated as if she or he possessed the requisite knowl- treatments to the wrong patient, failure to adequately
edge and skill to perform the task. For example, if a respond to information about changes in a patient’s
resident physician performs a procedure such as medical condition, or prescribing medications that
insertion of a chest tube and causes the patient may be contraindicated based on a patient’s other
harm, that resident will be judged by the standards medications or medical history are examples of mis-
that govern the insertion of a chest tube by a fully takes or carelessness. These types of errors are also
trained physician in the appropriate medical spe- referred to as errors of commission. In its report To
cialty. If those reasonable-person standards are not Err Is Human: Building a Safer Health System, the
met, the resident will be deemed to have deviated national Institute of Medicine (IOM) identifies the
from acceptable standards of practice. types of errors that commonly occur in healthcare
The issue of “reasonable person” often emerges and establishes strategies to improve communication
when more than one group of professionals between healthcare workers as an approach to
Malpractice 701
reducing these errors. In addition, the Joint caused an injury when the infant was born with a
Commission has identified strategies to improve congenital malformation. However, an expert wit-
institutional responses to sentinel events, those ness for the plaintiff might allege that the failure to
instances of misfeasance that lead to death or seri- correctly read the fetal monitor strips led to a delay
ous injury. Although most of the breaches of stan- in the delivery of the infant, which further compro-
dards of care that lead to claims of malpractice mised the infant’s condition at birth.
come from errors and mistakes that are deemed mis- Sometimes there are areas of disagreement
feasance, not all misfeasance will lead to sustainable about causation depending on the types of health-
claims of malpractice. care providers involved and the applicable scopes
Malfeasance is intentional wrongdoing. It occurs of practice. For example, if a nurse saw that a
when an individual or group does something that patient was not responding to a particular treat-
is legally or morally wrong. An example of inten- ment or medication and communicated that to the
tional wrongdoing in healthcare might be filling a physician and the physician delayed getting to the
patient’s prescription for an expensive medication hospital to care for the patient, it may not be pos-
with a placebo yet charging the patient or the sible to attribute responsibility to the nurse for the
health insurance company for the medication that delay. However, if the nurse saw that the patient
was ordered. At a time when the cost and quality was not responding to treatment and communi-
of healthcare are under intense scrutiny, it has cated it only in the medical record, without mak-
been argued that health insurance company actions ing the physician aware of the problem, then he or
denying access to needed costly services for sub- she could be judged with a reasonable degree of
scribers is also a form of malfeasance. Although medical probability to have caused the injury that
malfeasance can result in allegations of malprac- occurred to the patient as the result of delayed
tice, the intentional wrongdoing often makes this a medical care.
criminal offense.
Damages
Causation
The final element that must be satisfied in a case
The third element that is necessary to establish alleging malpractice is that damages have occurred.
a claim of malpractice is that the breach of duty or To recover damages, a plaintiff must establish that
failure to meet the prescribed standard of care he or she suffered physical, financial, or emotional
must be the direct cause of injury to the patient. injury as the result of the healthcare professional’s
This is often the most difficult element to prove in deviation from the acceptable standard of care. If
a lawsuit that arises out of an act of negligence. To a plaintiff is able to establish that all the elements
satisfy this element, the plaintiff or injured party of malpractice have been satisfied and a judge or
must prove that but for the actions of the health- jury agrees with this determination, a monetary
care provider, the injury sustained would not have settlement is imposed to compensate for the inju-
occurred. Causation is attributed based on the ries sustained.
concept of probability. To satisfy this element, an There are three types of damages that may be
expert witness must be able to state to a degree of awarded to a plaintiff: (1) economic, (2) noneco-
reasonable probability (51%) that the injury was nomic, and (3) punitive. Economic damages are
caused by the breach of standard of care. the result of actual costs or financial losses sus-
Major discrepancies can exist between the tained by the plaintiff or his or her family because
plaintiff’s and the healthcare professional defen- of the negligence. These may include the cost of
dant’s positions about causation even if there is additional or subsequent care associated with any
agreement that the professional did not meet the residual impairment, lost wages of the individual
applicable standard of care. For example, a nurse or of a family member who has had to provide
providing care to a mother in labor may have care to the injured individual, and estimations of
incorrectly read the fetal monitor strips. Although future care costs.
the nurse did not recognize some of the changes on Noneconomic damages are those damages
the strip, this error may not be deemed to have that the law assumes to accumulate from the
702 Malpractice
consequences of the negligent act. The plaintiff can was similar to that reported in earlier studies. A
be compensated for emotional stress, interference 1984 Harvard research study found that 1% of a
with his or her enjoyment of life, and what has representative sample of all patients hospitalized in
been called pain and suffering. Although some New York State experienced injuries and one quar-
jurisdictions have made efforts to limit awards for ter of that number died. If the New York findings
noneconomic damages, they still constitute a sig- were extrapolated nationwide, the numbers would
nificant amount of the damage recovery for a represent more than 234,000 patient injuries and
plaintiff. 80,000 deaths per year from negligence. A 2006
Punitive damages are what are called punishing follow-up of the 1999 national IOM study found
damages: Punitive damages are awarded to punish that 1.5 million people were harmed due to medi-
a wrongdoing that is outrageous in character. One cation errors alone. More than half of these errors
of the legal terms used when a request is made for occurred in long-term care facilities with the
punitive damages is that the act represented a reck- remainder divided between outpatient facilities
less disregard for the safety and well-being of the treating Medicare recipients and hospitals.
injured party or that the care rendered was incom- Despite the number of injuries and deaths
petent. Two examples of acts that could lead to the reported, fewer than 1% of physicians nationwide
award of punitive damages are providing health- have had claims made against them for malprac-
care when impaired by drugs or alcohol or failure tice. Although this number is rising, the scope of
to provide care for a patient despite repeated the involvement of physicians and other profes-
requests to be physically present. Hospitals can sionals remains small. About one half of all cases
also be charged with punitive damages when they brought to trial in 2002 in the 75 largest counties
continue to grant privileges to a staff member who in the United States involved cases against sur-
has acted in the manner described above. In addi- geons, and one third were against nonsurgeon
tion, hospitals have been charged punitive dam- physicians. In the same report, 90% of plaintiffs
ages for holding themselves out to the community alleged death or permanent disability.
as offering a particular type of service but not Although there are significant errors that can
delivering it in a way that meets the appropriate and do occur in the delivery of healthcare, the rate
standard of care. For example, if a hospital says of success in winning a malpractice claim in court
that it does open-heart surgery but does not have is low. Although almost 52% of other civil torts
trained and available support staff, an award of are settled in favor of the plaintiffs, in medical
punitive damages could result from the injury malpractice cases that number drops to 27%.
or death of a surgical patient because of the inap-
propriate staffing. Although punitive damages
Resulting Limitations
are often requested in malpractice cases, they are
infrequently awarded. However, when they are A major concern with medical malpractice is that
awarded, they can be significantly higher than the the increasing numbers of claims, the costs associ-
total of the economic and noneconomic damages ated with defending them, and the sizes of the
awarded. In some jurisdictions, health malpractice awards when the claims are successful have led to
insurance companies are prohibited from covering limitations in access to healthcare. The loss of
the cost to a defendant related to the award of access is not related to the inability of patients to
punitive damages. pay for care but rather to decisions by profession-
als to leave practice completely, leave specialty
practice, or limit the types of medical conditions
Incidence of Malpractice
that they are willing to treat. In the past several
Although the actual number of claims for malprac- years, for example, many obstetrician-gynecolo-
tice is unknown, there are data that suggest that gists are limiting their practices to gynecology
patient injuries occur too frequently. In 1999, a only, and neurosurgeons and other subspecialists
national IOM report estimated that as many as are limiting the sizes of their practices or are refus-
98,000 individuals die in the nation’s hospitals ing to perform complex surgical procedures. In
each year as a result of medical errors. This number many cases, these decisions are made due to the
Managed Care 703
high cost of malpractice insurance coverage. In Stubenrauch, James M. “Malpractice vs. Negligence,”
other cases, the decisions are made due to the high American Journal of Nursing 107(7): 63, July 2007.
cost of emotional investments in refuting claims Thorpe, Kenneth E. “The Medical Malpractice ‘Crisis’:
that the professionals believe are unjustified. Recent Trends and the Impact of State Tort
Rising medical malpractice insurance premiums Reforms,” Health Affairs Web Exclusive, January 21,
coupled with the growing number of uninsured or 2004, http://www.content.healthaffairs.org/cgi/
underinsured individuals nationally may be a pre- content/full/hlthaff.w4.20v1/DC1
scription for disaster. Many individuals who lack Vidmar, Neil. Medical Malpractice and the American
Jury: Confronting the Myths About Jury
adequate health insurance coverage have limited
Incompetence, Deep Pockets, and Outrageous
access to care and do not appropriately manage
Damage Awards. Ann Arbor: University of Michigan
their chronic medical conditions, nor do they
Press, 1997.
receive preventive care. When they do seek needed
care, often their disease conditions are more
advanced and complex, hence healthcare providers
are at increased risk of making errors. It is these Web Sites
errors that lead to future claims of malpractice and American Hospital Association (AHA): http://www.aha.org
a cycle that many believe is out of control. American Medical Association (AMA):
http://www.ama-assn.org
Linda F. Samson American Trial Lawyers Association (ATLA):
See also American Hospital Association (AHA); http://www.theatla.com
American Medical Association (AMA); Clinical Health Care Choices:
Practice Guidelines; Cost of Healthcare; Institute of http://www.healthcarechoices.org/profile.htm
Medicine (IOM); Joint Commission; Medical Errors; Joint Commission: http://www.jointcommission.org
Quality of Healthcare National Practitioner Data Bank (NPDB):
http://www.npdb-hipdb.hrsa.gov
Physician Insurers Association of America (PIAA):
Further Readings http://www.piaa.us
Anderson, Richard E., ed. Medical Malpractice: A U.S. Department of Justice: http://www.ojp.usdoj.gov/
Physician’s Sourcebook. Totowa, NJ: Humana Press, bjs/abstract/mmtvlc01.htm
2004.
Aspden, Phillip, Julie Wolcott, J. Lyle Bootman, et al.,
eds. Preventing Medication Errors. Washington, DC:
National Academy Press, 2006. Managed Care
Baker, Tom. The Medical Malpractice Myth. Chicago:
University of Chicago Press, 2005.
Managed care is a complex system that involves
Gorombei, D. A., P. Crowell, and L. Plate. “Medical
the active coordination of and arrangement for
Malpractice Tort Reform,” Journal of Legal Nurse
the provision of health services and the coverage
Consulting 18(1): 20–23, 2007.
of health benefits. The term managed care was
Helm, Ann, ed. Nursing Malpractice: Sidestepping Legal
coined in the 1980s to name the array of emerging
Minefields. Philadelphia: Lippincott, Williams and
Wilkins, 2003.
health insurance products that were evolving in
Kohn, Linda T., Janet M. Corrigan, and Molla S. response to skyrocketing healthcare costs. To dif-
Donaldson, eds. To Err Is Human: Building a Safer ferentiate these new products from traditional
Health System. Washington, DC: National Academy insurance, commercial insurers adopted the generic
Press, 1999. term managed care to describe health benefit
Sage, William M., and Rogan Kersh, eds. Medical products that attempted to control the cost of
Malpractice and the U.S. Health Care System. New care by restricting the choice of providers or the
York: Cambridge University Press, 2006. use of medical services. Today, it encompasses
Sloan, Frank A., Penny B. Githens, Ellen Wright a broad spectrum of organizational structures
Clayton, et al. Suing for Medical Malpractice. and benefit plans such as (a) health maintenance
Chicago: University of Chicago Press, 1993. organizations (HMOs), (b) preferred provider
704 Managed Care
organizations (PPOs), (c) point of service plans lower reimbursement, usually taking an additional
(POS), (d) individual practice associations (IPAs), 10% or 20% off the billed or UCR fees.
(e) exclusive provider organizations (EPOs), and Whereas the discounting of fees yielded some
(f) consumer-directed healthcare (CDH). initial cost relief, it did not change the inherent
The exact nature of managed care is constantly dynamics; each insurer developed different con-
evolving in response to the changing demands of tracting strategies to try to affect hospital costs.
consumers, employers, and regulators. There are Most hospitals preferred a variant of fee-for-
three key components of managed care: (1) the service. Thus, the most common arrangement was
network or contractual relationship with health- a greater discount off the billed charges. Under
care providers, (2) the oversight or coordination of some contracts, facilities would agree to a flat,
medical care, and (3) the structure of the covered daily rate (per diem). Initially, these rates were all-
healthcare benefits and copayments. Early man- inclusive for all levels of care. Eventually, per diem
aged-care plans were nothing more than networks contracts became more sophisticated, and the rates
of providers who agreed to accept lower reim- were negotiated based on the complexity of the
bursements to be included in a plan’s network of service provided, with higher rates for more com-
preferred providers: hence, preferred provider plex services such as intensive care units, mater-
organizations or PPOs. There were benefits or nity, pediatrics, and so on. As technology and costs
financial penalties if the insured did or did not use advanced, per diem contracts began to include
a preferred provider. Later on, managed-care orga- carve-outs for high-cost devices (e.g., implantable
nizations added medical-management initiatives pacemakers) and medications.
such as preauthorization of services and manda- Another method of facility reimbursement—
tory second opinions. In response to rising political developed and implemented by Medicare in the
pressures, medical management has evolved away mid-1980s—was based on Diagnostic Related
from prior authorization to focus more on care Groupings (DRGs). Facilities received a fixed
coordination and disease management. Recently, reimbursement for all anticipated services based
financial incentives and disincentives have taken on the expected average cost of care for a patient
the forefront in efforts to influence healthcare with a specific discharge diagnosis. DRG payments
costs, taking the form of CDH. CDH uses an array fundamentally changed the dynamics of hospital
of benefit designs with higher copayments, higher reimbursement. Once hospitals were no longer
deductibles, or both to empower consumers to reimbursed on a cost-plus basis, they began to
more effectively manage their healthcare. address the different factors that influenced the
cost of care in their facilities. Hospitals instituted
utilization reviews of patient stays to identify and
Contracting and Networks
address the excessive length of hospitalizations.
Provider contracting was the easiest and therefore Hospitals also implemented pharmacy and thera-
the first component of managed care to be imple- peutic committees to identify opportunities to
mented. Insurers began requiring providers who lower medication and medical-device costs. These
wanted to be included in their network of pre- efforts led to shorter lengths of hospitalization;
ferred providers to agree to negotiated discounts increased use of lower-cost, generic, and therapeu-
off their standard rates. Prior to the advent of tically equivalent medications; and greater stan-
PPOs, most hospital services were being reim- dardization of implantable medical devices and
bursed at 100% of the billed charges. These fees appliances.
were loosely based on cost plus some percentage A few hospital systems were so confident in
above the estimated cost. This methodology actu- their ability to manage costs that they began taking
ally encouraged higher charges and contributed to the risk of global capitation for the inpatient and
the rapid escalation of healthcare costs. outpatient care they provided. Some hospitals
Physicians and other healthcare providers had established their own health plans; others negoti-
been reimbursed at billed charges or community- ated full-risk contracts with insurers. Although
average rate, known as usual, customary, and few of these contracts and health plans remain, the
reasonable (UCR). Early PPOs simply negotiated a collective efforts of hospitals to manage their cost
Managed Care 705
of care have resulted in shorter lengths of hospital- clinical criteria for determining the medical need
ization and a more efficient use of resources. for ongoing hospitalization that were developed by
Although relatively rare, organ-transplant ser- InterQual, Inc. were the most commonly used cri-
vices were an early focus of managed-care organi- teria by hospitals and were adopted by the Medicare
zations due to their high cost, wide variation in program in 1999. InterQual’s criteria did not set
cost, and variation in the outcomes for similar an expected length of stay for a hospitalization;
transplant services across the country. Often, the rather, they assessed whether a patient needed to
higher-cost facilities were achieving less favorable remain at a particular level of care (e.g., intensive
outcomes with lower survival rates. In an effort to care or hospitalization) based on the treatment and
achieve better outcomes for lower costs, insurers services the patient was receiving.
began limiting coverage for transplants to pre- Health plans tended to use the inpatient care
ferred facilities. These preferred facilities were guidelines developed by Milliman and Robertson,
often referred to as centers of excellence. Eventually, Inc. (now Milliman, Inc.) in the late 1980s. The
preferential contracting for centers of excellence Milliman care guidelines assigned an expected
expanded to include other complex medical proce- length of stay for each hospitalization based on an
dures as well as some high-volume or high-cost optimal outcome. The guidelines were evidence
cardiac procedures. based and reviewed by expert panels of physi-
To encourage patients to seek care at these pre- cians. The Milliman care guidelines specified the
ferred centers of excellence, insurers would usually expected progression of hospitalized care for spe-
cover patients’ additional travel and housing cific medical and surgical procedures. Before the
expenses. In addition, health coverage plans were Milliman guidelines were introduced into a mar-
often designed to waive or limit patient cost shar- ket, the actual length of hospital stays was usually
ing if services were obtained at the insurers’ pre- significantly longer than the optimal length speci-
ferred centers. Initially, each insurer developed his fied by the guidelines. Initially, extended hospital-
or her own list of centers of excellence based on ization due to a delay in care would result in
individual criteria. However, as the process spread, denial or carving out of hospital days—that is,
specialty medical societies and academic medical nonpayment of hospital charges for the excess
centers became involved in developing criteria and days; within 6 to 12 months, hospitalization
tracking outcomes. This lead to increased account- lengths of stay shortened, approaching the guide-
ability and more transparency. line targets. Initially, denial of payment for hospi-
tal days accounted for a small portion of the
resultant savings (5–10%). Most of the savings
Medical Management
came from shorter hospitalizations due to the
and Care Coordination
changes in practice patterns brought on by the
A 1986 RAND Corporation Report suggested clinical guidelines.
that one third of medical procedures were unnec- Once physicians and hospitals modified their
essary. This perception of overuse became an early practice patterns to conform to the guidelines, the
focus of managed care. Initial efforts to influence denial of payment was minimal (2–3%), and
the care provided included (a) mandatory second there was marginal subsequent decrease in hospi-
opinions for elective surgery, (b) prior authoriza- talization lengths of stay. This lack of ongoing
tion for elective procedures and diagnostic tests improvement often called into question the need
such as CT scans, and (c) limiting the networks of for continuing inpatient utilization management
medical specialists. Prior authorization programs programs. This tension intensified in the late
were implemented to reduce the use of high-cost, 1990s when public and political perceptions of
frequently ordered procedures and to ensure that managed care soured. As a result, many insurers
patients were referred to in-network preferred scaled back their inpatient utilization manage-
facilities and providers. ment programs.
In addition to prior authorization of elective Outpatient utilization management programs,
hospitalizations, hospitalizations were reviewed although effective, did not result in such clear-cut
against external criteria and benchmarks. The savings. The major impact was not through denial
706 Managed Care
of services, which averaged 2% to 4%, but rather Disease and Care Management
was due to a reduction in the number of services
requested by providers due to their perception of In the 1970s and 1980s, some academic medical
oversight, the sentinel effect. In the inpatient set- centers, large medical groups, and staff- or group-
ting, the sentinel effect was demonstrated by the model HMOs had multidisciplinary specialty clin-
shorter length of hospitalization. In the outpatient ics that focused on a single condition or disease
setting, it was more difficult to measure the impact: (diabetes, cystic fibrosis, anticoagulation, etc.).
As the sentinel effect resulted in a reduction in These programs were predominantly disease focused
the services requested, it was measurement of a and institution based and were developed to stream-
nonevent. The impact of the sentinel effect was line the operational aspects of a clinic visit.
believed to be 2 to 3 times greater than the effect Health plans and insurers developed disease
of the actual denials. However, as most insurers management programs in the early 1990s to lower
did not have detailed authorization statistics to hospitalizations and emergency room visits for
measure the impact of changes in the utilization high-use patients with specific diseases, hence the
management programs, their effectiveness was name disease management. Individuals were iden-
often underestimated. tified for enrollment in disease management pro-
Even with the streamlining and automation of grams by retrospective claims reviews or by
these programs, they often cost 1% to 1.5% provider referrals.
of premiums. Ignoring the sentinel effect savings Nurse case managers, pharmacists, and physi-
of 4% to 9% and accounting only for the savings cians would review hospital medical claims and
from denials, the net savings from these utilization pharmacy records to identify opportunities for
management programs was in the 1% to 3% intervention to prevent repeat hospitalizations. A
range, which was often thought to be too little to key focus of these programs was educating patients
justify the administrative costs and the negative and their families so that they could better under-
marketing impacts. In response to a public and stand and manage their illness. These programs
political backlash against managed care in the late would emphasize the (a) importance of following
1990s, many insurers reduced or eliminated their treatment recommendations, (b) early recognition
utilization management programs, choosing of exacerbations and complications, and (c) meth-
instead to influence use through increased finan- ods for preventive intervention.
cial cost sharing and deductibles. By eliminating Numerous studies documented the lack of stan-
their utilization management programs, insurers dardization of care and the slow adoption of
also took themselves out of the unenviable role of national treatment guidelines by physicians. Disease
trying to control healthcare costs by managing the management programs were one method used by
demand for services. Instead, insurers attempted managed care to disseminate and encourage the
to influence healthcare costs through higher use of evidence-based guidelines. By adopting and
copayments, greater cost sharing, and higher promoting national guidelines to patients and phy-
deductibles. sicians, disease management programs attempted
By increasing consumers’ out-of-pocket costs to improve health outcomes through greater com-
for healthcare services, insurers and employers pliance with the recommended treatment guide-
hoped to slow the rise in healthcare costs by dis- lines. Managed-care organizations could identify
couraging unnecessary care. However, there is individuals who met the criteria for inclusion in a
concern that higher deductibles and cost sharing disease management program from medical claims
may have a negative impact on health outcomes by data, hospital admissions records, emergency
discouraging early intervention and preventive department visits, and pharmacy claims. Once the
care. For commercial and Medicare populations, individuals were identified, nurse case managers
there is greater emphasis on managing use through and pharmacists would review their medical histo-
financial disincentives and cost sharing than ries and claims data to assess if their care was in
through robust utilization management programs, compliance with the guideline recommendations.
one notable exception being in the area of man- If changes in treatment protocols were needed, a
aged Medicaid. nurse, pharmacist or physician would contact the
Managed Care 707
individual’s treating physician to obtain additional study, conducted by the Dartmouth Atlas Project,
information and review the recommended guide- suggests that 30% of U.S. healthcare costs could be
lines. If necessary, a nurse case manager or a physi- saved by increased standardization of care, empha-
cian could also contact the physician to discuss sizing preventive care, and focusing on managing
additional intervention, such as a consultation chronic disease.
with a specialist or more frequent physician visits.
Initially, disease management programs for asthma
Medicaid Managed Care
and congestive heart failure were very successful in
encouraging adoption of the guidelines, improving One area in which managed care has continued to
outcomes, and reducing costs. grow is Medicaid. Since the early 1990s, state
Disease management programs continued to Medicaid programs have turned increasingly to
evolve, increasing the number of diseases covered, managed care to improve access to care and to
the scope of the interventions, and the comprehen- contain costs. Many states have enrolled sizable
siveness of the interventions. Disease management portions of their Medicaid beneficiary populations
programs became more proactive in identifying in some form of managed care. As Medicaid pro-
candidates for their programs by using sophisti- grams provide health coverage to individuals and
cated predictive-modeling software in their analy- families with low incomes, the copayments and
sis of medical claims, pharmacy, and laboratory beneficiary out-of-pocket expenses are minimal.
data. Predictive modeling allowed disease manage- Unlike commercial programs in which managed-
ment programs to identify individuals who were at care organizations have attempted to substitute
greater risk for complications from their illness financial cost sharing to control costs, Medicaid
and to initiate interventions to prevent costly treat- managed care has continued to emphasize utiliza-
ments for complications and hospitalizations. tion management and disease management pro-
During the past decade, traditional disease man- grams to achieve savings. Although the nature and
agement programs have expanded beyond a single- composition of these utilization management pro-
disease focus to encompass the individual’s overall grams vary greatly by state and by company, the
healthcare needs. As a result, the term disease majority of their cost savings result from reduced
management has transitioned to care management inpatient use and pharmacy expenses.
to signify these changes. The options for interven-
tion have also greatly expanded. Current care
Future Implications
management programs provide a wide array of
education options, from quarterly newsletters to Over the past 30 years, managed care has under-
comprehensive Web-based educational offerings. gone a dramatic evolution. The term managed
Interventions may be as simple as prescription care now represents such a broad array of prod-
refill reminders or may include ongoing home- ucts, services, and interventions that it nearly
based monitoring of symptoms and an expanding defies explicit definition. Managed care can
array of biometric information such as blood pres- broadly be described as any strategy of organizing
sure, weight, and blood oxygen saturation. By healthcare delivery to influence cost. Another way
identifying early changes in their conditions, indi- to define managed care is to describe what it is
viduals, nurse case managers, and physicians can not—unmanaged care: unrestricted healthcare
intervene early and prevent or minimize exacerba- coverage that allows the beneficiary to see any
tions of the conditions. healthcare provider for any service at any time
Whereas the scope of care management programs without any financial consequences.
has expanded, the emphasis has remained on As healthcare costs continued to rise, the gov-
improving health outcomes through greater stan- ernment, payers, and individuals sought solutions
dardization of care in compliance with evidence- and alternatives. Managed care offered consumers
based medical guidelines. A RAND Corporation expanded coverage and lower out-of-pocket
study, in 2003, estimated that patients with chronic expenses with some restrictions on access and
illness received only 55% of the care recommended limitations on use. It offered employers price mod-
by the established national guidelines. Another eration and insulated consumers from the true
708 Managed Care
financial costs of their healthcare. Managed care’s coverage be affordable and accessible or will there
expansion of coverage for preventive services, be restrictions and limitations? Are individuals
well-child examinations, prenatal care, immuniza- entitled to all the healthcare services they want?
tions, pharmacy services, and disease care manage- Should everyone be guaranteed the healthcare they
ment programs went from being new and innovative need? Regardless of the payment mechanism—
programs to basic requirements of health insur- single payer, nationalized health system, or the
ance coverage. current model—some form of managed care will
In part as a result of managed care’s success in likely remain.
expanding covered benefits, controlling healthcare
costs, and financially insulating consumers from Bruce A. Weiss
the cost of their care, there was a backlash against
See also Carve-Outs; Case Management; Consumer-
any constraints or restrictions on individuals’
Directed Health Plans (CDHPs); Disease Management;
healthcare desires: In the face of managed care’s
Health Maintenance Organizations (HMOs);
successes, people questioned whether such restric- Medicaid; Preferred Provider Organizations (PPOs);
tions were necessary or appropriate. Managed care Primary Care Case Management (PCCM)
became the scapegoat for rising healthcare costs
and Americans’ reluctant recognition that societal
resources for healthcare were not unlimited.
In response to political and marketplace pres- Further Readings
sures, managed care developed new strategies and Bloche, M. Gregg. “Consumer-Directed Health Care,”
products that imposed fewer restrictions and gave New England Journal of Medicine 355(17): 1756–59,
consumers greater control along with greater October 26, 2006.
financial responsibility for their health care. These Committee on the Quality of Health Care in America,
consumer-directed products substituted the indi- Institute of Medicine. Crossing the Quality Chasm: A
vidual’s willingness to pay for managed care’s New Health System for the 21st Century.
medical-necessity criteria. For a price, this approach Washington, DC: National Academy Press, 2001.
removed managed-care programs from the process Enthoven, Alain C. “The History and Principles of
of making decisions about whom individuals could Managed Competition,” Health Affairs 12(Suppl.):
see or what care was medically necessary and 24–48, 1993.
allowed unimpeded access to care. Individuals Iglehart, John K. “The American Health Care System:
with sufficient financial means can access all the Managed Care,” New England Journal of Medicine
care that they desire; conversely, a greater number 327(10): 742–47, September 3, 1992.
of Americans are deciding what healthcare they get Marquis, M. Susan, Jeannette A. Rogowski, and Jose J.
based on what they can afford. Escarce. “The Managed Care Backlash: Did
Consumers Vote With Their Feet?” Inquiry 41(4):
Although CDH has been a politically successful
376–90, Winter 2004–2005.
strategy, rising healthcare costs continue to erode
McGlynn, Elizabeth A., Steven M. Asch, John Adams, et
health insurance coverage. The proportion of
al. “The Quality of Health Care Delivered to Adults
employers offering health insurance coverage has
in the United States,” New England Journal of
declined to 60% in 2006 from 69% in 2000. Medicine 348(26): 2635–45, June 26, 2003.
Employers that continue to offer health coverage Newhouse, Joseph P. “Consumer-Directed Health Plans
are requiring employees to pay a higher portion of and the RAND Health Insurance Experiment,”
health insurance costs through higher premium Health Affairs 23(6): 107–113, November–December
contributions, increased copayments, and larger 2004.
deductibles. All these changes are leading to a ris- Robinson, James C. “The End of Managed Care,”
ing number of uninsured individuals as people are Journal of the American Medical Association 285(20):
unable or unwilling to pay these higher out-of- 2622–28, May 23, 2001.
pocket costs. With the demand for healthcare ser- Starr, P. The Social Transformation of American
vices in the United States continuing to grow faster Medicine: The Rise of a Sovereign Profession and the
than our ability to pay for them, it is clear that Making of a Vast Industry. New York: Basic Books,
the future will require trade-offs: Will healthcare 1983.
Market Failure 709
Web Sites problem of uncertainty, (c) asymmetric informa-

Dartmouth Atlas Working Group: tion, and (d) the existence of positive and negative
http://www.dartmouthatlas.org externalities.
Disease Management Association of America (DMAA):
http://www.dmaa.org Market Power
http://www.kff.org Market power exists when an individual firm
InterQual, Inc.: http://www.interqual.com has the ability to influence the market price of a
Managed Care Museum: good or service with the result that the price
http://www.managedcaremuseum.com exceeds the marginal cost of the good or service.
Milliman, Inc.: http://www.milliman.com Market power violates the assumption that a suf-
RAND Corporation: http://www.rand.org ficiently large number of sellers exists to guarantee
that each individual seller is a price taker in a per-
fectly competitive market. Market power includes
situations ranging from imperfect competition, in
Market Failure which multiple sellers compete against each other
and each has some influence over the price, to a
A market failure exists in the healthcare market monopolistic market, in which there is only one
when the allocation of goods or services is not seller and this seller has control over the entire
efficient—an allocative inefficiency. Efficiency is market. The presence of market power leads to
measured by the concept of Pareto efficiency, a market failure because of deadweight loss—that is,
situation where goods or services have been allo- a loss to society due to a market price that is greater
cated among members of society in such a way than and a market quantity that is less than the
that they cannot be reallocated so as to improve market price and quantity in an efficient market.
the welfare of at least one member without reduc- A classic example of a monopoly in the health-
ing the welfare of others. A perfectly competitive care market is the market for a drug that is covered
market is a hypothetical ideal market in which by a patent. With a patented drug, only one manu-
there are (a) a large number of buyers and sellers facturer has the legal right to produce the drug
in the market, (b) free entry into and exit out of until the patent expires, creating a monopoly mar-
the market, (c) homogeneity of the goods or ser- ket until the patent’s expiration. As a monopolist,
vices, and (d) perfect knowledge. A perfectly com- the manufacturer will charge a price that exceeds
petitive market is an efficient market and the the efficient price (i.e., the price that would exist in
yardstick against which economists and others a perfectly competitive market) and sell a quantity
measure whether a market failure exists. A market of the drug that is less than the efficient quantity.
failure is problematic because it results in a mar- More commonly, firms may have monopoly
ket transaction that is socially inefficient—that is, power, a situation in which there are multiple sell-
where the market price does not equal the mar- ers of a good or service but one seller can increase
ginal cost and where potential welfare gains to its price and still maintain at least some of its
trade exist but are not achieved. In this entry, the market share. Both physicians and hospitals exer-
common types of market failure in healthcare are cise varying degrees of monopoly power. A physi-
explained, and then potential solutions to these cian could increase his or her fee for an office
failures are discussed. visit, for example, and still keep some patients.
Whereas some patients may decide to go to a dif-
ferent physician after the fee increase, other
Types of Market Failure
patients will remain at the physician’s practice.
The healthcare market exhibits a number of prop- This ability to increase fees without losing all the
erties that deviate from a socially efficient market. firm’s business is market power. Again, because
The most significant characteristics of the health- an efficient market means that sellers are price
care market that result in a market failure include takers, this is a clear violation of a perfectly com-
(a) the presence of market power, (b) information petitive assumption.
710 Market Failure
Uncertainty than the providers have about their own quality.

For primary care and other frequently purchased
Uncertainty about an individual’s future demand
services (e.g., care for chronic conditions), con-
for medical care is an information problem that
sumers have the opportunity to learn about the
leads to a market failure in the healthcare market.
quality of the provider over time, through experi-
The unpredictability of illness creates uncertainty
ence or trial and error. For services that individuals
regarding when healthcare will be needed, what
make use of infrequently or only need once (e.g., a
services will be required, and how much the care
kidney transplant), asymmetric information is a
will cost. Uncertainty creates a market failure
more important issue. The consumer cannot learn
because consumers (i.e., patients) do not know the
about the quality of a provider through experience
type or quantity of services that they will need and
and, therefore, is unable to monitor the quality of
producers (i.e., providers) do not know the type or
the care delivered.
quantity of services that they will need to provide.
Because of specialized medical training, a pro-
Uncertainty abounds in healthcare. The occur-
vider usually has more information than the patient
rence of illness is largely unpredictable. Once an
about his or her diagnosis and the necessary treat-
individual becomes ill, the diagnosis is not always
ment. The provider acts as an agent of the patient,
known with certainty. Clinical symptoms such as
thereby diagnosing the patient’s illness, recom-
fever, cough, abdominal pain, and shortness of
mending a treatment, and often, providing the rec-
breath are symptomatic of many illnesses. The
ommended treatment. Through this principal-agent
optimal treatment also may not be certain. Many
relationship, the patient delegates some decision-
illnesses can be treated in multiple ways, and the
making power to the provider, thereby allowing the
outcomes are not perfectly tied to these treatments.
provider to influence his or her demand. Even if a
Individuals would like to insure against all these
provider shares with the patient all available infor-
types of uncertainty; however, a market does not
mation about his or her illness, treatment options,
exist for all of them.
and expected outcomes, it may still be difficult or
even impossible for the individual consumer to
Asymmetric Information
make the optimal decision without the provider’s
A second information problem in the healthcare recommendation, given the complexity and quan-
market is asymmetric information. Asymmetric tity of medical information that must be assimilated
information is a situation where one party in a rela- for complicated health problems.
tionship has more information or more accurate
information than another party. This inequality of
Externalities
information violates the perfectly competitive
assumption that all parties involved in a transaction An externality exists when the decision of a
have perfect information. Asymmetric information consumer or producer incurs costs or benefits for
leads to a market failure if demand and supply are other consumers or producers. An externality is
interdependent rather than independent. negative when an individual’s or a firm’s decision
In healthcare, a market failure stems from creates a cost for others; it is positive when an
asymmetric information in situations where con- individual’s or a firm’s decision creates a benefit
sumers do not have the expertise to independently for others. An externality results in a market fail-
determine their own demand for healthcare ser- ure because the market price fails to take into
vices or monitor the quality of the services pro- account the social costs and benefits that are real-
vided. Consumers may lack sufficient knowledge ized by individuals or firms other than the con-
to diagnose their illness, evaluate the different sumer or producer.
courses of treatment, and select the optimal treat- Externalities in healthcare may affect produc-
ment. Hence, the provider influences the consum- tion or consumption. An example of a positive
er’s demand thereby creating interdependence consumption externality is obtaining a flu vacci-
between demand and supply. nation. By obtaining a flu shot, an individual
In addition, consumers have less information directly benefits by protecting himself or herself
about the quality of their healthcare providers from contracting the flu. And other members of
Market Failure 711
society benefit from the individual who obtained Health Insurance

the flu shot, as well, because it reduces their risk
Health insurance is a mechanism that miti-
of contracting the flu. An individual’s decision on
gates market failure associated with uncertainty.
whether to obtain a flu shot is based on his or her
Health insurance protects an individual against
marginal cost compared with his or her marginal
financial losses associated with healthcare costs
benefit from receiving the vaccination. The indi-
due to an illness or injury that cannot be pre-
vidual does not consider the downstream conse-
dicted either in terms of occurrence or magni-
quences of his or her decision (i.e., whether the
tude. For groups in which private coverage is not
risk to others of contracting the flu is reduced by
accessible, the government may function as the
him or her receiving a flu shot). When individuals
insurance provider. Public insurance programs,
bear the full cost of a decision in the presence of
such as Medicare and Medicaid, ensure that the
a positive consumption externality, too few goods
highest-risk individuals who do not have access
or services will be purchased in the market—that
to employer-provided health insurance offerings
is, too few people will purchase a flu shot—even
can obtain insurance coverage. At the same time,
though other members of society also benefit
health insurance also introduces additional mar-
from the decision. A classic example of a negative
ket problems, including moral hazard and adverse
consumption externality is smoking: An individu-
selection.
al’s decision to smoke in a public place has a
negative impact on others through secondhand
smoke.
Taxes
On the production side, research is a common
positive production externality. An individual or To solve the problems of externalities—where
firm producing scientific research affects the wel- the marginal private benefits do not equal the
fare of others in society by creating knowledge that marginal social benefits or where the marginal
could benefit the broader community. When the private costs do not equal the marginal social
full costs of research are wholly borne by the indi- costs—taxes and subsidies (i.e., negative taxes)
vidual scientist or institution, however, too little can be used. Taxes are used when the marginal
research will be undertaken. An example of a private costs are less than the marginal social
negative production externality is a hospital that costs, and subsidies are used when the marginal
incinerates used surgical supplies containing PVC, private benefits are less than the marginal social
which turns into the toxic chemical dioxin when benefits.
burned. The firm passes a social cost onto other Taxes alter the economic incentives of the
individuals by increasing their risk of cancer, but buyer and seller: Taxes make it more costly to
this cost is not borne by the firm itself. produce the externality, causing the quantity of
the externality to decrease. The tax should equal
the additional cost levied on the parties harmed
Solutions by the externality, and the funds raised should
The government may intervene in situations where be used to compensate those individuals.
the market cannot achieve an efficient allocation Although taxes force the creator of the external-
on its own. The government has several mecha- ity to internalize the costs of their actions, taxes
nisms by which to intervene and improve the are not a perfect solution for several reasons.
market. However, government involvement is not First, they allow the externality to continue;
necessarily the optimal action; many believe that hence, individuals will still be harmed by the
it should only step in if the marginal benefits from externality but will theoretically be compensated
the intervention exceed the marginal costs of the for their loss. Second, it is difficult to assess the
intervention, after factoring in spillover effects on actual cost of the externality that is imposed on
other markets and individuals. In addition, as others, so the tax is only an approximation of
technology and other innovations evolve over the real cost. Third, taxes generate monitoring
time, new markets may develop to facilitate more costs to ensure that the parties creating the
efficient allocations. externality pay the tax.
712 Market Failure
Regulation technologies can improve the certainty of a diagnosis,

and the Internet has created a venue for consumers to
Direct government involvement is another solu-
freely access information on healthcare providers. For
tion to many market failures. With no regulation,
example, the Centers for Medicare and Medicaid
pharmaceutical companies might invest less in
Services (CMS) now publish information on the
research and development—and ultimately develop
Internet on hospital processes of care, outcomes of
fewer new drugs that society would benefit from—
care, and patient satisfaction to allow consumers to
because other companies could act as free riders
compare the quality of care provided across the
and replicate the inventor’s products without incur-
nation’s hospitals.
ring the research and development costs required to
New technological advances such as those
bring a new product to market. Patent protections,
made through the widespread adoption of the
therefore, encourage pharmaceutical companies to
Internet will continue to improve the availability
invest more in research and development by pro-
of information, which may be the most conse-
viding a protected period of time when the develop-
quential change. Yet, distilling the vast amount
ing company will be the sole provider of its drug.
of medical information available on the Internet,
Regulation also more clearly defines and enforces
selecting the most valid and credible informa-
property rights when they are ambiguous in the
tion, then assimilating it to a level that is useful
market. By assigning property rights, regulations
to the individual consumer is no small feat. An
determine whether one party has the right to pro-
Internet search through Google on diabetes
duce an externality or another party has the right
treatment or diabetes care, for example, turned
to not consume the externality. Smoking bans in
up 2.5 million results.
public places—restaurants or bars, for example—
Although the Internet has armed consumers with
implicitly assign the right to clean air to the non-
more information to help diagnose their illnesses,
smoker and remove the right to smoke in these
determine alternative courses of treatment, judge
places, thereby prohibiting smokers from passing
the potential health outcomes, and judge provider
along secondhand smoke to others. As with taxes,
quality, healthcare providers nevertheless remain
it is important to assess the marginal costs and
the experts in delivering healthcare. Comparative
benefits of regulations. Smoking bans decrease the
information on healthcare quality—about which
likelihood of illnesses such as lung cancer but may
providers give the best care and have the best risk-
impose a cost on other parties (e.g., restaurants
and severity-adjusted outcomes—remains limited.
and bars) if the net effect is fewer patrons, smaller
Although several Web sites provide comparative
tabs per patron, or both.
information on some hospital-based healthcare out-
Antitrust policies prevent the existence of
comes, most quality comparisons continue to rely
monopolies, the most extreme type of market
on either intermediate outcomes or proxies of
power. If a monopoly or oligopoly is beneficial to
quality—such as the occurrence of malpractice
a market because of economies of scale, however,
judgments, patient satisfaction data, and process
the government may allow its formation but may
outcomes—rather than health and healthcare out-
regulate prices.
comes. Further work is needed to determine how to
Licensing of health professionals and healthcare
accurately measure and compare health and health-
organizations is a regulatory strategy to mitigate a
care outcomes across the continuum of providers
market failure related to the lack of information
(e.g., hospitals, physicians, nursing homes) and
on the quality of providers. Licensing and certifica-
report the findings in a manner that is both easily
tion ensures a minimum quality level but restricts
accessible and comprehensible to consumers.
the quantity of providers and limits competition
Two external forces may also increase informa-
from other types of providers through restrictions
tion transparency. First, a shift to high-deductible
on the scope of practice.
health insurance plans increases the need for con-
sumer-targeted information in the public domain on
The Availability of Information
both quality and prices so that consumers can assess
New technology and other innovations can improve both the quality and out-of-pocket costs of alterna-
the availability of information. New diagnostic tive treatments. Second, medical travel—travel for
Marmor, Theodore R. 713
medical care outside one’s home country—may also Rice, Thomas H. The Economics of Health
increase the availability and comparability of infor- Reconsidered. 2d ed. Chicago: Health Administration
mation on quality and prices for some services. Press, 2003.
Non-U.S. healthcare providers catering to interna- Sloan, Frank A. “Arrow’s Concept of the Health Care
tional patients, including U.S. patients, now publish Consumer: A Forty-Year Retrospective,” Journal of
on the Internet inclusive prices for the common sur- Health Politics, Policy and Law 26(5): 899–911,
gical procedures provided at their facilities. (In the October 2001.
United States, although prices have been relatively
transparent for a small set of elective procedures
traditionally not covered by health insurance [e.g., Web Sites
Botox and LASIK surgery], it has generally been American Economics Association (AEA):
very difficult if not impossible to obtain, in advance, http://www.vanderbilt.edu/AEA
the price that an uninsured individual will pay out American Society of Health Economists (ASHE):
of pocket for a surgical procedure or hospitaliza- http://healtheconomics.us
tion.) These two forces may ultimately drive provid- International Health Economics Association (iHEA):
ers to disseminate information on prices and quality http://www.healtheconomics.org
and, ultimately, compel the government to facilitate National Bureau of Economic Research (NBER):
the collection and dissemination of comparative http://www.nber.org
information. World Health Organization (WHO): http://www.who.int
Tricia J. Johnson
See also Adverse Selection; Economic Spillover;

Healthcare Markets; Health Economics; Health
Marmor, Theodore R.
Insurance; Moral Hazard; Regulation; Supplier-
Induced Demand Theodore (Ted) R. Marmor is Professor Emeritus
of Public Policy and Political Science at Yale
University, where he taught from 1979 to 2007.
Further Readings Currently he is an adjunct professor of public
policy at the John F. Kennedy School of
Arrow, Kenneth J. “Uncertainty and the Welfare Government at Harvard University. His special-
Economics of Medical Care,” American Economic ization is the contemporary welfare state in
Review 53(5): 941–73, December 1963. North America and Europe, with particular
Glied, Sherry A. “Health Insurance and Market Failure expertise on healthcare policy. His research on
Since Arrow,” Journal of Health Politics, Policy and
healthcare has yielded a national and interna-
Law 26(5): 957–65, October 2001.
tional reputation as the most recognized acade-
Haas-Wilson, Deborah. “Arrow and the Information
mician in healthcare policy and politics. Marmor’s
Market Failure in Health Care: The Changing
first book, The Politics of Medicare (1970), is a
Content and Sources of Health Care Information,”
classic in the field. The second edition of The
Journal of Health Politics, Policy and Law 26(5):
1031–1044, October 2001.
Politics of Medicare (2000) traces developments
Hammer, Peter J., Deborah Haas-Wilson, and William in healthcare policy since the enactment of
M. Sage. “Kenneth Arrow and the Changing Medicare in 1965. In the decades since Medicare
Economics of Health Care: ‘Why Arrow? Why was enacted, Marmor has been a prominent ana-
Now?’” Journal of Health Politics, Policy and Law lyst of health policy and advocate of universal
26(5): 835–49, October 2001. healthcare.
Kuttner, Robert. “Market-Based Failure: A Second Born in New York City on February 24, 1939,
Opinion on U.S. Health Care Costs,” New England he received his bachelor’s degree from Harvard
Journal of Medicine 358(6): 549–51, February 7, 2008. University in 1960; attended Wadham College,
Reinhardt, Uwe E. “Can Efficiency in Health Care Be Oxford from 1961 to 1962; and then returned to
Left to the Market?” Journal of Health Politics, Harvard, earning his doctoral degree in 1966.
Policy and Law 26(5): 967–92, October 2001. Marmor began his academic career as an assistant
714 Mathematica Policy Research (MPR)
professor of political science and was promoted to See also Cohen, Wilbur J.; Equity, Efficiency, and
associate professor at the University of Wisconsin Effectiveness in Healthcare; Healthcare Reform;
during 1967 to 1970, then joined the faculty at the Medicaid; Medicare; Public Health Policy Advocacy;
University of Minnesota (1970–1973) and later Public Policy; Regulation
the University of Chicago (1973–1979) before
going to Yale University in 1979.
In 1966, Marmor was special assistant to Further Readings
Wilbur Cohen, the Secretary of Health, Education, Marmor, Theodore R. America’s Misunderstood Welfare
and Welfare; he served as associate dean at the State: Persistent Myths, Enduring Realities, with Jerry
School of Public Affairs during his tenure at the L. Mashaw and Philip L. Harvey. New York: Basic
University of Minnesota; and at Yale University, Books, 1990.
he chaired the board of its Center for Health Marmor, Theodore R. Understanding Health Care
Services. He was a member of President Carter’s Reform. New Haven, CT: Yale University Press, 1994.
Commission on the National Agenda for the 1980s Marmor, Theodore R. The Politics of Medicare. 2d ed.
and a senior policy advisor to Democratic presi- New York: Aldine de Gruyter, 2000.
dential candidate Walter Mondale during the 1984
election campaign. Marmor has testified before
congressional committees about healthcare reform, Web Sites
social security, and welfare policy in addition to Yale School of Management: http://mba.yale.edu
acting as an expert witness in health-related judi-
cial proceedings, including the constitutionality of
the Canada Health Act, disputes over Medicare,
and U.S. asbestos litigation. Mathematica Policy
Marmor serves on the editorial boards of the
Journal of Comparative Policy Analysis: Research Research (MPR)
and Practice; the Journal of Health Services
Research and Policy; the International Journal of Mathematica Policy Research, Inc. (MPR), estab-
Health Planning and Management; and the Journal lished in 1968 as a division of Mathematica, Inc.,
of Health Politics, Policy, and Law. He was a cen- is a policy research organization that specializes in
tennial visiting professor at the London School of data collection and evaluation and policy analysis.
Economics (2000–2003) and has been a fellow or The company provides research expertise, survey
visiting fellow with the Australian National design and implementation techniques, informa-
University, the Canadian Institute for Advanced tion technology, and policy assessments to a wide
Research, All Souls College at Oxford University, variety of clients, including government agencies,
and the Netherlands Institute for Advanced Study. universities, and foundations. For the past 40
During 1993 to 2003, he was director of the years, MPR has helped to inform, shape, and
Robert Wood Johnson Foundation Post-doctoral enrich public policy.
Program (Medical Care and Social Sciences).
Marmor has authored or coauthored 13 books,
nearly 200 scholarly articles and book chapters, and
more than 100 op-ed pieces in magazines and news- MPR was incorporated under its current name in
papers here and abroad. His scholarship has appeared 1975, and it became an employee-owned entity in
in many prestigious journals, including the American 1986. Headquartered in Princeton, New Jersey,
Political Science Review, the Michigan Law Review, the organization also has offices in Washington,
the American Journal of Obstetrics and Gynecology, D.C.; Cambridge, Massachusetts; and Ann Arbor,
the New England Journal of Medicine, the Journal Michigan. The organization has partnered with
of Health Politics, Policy, and Law, and the Canadian the Robert Wood Johnson Foundation (RWJF) to
Medical Association Journal. establish the Center for Studying Health System
Change (HSC), which is a wholly owned subsid-
Raymond Tatalovich iary of Mathematica, Inc. The HSC and MPR
Mathematica Policy Research (MPR) 715
share administrative resources and collaborate on healthcare. The organization focuses on these
key studies and research projects. areas because they remain central to local, state,
Two major divisions of MPR are the surveys and federal policy.
and information services division and the research
division. The surveys and information services
division gives clients the tools, technology, and Education
customized surveys that help them gather appro- MPR provides research and evaluation of edu-
priate and meaningful facts and figures. The cation efforts ranging from early-childhood school-
research division builds on these efforts, providing ing, to kindergarten through 12th grade, and
findings and scientific evidence that policymakers beyond. It examines elementary reading and math-
can use in their decision making. ematics curricula, teacher quality, interventions for
In the surveys and information services division, at-risk youth, after-school initiatives, college access
staff members help clients (a) identify the best data and preparation, charter schools, school choice
collection methods, (b) design custom survey instru- programs, education technology, school and stu-
ments for small and large samples, (c) recognize the dent performance competencies, and career-focused
special needs of data collection in diverse popula- education. The organization is also committed to
tions, (d) conduct statistical analysis and modeling, improving education research overall by strength-
and (e) use advanced technology for surveying and ening research methods and reviews. The organi-
data management. MPR takes into account factors zation administers the What Works Clearinghouse,
that may cause bias and skew survey results such as a tool established by the U.S. Department of
language barriers and subject disabilities. The orga- Education’s Institute of Education Services that
nization also employs Internet technology and collects, reviews, and reports on studies of educa-
Web-based techniques to enhance its surveys. tion programs, practices, and products. It is also
The research division conducts research for the involved with the evaluations of the Teach for
public and private sectors, strengthening an evi- America, No Child Left Behind, Head Start, and
dence-based approach to shaping policy agendas. Upward Bound programs.
The division is responsible for (a) developing
experiments and demonstrations; (b) quantita-
tively evaluating programs by looking at econo- Labor
metric and statistical analyses of their effects, By examining the factors that affect the work-
benefits and costs, quality, and value of output; force, MPR helps to inform career training and
and (c) qualitatively evaluating implementation placement interventions as well as employment
and operations, using process and case study policies. The organization focuses on research
analyses. Researchers also predict the effects of aimed at expanding opportunities for at-risk youth,
proposed changes through the use of microsimula- disadvantaged adults, young people living in pov-
tion and provide ongoing support to bolster erty, experienced workers who have lost their jobs,
research infrastructure. Through the expertise of people who are involved in criminal activity and
systems analysts, social psychologists, economists, the criminal justice system, and others who face
sociologists, demographers, and education special- barriers to entering the workforce.
ists, the division is focused on conducting policy
analyses to better understand the implications of
Welfare
policy choices in key research areas. The organiza-
tion strives to communicate and disseminate its MPR is involved in many projects that evaluate
findings to policymakers and the general public. welfare reform efforts at the state and national
levels. For example, it has examined initiatives—
designed to help Technical Assistance for Needy
Main Research Areas
Families (TANF) recipients—that look at interven-
MPR has conducted studies on programs and tions aimed at strengthening families, father involve-
policy in the following areas: education, labor, ment and support, healthy relationships, and
welfare, nutrition, disability, early childhood, and abstinence education for teens. The organization
716 Mathematica Policy Research (MPR)
evaluates welfare-to-work initiatives, efforts to (c) affordable day-care programs, (d) preschool curri-
increase job opportunities, long-term dependency cula, and (e) initiatives serving low-income families.
on multiple public aid programs, and cost projec-
tions for federal and state programs. These research
efforts help educate policymakers and program Healthcare
administrators seeking to improve the systems. In addition to its work relating to chronic dis-
ease and disability, MPR conducts a wide range of
studies on health and the healthcare system.
Nutrition
Researchers analyze costs, financing, insurance
The organization’s researchers study nutrition mechanisms, and coverage. MPR has also explored
issues such as access to food, public food and the effectiveness and quality of public- and private-
nutrition assistance programs, emergency food sector services and the delivery of care. Specific
assistance networks, and growing trends in obe- projects include assessing the success of Medicaid,
sity. For more than 30 years, the organization has the State Children’s Health Insurance Program
extensively examined the Food Stamp Program (SCHIP), and private coverage options at increasing
and the Special Supplemental Nutrition Program access to care for low-income families. The organi-
for Women, Infants, and Children (WIC), helping zation’s work is also concerned with public health
policymakers assess reform efforts and continue to initiatives such as chronic-disease management pro-
make revisions. In addition, its researchers have grams and infectious-disease control measures. It
studied school nutrition programs, including school evaluates programs that are designed to address
lunch and breakfast programs, as well as initiatives mental health parity and health systems quality,
to improve children’s diets and eating habits. With and it also examines the role of advanced technol-
its findings, MPR informs ongoing efforts to ogy in improving health outcomes. Last, it provides
improve the dietary status of all Americans. leadership and policy advocates with the tools to
promote sound and informed policy agendas.
Disability
For people living with disabilities and chronic Future Implications
diseases, advances in medicine and technology lead MPR continues to provide policymakers and the
to more opportunities and increased independence; general public with key information. Over the past
such changes may have important public policy few years, it has worked increasingly with interna-
implications at the state and national levels. The tional clients and begun addressing issues at a
organization conducts research on programs such as global level. Moving forward, the organization
Social Security and Medicaid, and it also gathers will ensure quality data collection, evaluation, and
data on children with disabilities and their families. analysis for the United States and beyond.
In addition, the organization looks at job programs
for disabled adults. Mathematica’s Center for Kathryn Langley
Studying Disability Policy (CSDP) works with dis-
ability organizations and advocacy groups to See also Center for Studying Health System Change;
enhance policy changes; it focuses on assessing ser- Health Insurance; Health Surveys; Medicaid;
Medicare; Public Health; Public Policy
vice delivery, financing, resources, and disincentives.
These efforts help leaders develop public policy to
meet the changing needs of this special population.
Further Readings
Del Grosso, Patricia, Amy Brown, Heather Zaveri, et al.
Early Childhood
Oral Health Promotion, Prevention, and Treatment
MPR studies and evaluates interventions aimed Strategies for Head Start Families: Early Findings
at improving the well-being of young children. From the Oral Health Initiative Evaluation. Vol. 1:
These programs include (a) Head Start, (b) the Final Interim Report. Princeton, NJ: Mathematica
Family and Child Experiences Survey (FACES), Policy Research, 2007.
Maynard, Alan 717
Mathematica Policy Research. Establishing Evidence, where he founded the Graduate Program in Health
Elevating Standards, Enriching Policy: 40 Years. Economics, serving as its director until 1983. In
Princeton, NJ: Mathematica Policy Research, 2008. 1983, he became a professor of economics and the
Rosenbach, Margo, Carol Irvin, Angelia Merrill, et al. founding director of the Centre for Health
National Evaluation of the State Children’s Health Economics at York. From 1995 to 1996, he served
Insurance Program: A Decade of Expanding as the secretary and chief executive of the Nuffield
Coverage and Improving Access: Final Report. Provincial Hospitals Trust, a foundation that
Princeton, NJ: Mathematica Policy Research, 2007. funds research in health policy. In 1996, he
returned to the University of York as a professor
of health economics and the director of the York
Web Sites
Health Policy Group.
Center for Studying Health System Change (HSC): Maynard was made an honorary member of the
http://www.hschange.com Faculty of Public Health Medicine of the Royal
Mathematica Policy Research (MPR): Colleges of Physicians in 1993. He was elected
http://www.mathematica-mpr.com president of the International Health Economic
Association (iHEA) in 1999. He was named a fel-
low at the Academy of Medical Sciences for the
United Kingdom in 2000. In 2002, he was named
Maynard, Alan adjunct professor at the Centre for Health
Economics in Research and Evaluation at the
Alan Maynard is a well-known, highly respected University of Technology in Sydney, Australia. He
health economist in the United Kingdom. Maynard has been awarded honorary doctorate degrees
has been instrumental in initiating policies for the from the Universities of Aberdeen (2003) and
UK National Health Service (NHS). Specifically, Northumbria (2006).
he proposed the establishment of the General He is the founding editor of Health Economics
Practitioner Fund Holding, from which physi- and has written more than 250 scholarly articles and
cians are given budgets to fund their activities as 10 books. He also is a member of the editorial boards
well as secondary care for their patients. He also of the British Journal of Obstetrics and Gynaecology,
proposed that the NHS only pay for pharmaceu- Pharmacoeconomics, Health Manpower Manage
tical drugs that their manufacturers could demon- ment, and the Drug and Alcohol Review.
strate to be cost-effective and efficient. This In addition to Maynard’s academic experience,
proposal ultimately led to the formation of the he has served the NHS as a member of the York
National Institute of Clinical Excellence (NICE). Health Authority (1983–1991), nonexecutive
Maynard is a professor of health economics and director of the York National Health Service
the director of the York Health Policy Group in Hospital (1991–1997), and has been the chair of
the Department of Health Sciences at the University the hospital since 1997.
of York. He is also an adjunct professor at the Maynard has provided consultant services for
University of Technology in Sydney, Australia. the UK Department for International Development,
Maynard was educated at the University of the World Health Organization (WHO), and the
Newcastle-upon-Tyne, earning first-class honors World Bank on healthcare issues in Cyprus, Greece,
in economics in 1967. He received a bachelor’s Thailand, Brazil, Mexico, China, Botswana, South
degree from the University of York in 1968. He Africa, Bolivia, Chile, Lithuania, Latvia, Hungary,
did his postgraduate work at the University of Russia, Malawi, Serbia, Kyrgyzstan, and Ukraine.
York; while there, he was introduced to the field of Currently, Maynard is working on improving the
public expenditure, which ignited his interest in performance of health technology assessment and
healthcare. He taught economics as an assistant workforce productivity. In the next 10 years, he
lecturer and then lecturer at the University of hopes to see proper routine measurement and man-
Exeter from 1968 to 1971. From there, he returned agement of patient-reported outcome measures.
to the University of York as a lecturer in econom-
ics. In 1977, he became senior lecturer at York, Amie Lulinski Norris
718 McNerney, Walter J.
See also Health Economics; International Health positions in hospitals in Providence, Rhode Island,
Economics Association (iHEA); Pharmacoeconomics; and Pittsburgh, Pennsylvania.
United Kingdom’s National Health Service (NHS); McNerney joined the faculty of the University
United Kingdom’s National Institute for Health and of Michigan in 1955, where he founded and
Clinical Excellence (NICE)
headed the university’s hospital administration
program in the School of Business. While at the
university, he developed the program’s curriculum,
Further Readings
taught hundreds of students, and conducted one of
Maynard, Alan. The Public-Private Mix for Health. the largest, most comprehensive research projects
Abingdon, UK: Radcliffe, 2005. ever undertaken in healthcare. The landmark proj-
Maynard, Alan. “European Health Policy Challenges,” ect detailed the availability, use, quality, finance,
Health Economics 14(Suppl. 4): S255–63, September and politics of healthcare across the state of
2005. Michigan. The results of the project were pub-
Maynard, Alan. “Is Doctors’ Self Interest Undermining lished in Hospital and Medical Economics, a mas-
the National Health Service?” British Medical Journal sive two-volume set.
334(7587): 234, February 3, 2007. In 1961, McNerney left the University of
Maynard, Alan, Karen Bloor, and Nick Freemantle. Michigan to become the president of the national
“Challenges for the National Institute for Clinical Blue Cross Association. As president, he oversaw
Excellence,” British Medical Journal 329(7459): the merger with the Blue Shield Association and
227–29, July 24, 2004.
the subsequent creation of the national Blue Cross
Scott, Anthony, Alan Maynard, and Robert Elliott, eds.
and Blue Shield Association. McNerney was instru-
Advances in Health Economics. New York: Wiley,
mental in getting the independent Blue Cross and
2003.
Blue Shield plans to offer health maintenance orga-
nizations (HMOs) and managed-care plans,
because he thought that the implementation of
Web Site
managed care was inevitable.
University of York, Department of Health Sciences: In 1963, he founded the journal Inquiry. Today,
http://www.york.ac.uk/healthsciences/gsp/staff/ Inquiry is one of the top three peer-reviewed schol-
amaynd.htm arly publications in the field of health services
research.
McNerney was a leading advisor to President
Lyndon B. Johnson. In partnership with the
McNerney, Walter J. administration’s Wilbur J. Cohen, he developed
the blueprint for the Medicare program that,
In his 45-year career, Walter J. McNerney together with Medicaid, was signed into law in
(1925–2005) had a profound impact on the 1965. Under President Richard M. Nixon,
nation’s healthcare system. McNerney played a McNerney also served as chairman of the task
pivotal role in the creation of the federal Medicare force on Medicaid. The panel’s final report called
program, he was a leading educator in hospital for an overhaul of the federal-state apportionment
administration, and he was the president of the of costs and responsibilities, issues that remain
national Blue Cross and Blue Shield Association. contentious to this day.
Born in 1925 in New Haven, Connecticut, After retiring from the Blue Cross and Blue
McNerney earned a bachelor’s degree in industrial Shield Association in 1981, McNerney went back
administration from Yale University in 1947. After to academe, becoming the Herman Smith Professor
graduation, he taught advanced mathematics at the of Health Policy at the Kellogg School of Business
Hopkins School, a private college-preparatory school at Northwestern University. While teaching at the
in New Haven. He left New Haven to attend the university, he continued to consult with numerous
University of Minnesota, where he earned a master’s organizations. He retired in 1998 after suffering a
degree in hospital administration in 1950. Over the stroke. In 2005, McNerney died at his Winnetka,
next several years, he held various administrative Illinois home, at the age of 80.
Measurement in Health Services Research 719
During his long and illustrious career at the Web Site

University of Michigan, the Blue Cross and Blue Blue Cross and Blue Shield Association (BCBSA):
Shield Association, and Northwestern University, http://www.bcbs.com/about/history
McNerney mentored hundreds of students as well
as junior and senior managers. He served on
numerous government and private-sector commit-
tees and advisory bodies. He frequently testified
before various congressional committees. He
Measurement in Health
worked tirelessly with community organizations Services Research
and charitable foundations. He wrote 3 books and
more than 75 articles on various aspects of health- Measurement in health services research often
care. His areas of expertise included healthcare involves assessing a person’s well-being through
insurance, management, financing, education, self-report instruments. Whereas the presence of
leadership, philanthropy, strategy, and policy. disease and its effects on mortality can be directly
Because of his large number of areas of expertise ascertained through clinical observation, the
and wide general knowledge, many considered assessment of well-being requires the development
McNerney a 20th-century Renaissance man. of self-report instruments. The measurement of
well-being and other internal states (e.g., depres-
Tara Moore sion) involves an individual’s responses to items
See also Association of University Programs in Health that represent various manifestations (e.g., symp-
Administration (AUPHA); Blue Cross and Blue Shield; toms, attitudes, and beliefs) that collectively reflect
Cohen, Wilbur J.; Health Insurance; Medicaid; the main features of the constructs. The use of
Medicare; Public Policy measurement in health services research has grown
since the 1960s due to policy initiatives such as
President Lyndon B. Johnson’s “War on Poverty”
Further Readings
that necessitated self-report measures to guide
Berman, Howard. “Walter J. McNerney: program planning and monitor program effective-
Remembrances,” Inquiry 42(3): 201–207, Fall 2005. ness. With support from the National Center for
Conrad, Douglas A. “Memories of Walter J. McNerney: Health Services Research (NCHSR), development
His Contributions to Health Administration and to and use of multi-item scales has increased dra-
Health Administration Education,” Journal of Health matically across the spectrum of health services.
Administration Education 23(4): 331–34, Fall 2006. As a result of contributions from many different
Cunningham, Robert, III and Robert M. Cunningham, disciplines, an array of measures of health status
Jr. The Blues: A History of the Blue Cross and Blue and health outcomes have been developed to
Shield System. De Kalb: Northern Illinois University evaluate whether healthcare is achieving its mis-
Press, 1997.
sion of reducing disease, disability, and pain and
McNerney, Walter J. Health Care Coalitions: New
improving health-related quality of life.
Substance or More Cosmetics? (The Michael M.
Davis Lecture). Chicago: Graduate School of
Business, Center for Health Administration Studies, Overview
University of Chicago, 1982.
McNerney, Walter J. “In Our New Competitive World,
For health service measures to achieve their
Is the Health Field Headed for Investor-Owned
intended purpose, they must be developed on the
Takeover? Is It for Better or Worse?” (The Andrew basis of a sound theoretical framework and a thor-
Pattullo Lecture). Journal of Health Administration ough understanding of the constructs being mea-
Education 14: 77–91, 1996. sured, and rigorous procedures must be used
McNerney, Walter J., and Study Staff, University of during instrument validation. Sophisticated statis-
Michigan. Hospital and Medical Economics: A Study tical procedures for data analysis cannot compen-
of Population, Services, Costs, Methods of Payment, sate for measures that lack sufficient reliability,
and Controls. 2 vols. Chicago: Hospital Research and validity, and sensitivity. For the responses to
Educational Trust, 1962. individual items or questions to translate into
720 Measurement in Health Services Research
meaningful measures, consideration should be given the ultimate patient population for which future
not only to the underlying theory and the empirical instruments will be constructed. Unfortunately,
evidence but also to the measurement model being such similarity is rare because instrument valida-
used. Presently, the most common approach in tion studies most often rely on samples of conve-
health services research for obtaining meaningful nience, and over time, a population’s level of the
scores on measurement instruments is the classical construct being measured may change.
test theory (CTT) approach in which raw item
scores are mathematically manipulated, usually by
summing across the item scores to obtain a total Test Dependence
score. Similarly, the prevalent instrument validation The test score, which is often used as a descrip-
strategies are derived from the CTT procedures for tor of a respondent on a given construct, is test
instrument development. However, there are alter- dependent. If the level of “difficulty” of the items
native measurement models, including the Rasch in the test instrument is changed, as might be done
model and item response theory (IRT), that provide in the context of computer-adaptive tests, then the
viable alternatives to CTT and are starting to gain test scores are no longer on the same mathematical
acceptance in health services research. metric. Therefore, they are not a useful variable for
comparing respondents to each other or to perfor-
mance standards.
Classical Test Theory
For more than 80 years, CTT has been the basis
All Items Are Not Created Equal
for the development and evaluation of health ser-
vices instruments. Under this framework, no dis- The creation of raw scores by summing item
tributional assumptions about scores are made. responses assumes that the items are equivalent
Like modern test theories, CTT does make the with respect to their position on the construct. In
assumption that the trait being measured is unidi- general, this is not a valid assumption.
mensional. Perhaps due to its simplicity and rela-
tively weak assumptions, CTT continues to be the
Scores Are Nonlinear and Noninterval
prevalent measurement model in health services
research. Whereas CTT has played an important Ideally, measures derived from health services
role in measuring the diverse panoply of health instruments should be linearly related to the con-
conditions, the major limitations associated with struct being measured. Furthermore, the magnitude
it have been well-documented in the psychometric of change represented by a single unit on the mea-
literature: (a) sample dependence, (b) test depen- surement continuum should remain constant across
dence, (c) all items are not created equal, the measurement spectrum. Regardless of a score’s
(d) scores are nonlinear and noninterval, and range or whether it is converted to a standard met-
(e) lack of efficiency. ric, raw scores do not possess the property of linear
interval measurement. Noninterval measurement
can have serious implications regarding the sensitiv-
Sample Dependence
ity of CTT-based instruments. Research comparing
Under CTT, item parameters (e.g., item diffi- CTT-based scores to Rasch-based measures indi-
culty and other item statistics) are sample depen- cates that the raw scores tend to overestimate trait
dent. This means that items may have greater levels at the low end of the measurement spectrum
difficulty estimates or reflect high severity when and underestimate trait levels at the high end.
they are administered to respondents at the low
end of the score continuum but have smaller diffi-
Lack of Efficiency
culty estimates or reflect less severity with respon-
dents at the high end of the score continuum. That In the 1980s, with healthcare practitioners and
item statistics depend on the sample with which researchers demanding more measures, the need
they are estimated means that these statistics have arose for greater efficiency without a loss of reli-
limited value, except when the sample is similar to ability and validity. The CTT model is less than
ideal for efficiency because it achieves greater test but rather logarithmic. This suggests that the loga-
reliability by increasing the number of items. rithmic scale both has desirable measurement
properties and is well suited for measuring many
human characteristics.
Rasch and IRT Measurement Models
Although the early work in IRT took place at the
Multiparameter IRT Models
same time as that of the Rasch model, the Danish
mathematician and statistician Georg Rasch Other IRT models include additional item
(1901–1980) was the first to formalize his mea- parameters. Whereas the Rasch model makes the
surement model. Common to the Rasch and other assumption that discrimination is equal for all
IRT models is the idea that underlying a respon- items, multiparameter models typically estimate an
dent’s performance on a set of items, questions, item discrimination parameter. In educational test-
performance tasks, or even rating scales is a set of ing, a guessing parameter also may be included.
human characteristics known as latent traits. Whereas its difficulty refers to the location of the
These traits, broadly or narrowly defined, are not item on the measurement continuum, its discrimi-
directly observable. Instead, they must be inferred nation refers to the steepness or the slope of the
from an individual’s responses to the items or item’s characteristic curve (ICC). Items with steep
questions comprising the measurement instru- ICCs indicate that a unit change in a person’s mea-
ment. The IRT measurement model provides an sure corresponds to a large change in the probabil-
estimate of a given trait by specifying a probabilis- ity of endorsing the item. Conversely, low
tic relationship between the items and their char- discrimination indicates that a unit change on the
acteristics and the estimated trial level. In the measure corresponds to a relatively small change in
Rasch model, this probabilistic relationship is the probability of item endorsement. The guessing
stated most simply for dichotomous items. parameter is quantified as the probability of item
There are three features of the Rasch model that endorsement at the lower asymptote of the ICC.
are of particular note. First, the use of a probabilis- Research has demonstrated that the Rasch
tic model allows instrument developers to compare model has properties, associated with additive
the actual and expected response patterns for a set conjoint measurement, that are required by para-
of items, thereby providing a mechanism for assess- metric statistics and advantageous for accurate
ing the model fit. If the responses are generally assessment of change over time. If the data fit the
consistent with the model expectations, the mea- model reasonably well, the Rasch model—
sure is judged to fit the Rasch model and, there- compared with CTT and other IRT models—makes
fore, has the desired properties of conjoint the clearest justification that interval- and even ratio-
additivity and sample-free and test-free measure- level measurement is obtainable with the survey
ment. Second, the direct comparison between per- instruments.
son measures and item parameters is possible
because both are measured on the same scale: the
Application of Rasch Measurement
logit or “log odds ratio” scale. The ability to dis-
tinguish person measures and item parameters has Although Rasch and IRT have their roots in edu-
important implications with respect to the assess- cational testing, these measurement models have
ment of change and the evaluation of an instru- been adapted for use in health services research.
ment’s generalizability across cultures. Third, the Some of the earliest health-related applications of
use of logarithms permits the “bent ruler” of raw Rasch and IRT were in the field of rehabilitation.
scores to have linear and equal-interval properties. The initial efforts generally involved the use of the
Logarithms are useful in transforming curvilinear Rasch model. This may be due, in part, to the fact
functions into linear relationships. In the 19th cen- that the Rasch model has lower sample size
tury, the German experimental psychologist Gustav requirements, compared with multiparameter
Fechner (1801–1887) was the first to realize that models, to obtain stable item parameters and
the relationship between stimuli and responses accurate person measures. This makes it more
when measuring human characteristics is not linear suitable for the measurement of highly select
722 Measurement in Health Services Research
populations such as persons with specific types of equivalent between culturally defined groups.
physical impairments. Measurement equivalence is necessary to make
Rehabilitation emphasizes monitoring and accurate quantitative comparisons across cultur-
assessing a person’s abilities with respect to physi- ally or linguistically defined groups. During the
cal functioning and the performance of the activi- past decade, numerous journal articles have been
ties of daily living (ADL). Rehabilitation researchers published concerning the cross-cultural and lin-
quickly recognized the limitations in raw scores guistic equivalence of health and health outcome
and the potential of Rasch measurement to pro- measures using modern measurement methods.
duce precise, equal-interval measures. The use of The ability of the Rasch and other IRT measure-
the Rasch model to provide unambiguous mea- ment models to separate person measures and
sures of the change resulting from rehabilitation item parameters and the use of differential item
made it an attractive alternative to the estimation functioning (DIF) analysis have undoubtedly con-
of change using raw scores, which has long been tributed to the growth of this area. Compared
known to have serious problems. The application with test developers in the fields of education and
of modern measurement models quickly spread to psychology, health outcome researchers have been
other areas of health research, including health slow to acknowledge the presence of DIF in their
services research. instruments. However, the incorporation of Rasch
and IRT methods in health services research in
recent years has led investigators to examine DIF
Measurement of Change
on several measures across a variety of culturally
In health services research, the analysis of change and linguistically defined groups. DIF by country
is a difficult issue, which may be complicated or or language has been identified on measures of
confounded by the properties of the measurement functional status, disease activity, pain, substance
instruments. Because of its linear, interval-scaling abuse, and health-related quality of life. The pres-
properties, Rasch measurement enables the assess- ence of DIF does not necessarily indicate that the
ment and adjustment of measures over time— item(s) producing DIF are biased. DIF may reveal
when the meanings of items may have changed the presence of real group differences. For instance,
due to differing interpretations of the items and males and females frequently differ in their pre-
differing use of the rating scale from time one to sentation of depressive symptoms; likewise, ado-
time two. For the research purpose of interpreting lescents and adults may differ in their patterns of
the outcomes, the development of linear, interval, substance use and symptoms of substance depen-
clinical measures makes it possible to move past dence and abuse.
the reliance on statistical significance, with num- Whereas the Rasch and IRT models provide a
bers that are difficult to interpret clinically, to the mechanism for detecting and adjusting for DIF, it is
assessments of outcomes that have clear clinical also important to generate theories and hypotheses
criteria. Having clinical milestones on the ruler that explain the causes of DIF. Rather than simply
enables the use of much simpler and more easily purging items that fail to fit the measurement
interpretable numbers that tell the practitioner model or controlling for DIF through the use of
and researcher (a) how many patients got better in anchoring and equating procedures, understanding
each group, (b) how many patients are borderline the causes of these problems can add greatly
and require careful watching, and (c) how many to the researchers’ ability to write better items. It
patients are still severe and require a stronger or a is also important to note that although DIF is
different intervention. extremely useful in detecting item bias, measures
may be biased or nonequivalent in other ways. For
instance, a construct can be defined differently
Assessing the Cross-Cultural
across different cultures (construct bias), and there
Stability of Item Parameters
may also be differences in the sample characteris-
To assess individual change, it is important to tics and administration procedures (method bias).
establish the stability of item parameters over Thus, whereas DIF represents an important tool in
time. It is also critical to determine if measures are establishing cross-cultural equivalence, it must be
integrated into a larger process of establishing a working CAT requires considerable time and
cross-cultural validity. resources, particularly with respect to item bank
development and maintenance. A well-developed
CAT, however, if it gains widespread acceptance
Computerized Adaptive Testing
in the field, has the potential to replace the pleth-
Healthcare providers are under increasing pres- ora of instruments that now exist for the measure-
sure from consumers as well as public and private ment of health constructs. A CAT item bank can
funders to demonstrate that they can provide evi- contain enough items to exhaustively represent the
dence-based interventions that achieve reliable construct of interest and produce scores on a single
outcomes. To make matters more complicated, standardized ruler.
public and private funders have been demanding
more detailed assessment (e.g., to diagnostic crite-
ria or a standard for a given area) or other evi- Future Implications
dence of the standardization of care. Of course, The tools for achieving high-quality, valid, and
they are also concerned about how the scores precise measurement in health services research
translate into diagnosis, placement, and treatment- are now readily available. The use of Rasch mod-
planning recommendations, particularly for spe- els is increasing, and they can be applied to a wide
cialty and costly services. Although these efforts range of new applications. These measurement
hold promise, they also have associated costs: models will likely continue to be adopted toward
Longer assessments may lead to patient fatigue or the ultimate goal of improving each individual’s
agitation; the staff time to learn, administer, inter- health and well-being.
pret, and report on the standardized assessment
consumes resources and is costly for the treatment Barth B. Riley, Kendon J. Conrad,
agencies. and Karon Cook
Computerized adaptive testing (CAT), coupled
See also Disease; General Health Questionnaire; Health;
with modern psychometric methods and item bank-
Health Surveys; Quality of Well-Being Scale;
ing, represents a promising solution to the measure-
Satisfaction Surveys; Short-Form Health Surveys
ment problems encountered with the traditional (SF-36, -12, -8); Ware, John E.
fixed-form instruments. The combined use of CAT,
Rasch, and IRT measurement models plus item
banking provides comprehensive and precise mea- Further Readings
surement with a limited burden to respondents.
CAT algorithms are designed to select and Allen, Mary J., and Wendy M. Yen. Introduction to
Measurement Theory. Long Grove, IL: Waveland
administer a subset of items in a process likened to
Press, 2002.
a binary search. The selected items are tailored to
Bond, Trevor G., and Christine M. Fox. Applying the
the person’s level on the measured construct, and
Rasch Model: Fundamental Measurement in the
the unnecessary items are eliminated from the
Human Sciences. 2d ed. Toledo, OH: University of
assessment process with a minimal loss of mea- Toledo, 2007.
surement precision. This results in a reduced Conrad, Kendon J., and Everett V. Smith. “International
respondent burden and enhanced content specific- Conference on Objective Measurement Applications
ity. Conversely, item banking increases the content of Rasch Analysis in Health Care,” Medical Care
coverage and minimizes the presence of measure- 42(1 Suppl.): 4–6, January 2004.
ment floor and ceiling effects. In addition, CAT is Embretson, Susan E., and Steven P. Reise. Item Response
more practical and reliable over a wide range of Theory for Psychologists. Mahwah, NJ: Lawrence
score levels. Evidence of the efficacy of CAT has Erlbaum, 2000.
revealed several practical advantages, including McDowell, Ian. Measuring Health: A Guide to Rating
(a) substantial reductions (50–90%) in the respon- Scales and Questionnaires. 3d ed. New York: Oxford
dent burden, (b) the virtual elimination of ceiling University Press, 2006.
and floor effects, and (c) gains in precision. Though Velozo, Craig A., Ying Wang, Leigh Lehman, et al.
CAT offers significant benefits, the development of “Utilizing Rasch Measurement Models to Develop a
724 Mechanic, David
Computer Adaptive Self-Report of Walking, perceive, evaluate, and selectively act in response
Climbing, and Running,” Disability and to symptoms. His conceptualization of the
Rehabilitation 30(6): 458–67, 2008. appraisal and meaning processes that accompany
Wilson, Mark R. Constructing Measures: An Item illness as affected by socialization and situational
Response Modeling Approach. Mahwah, NJ: cues has influenced generations of work on the
Lawrence Erlbaum, 2005. use of health services.
One of Mechanic’s distinctive qualities has
been his vision in identifying trends and defining
Web Sites new research areas and perspectives in healthcare
American Statistical Association (ASA): policy. In his classic study on the social adapta-
http://www.amstat.org tion to stress, he developed an alternative theory
Council of American Survey Research Organizations to the then pervasive psychodynamic perspective.
(CASRO): http://www.casro.org His model, showing how adaptation was influ-
Institute for Objective Measurement (IOM): enced largely by active instrumental initiatives
http://www.rasch.org structured by social context and communication
patterns, became the dominant research para-
digm in the study of stress, coping, and social
support.
Mechanic, David Mechanic was one of the first researchers to
recognize the possibilities yet also the worrisome
David Mechanic is the René Dubos Professor of issues related to managed care. His early articles
Behavioral Sciences and the director of the Institute on the rationing of healthcare established a
for Health, Health Care Policy, and Aging Research framework for examining alternative allocation
(IHHCPAR) at Rutgers University. He is a pre- mechanisms. His work on the dynamics of physi-
eminent medical sociologist whose research and cian payment in capitation and fee-for-service
writing deal with the social aspects of health and practices in the United Kingdom and the United
healthcare. States anticipated future studies of payment mech-
Mechanic earned his bachelor’s degree from the anisms. Other major contributions are notewor-
City College of New York (1956) and his master’s thy for examining risk selection, population
(1957) and doctorate (1959) degrees in sociology health, policy challenges in addressing racial dis-
from Stanford University. In 1960, he joined the parities, and trust relationships between clients
faculty of the University of Wisconsin–Madison and physicians.
where he was the chair of the Department of Mechanic’s recent work explores why reaching
Sociology (1973–1979) and the director of the consensus and implementing significant reform in
Center for Medical Sociology and Health Services the American healthcare system is so problematic.
Research (1972–1979). In 1979, he moved to He reasons that until the political will and con-
Rutgers University where he was dean of the certed efforts for change favor the healthcare needs
Faculty of Arts and Sciences (1980–1984) and, in of the population and not the benefit to individuals
1985, became the founding director of IHHCPAR, and organizations who profit from healthcare,
which he continues to direct. Mechanic also serves reform will remain elusive.
as the director of the Robert Wood Johnson Mechanic has received many notable awards,
Foundation’s Investigator Awards in Health Policy including the Health Services Research Prize from
Research Program. the Association of University Programs in Health
Mechanic has been an extraordinary and pio- Administration (AUPHA) and the Baxter Allegiance
neering leader in the social and behavioral sci- Foundation; the Distinguished Investigator Award
ences of health, health services, and health and from the Association for Health Services Research;
mental health policy over the past 40 years. His the Rema Lapouse Award and the first Carl Taube
work has been innovative in a number of research Award from the American Public Health
areas. Mechanic developed the field of illness Association (APHA); and the Distinguished Career
behavior—that is, the study of how people Award for the Practice of Sociology, the
Medicaid 725
Distinguished Medical Sociologist Award, and the

Lifetime Achievement Award in Mental Health Medicaid
from the American Sociological Association (ASA).
He received the Benjamin Rush Award (with Medicaid is a federal and state entitlement pro-
Lecture) from the American Psychiatric Association gram that provides medical benefits to low-income
(APA) and gave the Inaugural Lecture of the and low-resource individuals and families who
Award in the Behavioral and Social Sciences hon- meet federal and state eligibility requirements. The
oring Matilda White Riley at the National Institutes Medicaid program is the largest source of medical
of Health (NIH). Mechanic was elected to the funding for poor people in the United States.
National Academy of Sciences (NAS), and he was Medicaid is overseen by the Centers for Medicare
also the first sociologist elected to the national and Medicaid Services (CMS) in the U.S.
Institute of Medicine (IOM). Department of Health and Human Services (HHS),
but the program is primarily administered at the
Carol A. Boyer state level. The federal government provides finan-
cial assistance to states, with a greater share of
See also Access to Healthcare; Health Disparities;
Managed Care; Medical Sociology; Mental
financial support going to states with lower aver-
Health; Public Health; Public Policy; Rationing age per capita incomes. Although states vary
Healthcare widely in their program requirements and the ser-
vices offered, there are certain groups and services
that must be covered, including care for children,
Further Readings pregnant women, and disabled individuals. The
State Children’s Health Insurance Program
Mechanic, David. The Truth About Health Care: Why (SCHIP) and the Program for All-Inclusive Care
Reform Is Not Working in America. New Brunswick,
for the Elderly (PACE) are two special
NJ: Rutgers University Press, 2006.
programs within Medicaid designed to cover unin-
Mechanic, David. “Barriers to Help-Seeking, Detection,
sured children and to provide home- and commu-
and Adequate Treatment for Anxiety and Mood
nity-based care to the elderly, respectively.
Disorders: Implications for Health Care Policy,”
Journal of Clinical Psychiatry 68(Suppl. 2): 20–26,
February 2007. Background
Mechanic, David. “Mental Health Services Then and
Now,” Health Affairs 26(6): 1548–50, November– Medicaid was initially planned as an addition to
December 2007. programs that provided cash assistance to vulner-
Mechanic, David. “Population Health: Challenges for able groups such as the elderly, disabled, and chil-
Science and Society,” Milbank Quarterly 85(3): dren and families. Medicaid was signed into law
533–59, 2007. in 1965, as Title XIX of the Social Security Act. It
Mechanic, David. Mental Health and Social Policy: was designed to be a joint program between the
Beyond Managed Care. 5th ed. Boston: Allyn and states and the federal government to provide
Bacon, 2008. medical assistance to qualified needy individuals.
Mechanic, David, and Scott Bilder. “Treatment This program is primarily coordinated by state
of People with Mental Illness: A Decade Long agencies with additional funding provided by the
Perspective,” Health Affairs 23(4): 84–95, federal government.
July–August 2004. Medicaid has grown significantly in recent years
Mechanic, David, Lynn Rogut, David Colby, et al., eds. due to (a) increased use of services; (b) expanded
Policy Challenges in Modern Health Care. New coverage to larger and growing populations; (c)
Brunswick, NJ: Rutgers University Press, 2005. increased costs associated with medical care, drugs,
and technology; and (d) an increased need for
acute and long-term care. In 2006, total federal
Web Site
and state Medicaid costs reached $303.8 billion,
Institute for Health, Health Care Policy, and Aging and the program covered close to 59 million peo-
Research (IHHCPAR): http://www.ihhcpar.rutgers.edu ple or 20% of the population in fiscal year (FY)
726 Medicaid
2005. Medicaid costs are expected to rise signifi- In addition to the categorically needy groups,
cantly in the coming years: Estimates place 34 states and the District of Columbia offer cover-
Medicaid costs in FY2009 at $445 billion. age to those fitting in designated medically needy
groups. This category allows states to offer cover-
age to individuals who otherwise would not be
Who Medicaid Covers
covered under Medicaid. The conditions for the
To receive Medicaid, individuals or families medically needy groups can be more restrictive
must fit in a certain designated group. Although than those for the categorically needy, but people
there is wide variation among the states, there are able to spend down to reach their state’s medi-
are certain groups they must cover to receive cally needy level. If a state does choose to have a
federal funds. States must provide coverage to medically needy category, there are certain groups
those already receiving federal income assis- that the federal government requires the state to
tance, such as families eligible for coverage cover: (a) pregnant women for 60 days post-deliv-
through Aid to Families With Dependent Children ery, (b) children under 18, (c) certain newborns for
(AFDC). Although AFDC was replaced in the the 1st year of life, and (d) some blind people.
1996 welfare reform bill with Temporary Aid Additional groups that states may choose to cover
for Needy Families (TANF), Medicaid generally include (a) children under 21 who are full-time
covers anyone who would have been eligible students, (b) caretaker relatives, (c) people over
under the AFDC guidelines of 1996. States must age 65, (d) blind people, (e) disabled people, and
also cover individuals falling into one of the (f) others who would be eligible if they were not
other seven categorically needy eligibility groups. already enrolled in a health maintenance organiza-
Many of the designations for coverage require tion (HMO).
incomes at or below the federal poverty level; for There is a third group of people that receive
reference, for 2007, 100% of the federal poverty benefits from Medicaid, and they fall in another
level for a family of four was $20,650 per year category known as “special groups.” For example,
or $1720.83 per month. (There are different Medicaid will pay the Medicare premiums, deduct-
poverty levels for families in Hawai'i Alaska, ible, and coinsurance fees for Medicare recipients
and Washington, D.C.) However, having a low who have incomes less than 135% of the federal
income is not sufficient to receive coverage poverty level. Medicaid will also pay Medicare
through Medicaid: One must also fit in one of Part A premiums for Qualified Working Disabled
the designated eligibility groups. Furthermore, Individuals, who are disabled people who lose
low-income persons with a certain amount of Medicare because they are working. These indi-
other assets usually would not be eligible for viduals must meet certain income requirements as
Medicaid until they “spend down” or deplete well and have an income less than 200% of the
their assets to fit in a medically needy category federal poverty level. The Ticket to Work and
(see below). Work Incentives Acts of 1999 allow states to
The categorically needy include (a) families expand their Medicaid eligibility to working dis-
eligible for AFDC (as of 1996), (b) pregnant abled people. Disabled individuals between the
women and children under 6 years old with a ages of 18 and 65 can be offered Medicaid cover-
family income at or below 133% of the federal age, even if they exceed Social Security income
poverty level, (c) children aged 6 to 19 with a fam- guidelines, if they are able to and choose to work.
ily income up to 100% of the federal poverty If an individual’s disabling condition improves, he
level, (d) caretakers of children under age 18 (or or she may still be eligible for coverage but may
age 19 if the child is still in school), (e) Social have to share part of the cost of medical care.
Security Income recipients, (f) individuals receiv- Certain states offer coverage for special medical
ing adoption or foster care assistance through conditions as well, but this varies widely by state.
Title IV of the Social Security Act, (g) people liv- For example, 10 states and the District of Columbia
ing in medical institutions meeting certain Social offer Medicaid coverage to uninsured tuberculosis
Security income requirements, and (h) certain patients (for tuberculosis treatment only), and all
Medicare beneficiaries. 50 states offer Medicaid coverage for a specific
Medicaid 727
period of time for women with breast or cervical Approximately 25% of all the children in the
cancer. All 50 states provide long-term care ser- United States, and 50% of all the low-income chil-
vices for Medicaid-eligible people who qualify for dren, receive their health coverage through
individual care. Medicaid or SCHIP. Since SCHIP was authorized
Under the Personal Responsibility and Work in 1997, the rate of uninsured children has dropped
Opportunity Reconciliation Act of 1996, also from 23% in 1997 to 14% in 2005. Children who
known as the welfare reform bill, legal resident are covered report similar access to primary and
aliens who entered the United States after 1996 are preventive care as children covered by private
ineligible for Medicaid coverage for the first 5 insurance (but lower access to dental care). Since
years they are in the country. However, states have SCHIP began, improved health outcomes for cov-
the ability to modify this requirement if they ered children have been reported, such as fewer
choose to cover legal resident aliens earlier. All emergency room visits for asthma and improved
states must provide and cover emergency services school performance.
for legal aliens.
What Medicaid Covers
Program of All-Inclusive Care for the Elderly
There are certain services that states must provide
PACE was designed to provide an alternative to coverage for, as mandated by the federal govern-
institutional care for those over 55 years of age ment. For people who fall in the categorically
requiring skilled nursing care. Working in PACE needy groups, states must provide coverage for (a)
teams, caseworkers manage and coordinate all the inpatient and outpatient hospital visits; (b) labora-
necessary care and services for these individuals, tory tests and X rays; (c) pediatric and family
usually provided through adult day-care centers, nurse practitioners; (d) nursing facility services for
home health care, and outpatient hospital care. individuals over age 21; (e) regular screening up to
The program helps individuals maintain a more age 21 as part of Early and Periodic Screening,
independent lifestyle and still receive the care they Diagnosis, and Treatment (EPSDT); (f) family
need. The providers are paid exclusively through planning care and supplies; (g) rural health clinic
PACE, and they are not able to implement any care; (h) physician services; (i) dental services; (j)
limits or costs to the patients. home health services for individuals eligible for
nursing care, including home health aides and
medical supplies; (k) nurse midwife services; (l)
State Children’s Health Insurance Plan
prenatal care; and (m) postpartum care for 60
Title XXI of the Social Security Act enacted days. For states with medically needy categories,
SCHIP and allows states to incorporate SCHIP as the following services must be covered: (a) prena-
part of Medicaid or as an independent program. tal care and delivery, (b) postpartum care for cer-
SCHIP provides additional federal funds for states tain groups under age 18, and (c) home health
to cover uninsured children through Medicaid. services for certain groups.
SCHIP reaches a group of children that would not States have the option of providing additional
have otherwise been eligible for Medicaid coverage services that are listed under Medicaid law and may
by covering those up to age 19 whose parents’ also provide some services to certain groups of
income is too high for Medicaid but too low to medically needy individuals. For some of these
afford private insurance. SCHIP usually covers optional services, states are eligible for federal fund-
families with an income at or below 200% of the ing. Examples of additional services for which states
federal poverty level. All state SCHIP programs can receive federal support are (a) diagnostic ser-
must include free immunizations and well-baby vices, (b) clinic services, (c) care centers for mentally
visits; other services may have a copay. The immi- retarded individuals, (d) prescription drugs and
gration status of the parents usually does not mat- prosthetic devices, (e) optometrist services and eye-
ter in regard to medical coverage for their children: glasses, (f) nursing services for individuals under age
As long as the child is a U.S. citizen, he or she will 21, (g) transportation services to and from medical
be covered by Medicaid. care, (h) rehabilitation services and physical
728 Medicaid
therapy, and (i) home- and community-based care approximately 65% of Medicaid recipients were
for individuals with chronic conditions. enrolled in managed-care programs, up from only
14% in 1993.
The state is responsible for paying the providers
How Medicaid Works
who offer services to Medicaid recipients and
Medicaid is overseen by the CMS in the HHS. The accept Medicaid payments. Providers are usually
federal government provides some guidelines for paid through fee-for-service methods or prepay-
who will be covered and how, but the requirement programs such as the managed-care pro-
ments and programs vary widely by state, and grams mentioned above. It is also the responsibility
states take the primary role in administering their of states to ensure that there are enough providers
statewide Medicaid programs. Medicaid is funded in certain geographic areas who accept Medicaid.
through federal and state funds, and the federal For hospitals that treat a disproportionate number
government pays different shares for different of Medicaid recipients and other low-income or
states. The share from the federal government is uninsured people, the state must make additional
determined by the Federal Medical Assistance payments through a system known as the
Percentage (FMAP), which uses a formula com- Disproportionate Share Hospital Adjustment.
paring the state’s average per capita income with Some Medicaid beneficiaries may pay a small
the national average per capita income. This fed- copayment for services, but there are certain
eral-funding share is inversely associated with the groups that the federal government excludes from
state’s per capita income. Thus, in a state with a having to pay any share of medical costs. These
lower per capita income, the federal government special groups include (a) pregnant women,
will pay a larger share of Medicaid, and in states (b) children under the age of 18, (c) hospital or
with higher per capita incomes, the federal gov- nursing home patients who would otherwise pay
ernment will pay a smaller share. The government for their own care, and (d) anyone receiving emer-
share, or FMAP, must be between 50% and 83% gency care or family planning services.
of Medicaid costs. In 2008, the federal minimum States have the power to determine the amount
FMAP was 50% with the highest share, paid to and duration of services they will cover, such as
Mississippi, at 76.29%. The FMAP for Washington, the number of days in the hospital or the number
D.C. was recently raised permanently from 50% of doctor visits. However, federal law stipulates
to 70%. For children covered under SCHIP, the that these limits be fair and not discriminate on
federal government pays a higher share, averaging any basis. For example, states cannot limit cover-
about 70% for all states. The federal government age for medically necessary services for children,
reimburses 100% for care through the Indian such as those considered part of EPSDT.
Health Service (IHS), a branch of the HHS. It also Like the waivers for managed-care programs
provides extra financial support to the 12 states and the inclusion of extra groups, states can also
that provide the highest rates of emergency care to apply for waivers to cover additional services such
undocumented immigrants. as community- or home-based services for indi-
There has been recent growth in the use of viduals who would otherwise require institutional-
managed care in Medicaid as an alternative ization. However, to receive a waiver the state
method of both payment and delivery of services. must offer evidence that the plan or service addi-
States can apply for waivers from the government tion is cost-effective.
in designing and implementing Medicaid man- In administering the state Medicaid program,
aged-care programs. Two sections of the Social each state is responsible for (a) setting the rates
Security Act describe waivers available to states in of payment; (b) establishing eligibility guidelines;
this area: (1) Section 1915(b) allows states to (c) determining the types and durations of eligible
design “innovative healthcare delivery or reim- services; (d) informing recipients about participat-
bursement systems” and (2) Section 1115 allows ing providers; and (e) ensuring that recipients
states to carry out demonstration projects to test receive timely, quality, and appropriate medical
programs designed to cover uninsured individuals care. In addition, the state legislature is able to
without significantly raising costs. In 2006, change state Medicaid policies.
Medicaid 729
The Cost of Medicaid eligibility requirement, and Medicaid will pay

Total Medicaid costs for 2006, including both their Part A and Part B premiums. A third group—
the federal and state expenditures, reached approx- working disabled people who have incomes less
imately $303.8 billion. Of this figure, 57.8% was than 200% of the federal poverty level and who
for acute care, 36.6% for long-term care, and 5.6% have lost Medicare because they have returned to
for disproportionate-share hospital payments. work—are known as Qualified Disabled and
Considering the approximately 59 million Working Individuals; they are eligible to buy
Medicaid recipients, the overall average cost per Medicare Parts A and B, and Medicaid will pay
person is about $4,662, but the costs vary consid- their Medicare Part A premiums. A final group of
erably among certain groups. For example, chil- qualified individuals—those who have Medicare
dren constitute about 50% of all Medicaid and are between 120% and 175% of the federal
recipients and are covered at an average cost of poverty level—are also eligible to receive Medicaid
about $1,617 per child. Adults make up about assistance in paying their Part B premiums. With
26% of Medicaid recipients at an average cost of Medicare Part D recently enacted, Medicaid will
$2,102 per person. Care for elderly and disabled no longer provide prescription drug benefits for
Medicaid recipients costs the most by far: the dually eligible Medicare recipients. It must be
elderly make up 10.3% of Medicaid recipients and noted that in all these cases of dually eligible
cost an average of $11,839 per person; disabled people, Medicare will always pay first because
individuals covered by Medicaid (14.1% of all Medicaid is the payer of last resort. Nationwide,
recipients) cost an average of $13,524 per person. about 6.5 million Medicare recipients receive
In the coming years, long-term care will continue supplemental assistance from Medicaid.
to be a large and growing expense for Medicaid. In
2006, Medicaid paid $48.6 billion for nursing Future Implications
facilities, accounting for 41% of the total costs in
In the future, managed care will likely become a
these areas. The program paid an additional $45.4
more popular method as states seek to provide and
billion for home health and personal care.
pay for care for Medicaid recipients and, at the
same time, control costs. Medicaid costs will con-
Dual Eligibility
tinue to rise as the population ages, long-term care
Under certain circumstances, individuals can be use becomes more frequent, eligible populations
dually eligible for both Medicare and Medicaid. grow, and the cost of medical care increases.
Medicare beneficiaries whose incomes and
resources are low enough to qualify in one of Emily Rosenthal
Medicaid’s eligible categories can receive Medicaid
assistance in addition to their Medicare coverage. (CMS); Coinsurance, Copays, and Deductibles; Cost
In these cases, Medicaid supplements Medicare of Healthcare; Fee-for-Service; Health Maintenance
coverage, and additional services not covered by Organizations (HMOs); Long-Term Care; Medicare;
Medicare may be covered (e.g., nursing home care State Children’s Health Insurance Program (SCHIP)
beyond Medicare’s 100-day limit). The two main
groups of Medicare recipients who are eligible for
assistance from Medicaid with Medicare premi- Further Readings
ums and copayments are known as (1) Qualified Engel, Jonathan. Poor People’s Medicine: Medicaid and
Medicare Beneficiaries (QMBs) and (2) Specified American Charity Care Since 1965. Durham, NC:
Low-Income Medicare Beneficiaries (SLMBs). Duke University Press, 2006.
QMBs are Medicare recipients with incomes less Grogan, Colleen M., and Michael K. Gusmano. Healthy
than 100% of the federal poverty level; for these Voices, Unhealthy Silence: Advocacy and Health
individuals, Medicaid pays their Medicare Part A Policy for the Poor. Washington, DC: Georgetown
and Part B premiums, coinsurance, and deduct- University Press, 2007.
ibles. For SLMBs, an income less than 120% of Hoffman, Earl Dirk, Jr., Barbara S. Klees, and Catherine
the federal poverty level is sufficient to meet the A. Curtis. “Overview of the Medicare and Medicaid
730 Medical Errors
Programs,” Health Care Financing Review, Statistical develop regulations and guidelines for reducing
Supplement. pp. 1–281, 283–304, 2005. errors to improve patient safety and the quality of
Ketler, Sophia R., ed. Medicaid: Services, Costs, and care. There has also been a major shift from blam-
Future. New York: Nova Science, 2008. ing the individuals who make errors to recognizing
Smith, David G., and Judith Moore. Medicaid Politics that the individuals function within systems and
and Policy, 1965–2007. New Brunswick, NJ: that those systems critically influence individual
Transaction Publishers, 2008. performance.
Social Security Act. Available from Social Security
Online. http://www.socialsecurity.gov/OP_Home/
ssact/ssact.htm Definitions and Concepts
Stevens, Robert, and Rosemary Stevens. Welfare
Key definitions and concepts—many adapted
Medicine in America: A Case Study of Medicaid. New
from systems-based research on error prevention
Brunswick, NJ: Transaction Publishers, 2003.
in other industries—underlie the current efforts to
understand and prevent medical errors. An error
Web Sites is defined by the IOM as either the failure of a
planned action to be completed as intended or the
Center for Health Care Strategies (CHCS):
use of a wrong plan to achieve an aim. The former
http://www.chcs.org
is referred to as an error of execution and the lat-
ter as an error of planning. This formulation is
Kaiser Family Foundation, State Health Facts: based on the work of James Reason and others
http://www.statehealthfacts.org/comparetable. who extensively studied accidents in aviation and
jsp?ind=188&cat=4 other industries.
National Academy for State Health Policy (NASHP): Errors of execution are due either to slips or
http://www.nashp.org lapses. A slip is an observable error of execution,
National Association of State Medicaid Directors such as when a surgeon inadvertently cuts the
(NASMD): http://www.nasmd.org wrong tissue. A lapse is unobservable, as when an
National Conference of State Legislatures (NCSL): internist forgets to order antibiotics for a patient
http://www.ncsl.org with pneumonia after intending to do so. In both
cases the physician knew what the right thing was
to do and intended to do it. In contrast, errors of
planning are mistakes in that the actions proceeded
Medical Errors as planned but the plan was wrong.
Errors may be classified as biomedical or con-
Until the 2000 report by the national Institute of textual, the former occurring because of inatten-
Medicine (IOM) To Err Is Human: Building a tion to processes occurring within the boundary of
Safer Health System, medical errors were a rela- the skin and the latter from inattention to pro-
tively low priority in the U.S. healthcare system. cesses expressed outside that boundary—that is,
Medical errors were regarded as uncommon. processes that form the context of a patient’s ill-
Physicians and other healthcare providers gener- ness. Failing to prescribe a medication that effec-
ally attributed them to “a few bad apples” and the tively treats a serious condition is a biomedical
occasional slip. However, data pointing to the error. Prescribing a medication that a patient can-
pervasiveness of the problem were already avail- not afford when a less costly effective medication
able, leading the IOM to estimate that between is available is a contextual error. In both instances,
44,000 and 98,000 Americans die each year as a the patient does not obtain the necessary therapy:
result of medical errors. in the first, from a failure to attend correctly to the
Since that report, medical errors and patient patient’s disease and, in the second, from inatten-
safety have become a major focus of health ser- tion to the context surrounding the disease.
vices research and policy making, providing a key Fortunately, not all errors result in an adverse
role for the former in shaping the latter, as both event, the term for an injury that is caused by
government and nongovernmental organizations medical mismanagement. Neglecting to wash one’s
Medical Errors 731
hands prior to examining a postsurgical wound is The Scope of the Problem

an error, for instance, but in most cases this does
not result in a wound infection because of the Safety is defined as freedom from accidental
patients’ inherent capacity to fight off infection. injury. Because of the high prevalence of prevent-
Conversely, adverse events may occur despite able adverse events that injure patients, healthcare
flawless care: A patient’s surgical wound may is unfortunately not as safe as it could be. Early
become infected despite excellent sterile technique. awareness of the magnitude of the problem
Harm that is specifically attributable to error is emerged in 1991 from the Harvard Medical
termed a preventable adverse event. Practice Study of approximately 30,000 randomly
Occasionally, preventable adverse events are examined discharges from 51 hospitals in New
due to negligence—when the care provided falls York State in 1984. That study found that 3.7%
below the standard expected of a reasonable and of the hospitalizations were prolonged or resulted
knowledgeable practitioner under the circum- in disability because of an adverse event. More
stances, as established in a court of law. Most than half (58%) of these adverse events were
preventable adverse events, however, are consid- deemed preventable, and 27.6% met the legal cri-
ered to be the end result of conditions in the orga- teria for negligence. Nearly one fifth (19%) of the
nization that preceded the actual incident. adverse events were medication related, 14% were
James Reason distinguished active from latent due to wound infections, and technical complica-
errors. Latent errors may include the faulty design tions accounted for 13%. Overall, 13.6% of
of instruments or technologies, poorly installed or adverse events were fatal.
functioning equipment, or a dysfunctional work Similar findings emerged from a subsequent
environment where communication or work con- corroborative study published in 2000 and are
ditions are not suitable to meet the demands of the based on an analysis of 15,000 hospital discharge
job. They may be difficult to detect, but they form records from Colorado and Utah in 1992. The
the backdrop for the observed, or active, error. investigators selected a representative rather than a
The point where an active error occurs is also random sample of hospitals, and the records were
referred to as the sharp end of the system, as in the reviewed by only one rather than two physicians
slip of a surgeon’s knife, whereas the latent pre- but with greater standardization of the review pro-
conditions for the error are referred to as the blunt cess. Adverse events were found to be slightly less
end, as in the faulty lighting or poor staffing that common at 2.9%; however, the proportions
diminishes an operator’s technical performance at deemed preventable and negligent were nearly the
the time of the preventable adverse event. same as those found in New York at 53% and
The structured process for identifying contribut- 29.2%, respectively.
ing factors such as latent errors leading up to an The most significant difference between the two
incident is often described as root cause analysis, or studies was the incidence of adverse events that
systems analysis. A critical incident may be a near were fatal: The rate of 6.6% in Colorado and Utah
miss or close call, in which an error or series of was about half the number in New York. Variations
errors did not produce an injury only because of in study design, margin of error, and actual differ-
chance. It may also be a severe adverse event, some- ences in error rates in the two studies could all
times termed a sentinel event, in which severe injury contribute to the discrepant findings. Extrapolating
or death to a patient occurred. Reason has described from these numbers to the more than 33 million
what he calls the “Swiss cheese” model: the view hospital admissions in the nation in 1997, and
that “holes” may be identified in every layer of an excluding unpreventable adverse events from the
organization’s systems of operation. In organiza- analysis, produced the widely quoted estimate that
tions that lack a culture of safety, where teams may medical errors may cause 44,000 to 98,000 pre-
not work well together, or equipment is poorly ventable deaths per year.
functional, the holes may be sufficiently large and Smaller studies and the recognition that several
numerous that it is not uncommon for them to categories of errors are missed using exclusively
“line up,” leading to error chains that result in a hospital-based discharge data has led many to
high incidence of preventable adverse events. believe that the estimates of preventable adverse
732 Medical Errors
events and fatal incidents, as serious as they are, medications with established benefit (e.g., beta
nevertheless underrepresent the true magnitude of blockers for postmyocardial infarction).
the problem. In an analysis of more than 1,000 A compendium of data on medication errors
intensive-care units (ICUs) and surgical patients and preventable adverse drug events is contained
admitted to a teaching hospital, preventable adverse in the 2007 national IOM publication Preventing
events were identified in 45.8% of the cases, with Medication Errors. Prescribing and administration
17.7% leading to disability or death. The chance errors are the most common. In hospitals, between
of an adverse event increased by about 6% per day 0.1 and 0.3 medication orders are incorrect per
of hospitalization. patient per day. Medications are incorrectly admin-
Furthermore, because most methods for identi- istered 11% of the time, not counting “wrong
fying errors and their adverse effects are limited to time” errors. On average, one administration
assessments of the medical record, they miss con- error, such as the wrong dosage or the wrong rate
textual errors, which are rarely documented. For of administration, occurs per patient per day.
instance, the failure to take into account a patient’s Not all healthcare facilities have the same error
lack of transportation to a Coumadin clinic when rate. In studying 36 facilities, medication adminis-
prescribing the blood thinner for atrial fibrillation tration error rates ranged from 0% to 26%. Error
may lead to a preventable bleed, but the medical rates have been linked to incomplete or illegible
record will show only that the patient did not prescriptions and, at the blunt end of the system,
adhere to an apparently correct plan of care. to hiring practices that lead to high patient-to-
Identifying such errors requires case analysis, direct nurse ratios with high nurse workloads.
observation, or standardized patients to simulate The morbidity and costs of preventable adverse
the conditions under which they might occur. drug events are high. A 1997 study conservatively
estimated that 400,000 inpatient adverse drug
events occur in the United States per year at a cost
Preventable Adverse Drug Events
of $5,857 per incident. Adjusting for the rise in
Medication errors are the most studied medical healthcare costs and inflation, the additional hos-
errors because of the extensive charting associated pital costs incurred per inpatient preventable
with medication administration and the ever- adverse drug event in 2008 was $12,403 with
increasing volume of medications administered avoidable healthcare expenses totaling $5 billion.
each year. Medication errors may occur during Based on a 2000 study of the ambulatory costs of
(a) prescribing, (b) dispensing, (c) administering, Medicare patients (again making similar adjust-
(d) monitoring, and (e) the systems management ments), just in this subset of the nation’s popula-
control process. The latter includes failures to iden- tion, outpatient preventable adverse drug event
tify drug interactions or to coordinate the adminis- costs in 2008 are $3,406 per incident and $1.5
tration of medications with other aspects of care billion nationally. Note that none of these esti-
(e.g., holding anticoagulation medication before a mates take into account lost earnings, losses related
surgical procedure). When a medication causes an to not being able to carry out the activities of daily
injury it is called an adverse drug event (ADE). living (ADL) such as self-care, and the effects of
When such an event is due to medication error it is pain and suffering. The calculations also do not
termed a preventable adverse drug event. include the costs related to preventable adverse
At least 1.5 million preventable adverse drug drug events when patients do not take their medi-
events occur each year in the United States as a cations correctly or due to overuse and underuse
result of medication errors. Of these, about 22% errors by healthcare providers when prescribing.
occur in hospitals, 31% in outpatient Medicare
patients, and 47% in long-term care nursing
Disclosures of Errors
homes. These data exclude (a) all outpatients
under 65 years of age who are not enrolled in the Physicians have long feared disclosing medical
Medicare program, (b) errors patients made taking errors to patients because of concerns that they
their own medications, and (c) errors of omission are more likely to be sued. Employers and insurers
when healthcare providers neglected to prescribe shared similar concerns and did not encourage
Medical Errors 733
disclosure. However, recent evidence clearly shows that their reports, which are often time-consuming
that physicians who exhibit transparency and say to file, will be used to improve care. At the insti-
they are sorry for the medical error are, in fact, tutional level, organizations also face concerns
substantially less likely to be sued. Furthermore, about how they are regarded and practical issues
the legal penalties for deception—for withholding about how best to use the data. A major chal-
information or misleading patients—have become lenge, then, is creating reporting systems that
a further incentive for truth telling. (a) are easy to access, (b) provide certain legal
Several ethical tenets commonly applied to the protections to reporters and institutions, and (c)
physician–patient relationship also mandate full use the data to improve the processes of care.
disclosure of adverse events. First, adverse events Reporting systems for medical errors and
often have consequences that require medical adverse events can be mandatory or voluntary.
intervention. Patients can only participate in deci- Also, reporting can come directly from the pro-
sion making regarding subsequent care if they are vider, or reports may be submitted by the organi-
fully informed of the circumstances necessitating zation. Finally, reporting can be to an external
further intervention. In this respect, disclosure is monitor, such as a state or federal entity, or remain
an essential component of autonomy and informed internal to the organization with periodic external
consent. audits. Each has its advantages and disadvantages.
Second, truth telling is considered essential to For instance, direct reporting by practitioners to a
respect for persons. When patients entrust them- national database provides frontline information
selves to physicians, they expect full transparency, and bypasses the employer, which may be reassur-
even with regard to near misses. In studies where ing to a reporter who is reluctant to notify man-
patients have been given hypothetical scenarios agement each time an error occurs. On the other
involving even minor incidents related to their hand, internal tracking of errors enables organiza-
care, 98% say that they would want to know what tions to identify system problems and make the
happened. Furthermore, they have indicated that necessary changes.
they would be more likely to sue their physicians if Since the mid-1980s, a growing number of indi-
they later discovered that information had been vidual states have had adverse event reporting sys-
withheld or covered up. Hence deception— tems of various kinds. The number of reports filed
independent of the actual physical harm that has ranged from fewer than 20 in a year in some
occurred—is regarded by patients, almost univer- cases to tens of thousands in others, indicating the
sally, as a harm in itself. severity of the problem of underreporting. States
Third, full disclosure is essential to justice and have also varied greatly in the information made
fairness. Although they may, in fact, be less likely available to the public. Patient confidentiality is
to sue, patients have the right to seek compensation always maintained, but whether the names of phy-
for injuries when they occur, if they so choose. sicians, hospitals, and health systems or the num-
bers of adverse events per site are released and
whether the data are freely accessible on the Internet
Error Reporting
all vary. Synthesis and analysis of data, particularly
In addition to the legal and ethical imperatives for across states, has been almost uniformly poor.
candor with patients about errors related to their At the federal level, the U.S. Food and Drug
care, disclosure of all such incidents internally and Administration (FDA) is an example of a national
to regulatory bodies through formalized reporting reporting program for adverse events linked to
systems is critical to accountability and quality medications and other medical products. All mal-
improvement. There are a number of obstacles, functions, serious injuries, and deaths must be
however, to effective error reporting systems. reported by either the facility or the manufacturer,
Physicians may fear negative repercussions, includ- depending on the circumstances. However, these
ing malpractice litigation, disciplinary action, or problems are generally not due to provider or sys-
loss of hospital privileges. They may be hesitant to tems errors at the organizational level. The focus is
personally acknowledge errors in a profession that on identifying product defects or risks associated
emphasizes perfectionism. They may be skeptical with products through postmarketing surveillance.
734 Medical Errors
To address the unmet need for a comprehensive now believe that reporting errors is necessary to
reporting system that is easily accessible, provides improve patient safety, and most feel that they are
legal protections, and has analytic and response not getting adequate information about how to
capabilities, the U.S. Congress passed the Patient prevent them. Increasingly, physicians are embrac-
Safety and Quality Improvement Act of 2005, ing a culture of safety.
which established Patient Safety Organizations
(PSOs) to collect and process confidential informa-
Progress in Reducing Errors
tion reported by healthcare providers. The law
gives full confidentiality protection to reporters There has been a major shift in attitudes toward
and limits the use of the information in legal pro- medical errors and the need to protect patients
ceedings. Both public and private entities— from preventable harm. In the peer-reviewed
for-profit or not-for-profit (excluding insurance medical literature, articles addressing issues of
organizations)—may apply to become PSOs if they patient safety more than tripled during the 5 years
are capable of meeting the complex requirements following the 2000 IOM report, compared with
to qualify. The act also created a network of the previous 5 years. The number of federally
patient safety databases (NPSDs) for centralizing funded patient safety research awards increased
data to establish national as well as regional statis- nearly 30-fold. Starting in 2001, the U.S. Congress
tics related to errors, adverse events, and the effect has appropriated $50 million annually to fund
of safety improvement initiatives. many of these studies.
Internationally, concerns about medical errors, What has been the impact of such investments?
adverse events, and the strategies for reporting Evidence that healthcare has become substantially
them have developed in parallel. Australia, safer is not yet strong. There have been discrete
Canada, and the United Kingdom have all initi- studies showing improvements in certain areas.
ated reporting systems. The World Health For instance, hospitals with tight infection control
Organization (WHO) has created the World procedures have documented a reduction in hospi-
Alliance for Patient Safety, following a resolution tal-acquired infections, and fatalities related to the
in 2002. Its charge includes a broad range of accidental injection of concentrated potassium
safety initiatives, such as data collection on chloride have been prevented by removing the
adverse events related to healthcare delivery in product from nursing unit shelves. There may be
developing countries, as well as guidelines for many other such examples of a positive effect.
adverse event reporting. Underdeveloped error tracking systems have con-
Despite these efforts, physicians indicate that founded efforts to assess progress.
medical-error-reporting systems are still inade- A number of organizations, along with the gov-
quate. A survey of U.S. physicians found that they ernment, have committed to the patient safety
were more likely to discuss errors with their col- movement, setting specific goals and strategies for
leagues than make a formal report. Only a third of preventing medical errors. The Agency for
physicians felt that reporting systems at their orga- Healthcare Research and Quality’s (AHRQ’s)
nizations were adequate. Few had confidence in Center for Quality Improvement and Safety leads
the process. Nevertheless, 83% indicated that they the federal government’s efforts to (a) set standards
had, at some point, filed a formal report of an and measures called patient safety indicators;
error. Major areas where physicians wanted to see (b) educate healthcare providers, administrators,
improvement were in assurances that (a) reports and the general public; and (c) guide the research
remain confidential and nondiscoverable, (b) the agenda. The Joint Commission has played a key
data will guide system improvements, (c) there will role in enforcing change by requiring hospitals to
be no penalties or other negative repercussions, follow specific error prevention strategies, such as
and (d) the process will take less than 2 minutes to (a) improved patient identification, (b) surgical-site
complete. verification, and (c) standards for communicating
Although physicians have concerns about the information. Private–public partnerships—such as
reporting process, interest in the problem of errors the Institute for Health Improvement’s (IHI’s)
and how to prevent them is high. Most physicians 100,000 lives campaign, which enlisted thousands
Medical Group Practice 735
of hospitals to adopt proven methods of reducing Web Sites

avoidable deaths—have been cosponsored by the Agency for Healthcare Research and Quality (AHRQ):
federal AHRQ, the Centers for Disease Control http://www.ahrq.gov/qual
and Prevention (CDC), and the Centers for Health Grades: http://www.healthgrades.com
Medicare and Medicaid Services (CMS), exempli- Institute for Healthcare Improvement (IHI):
fying a broad-based commitment to make health- http://www.ihi.org/ihi
care safe. Building on that momentum, the IHI and Institute for Safe Medication Practices (ISMP):
its partners embarked on a “5 million lives” cam- http://www.ismp.org
paign to protect patients over a period of 2 years Joint Commission: http://www.jointcommission.org
from 5 million incidents of medical harm. The U.S. Food and Drug Administration (FDA):
movement to eliminate medical errors is still young http://www.fda.gov
but maturing rapidly.
Saul J. Weiner
Medical Group Practice
(AHRQ); Health Report Cards; Institute for
Healthcare Improvement (IHI); International
Medical group practice, a form of medical prac-
Classification for Patient Safety (ICPS); Joint tice that dates back to the 1800s, can be defined
Commission; Patient Safety; Pay For Performance; in a number of ways. The Medical Group
Quality of Healthcare Management Association (MGMA), an organiza-
tion representing group practice executives,
administrators, and managers, and the American
Medical Association (AMA), the nation’s largest
Further Readings
physician association, consider medical group
Aspden, Philip, and the Committee on Identifying and practices to have the following elements: (a) a for-
Preventing Medication Errors. Preventing Medication mal or legal arrangement; (b) three or more physi-
Errors. Washington, DC: National Academies Press, cians; and (c) shared business and clinical
2007. operations, facilities, staff, and equipment.
Dhillon, B. S. Reliability Technology, Human Error, and Recent federal health legislation regarding phy-
Quality in Health Care. Boca Raton, FL: CRC Press, sician self-referral, known as the Stark legislation
2008. (named for U.S. Congressman Fortney “Pete”
Kohn, Linda T., Janet M. Corrigan, Molla S. Donaldson, Stark), has defined medical group practice in a
and the Committee on Quality of Health Care in slightly different manner. First, the federal legal
America. To Err Is Human: Building a Safer Health
definition is broader in scope, including groups
System. Washington, DC: National Academy Press,
with two or more physicians. At the same time,
2000.
this definition applies more stringent criteria that
Moller, Aage R. A New Epidemic: Harm in Health Care:
stipulate that (a) all physicians in the group must
How to Make Rational Decisions About Medical and
Surgical Treatment. New York: Nova Biomedical
provide a full range of patient care services appro-
Books, 2007.
priate to their specialties and be responsible for the
Peters, George A., and Barbara J. Peters. Medical Error bulk of the care provided through the group;
and Patient Safety: Human Factors in Medicine. Boca (b) group income and expenses must be distributed
Raton, FL: CRC Press, 2008. according to an established plan; and (c) decision
Reason, James. “Human Error: Models and making in the group must be centralized with
Management,” British Medical Journal 320(7237): respect to functions such as governance, budgets,
768–70, March 18, 2000. billing, and use.
Vance, James E. A Guide to Patient Safety in the Regardless of how they are defined, the ways
Medical Practice. Chicago: American Medical medical group practices look and act vary consid-
Association, 2008. erably. Medical group practices may be composed
Wachter, Robert M. Understanding Patient Safety. New of physicians with the same specialty or physicians
York: McGraw-Hill Medical, 2008. with different specialties. And they can include
736 Medical Group Practice
other types of medical professionals such as den- medical group practices often provide malpractice
tists and podiatrists. These groups may be embed- coverage, the sharing of on-call duties, and the
ded within larger health systems. They may work intellectual challenge and stimulation of working
out of a single location or many locations. Medical with colleagues from a variety of disciplines and
group practices may or may not be physician specialties.
owned. These practices can range in size from a Medical group practices are thought to con-
few physicians to thousands of primary-care and tribute to the efficient and high-quality delivery of
specialty-care providers. One of the best-known medical care in a number of ways. Some medical
medical group practices in the nation is the Mayo group practices provide a wide and complex
Clinic, which is based in Rochester, Minnesota, range of services on-site. Medical group practices
and employs more than 3,300 physicians, scien- may contain costs through centralized purchas-
tists, and researchers at multiple sites across the ing, uniform coding and billing, and the sharing
country. of auxiliary medical and administrative staff.
These practice groups may be able to enhance
access to care through extended office hours. A
Importance
medical group practice’s organizational culture—
Medical group practices are important to the including factors such as the extent to which the
study of health services research because they rep- group’s physicians share information, are innova-
resent an increasingly common vehicle for the tive and collegial, and subscribe to a group iden-
delivery of medical care. They also, theoretically, tity—is also thought to affect healthcare costs and
hold much potential for improving the quality and quality.
efficiency of the delivery of medical services.
The number of medical group practices and the
number of physicians practicing in them has Future Implications
grown over time. The AMA reported that there Medical group practices are an increasingly impor-
were just over 4,000 medical group practices in tant feature in the healthcare delivery system in
1965 but nearly 20,000 in 1996, representing the United States. As a result, it is increasingly
approximately 11% and 32% of all physicians important and necessary when conducting health
in the nation. More recently, the Agency for services research to consider their impact on the
Healthcare Research and Quality (AHRQ) sup- quality, effectiveness, and efficiency of the deliv-
ported a collaborative study between the MGMA ery of medical care. However, given the large
and the University of Minnesota School of Public number of medical group practices and the wide
Health that sought to establish a nationally repre- variation in the ways they are organized, the
sentative database of medical group practices. This influences of this type of practice may be difficult
effort resulted in the estimate that the number of to disentangle from other causal factors in an
medical group practices had grown to nearly already complex system of healthcare delivery.
37,000 in 2003 and that the physicians in them These factors can include (a) a physician’s train-
represented almost 67% of all office-based physi- ing, (b) the medical group’s payment structure,
cians in the nation. Based on these findings, medi- (c) its organizational culture, (d) the influences
cal group practices deliver a large proportion of of partners and colleagues, (e) the rules and stan-
the medical care in the nation. dards established by the health maintenance orga-
One reason for the establishment and continu- nizations (HMOs) and health insurance companies
ation of medical group practices is that increased with which the group is contracted, (f) patient
medical specialization and technical complexity expectations, and (g) community standards. As
require the integration of multiple physicians into knowledge of medical group practices and their
a single practice to provide appropriate and nec- operations continues to grow, health services
essary patient care services. Medical group prac- researchers will be able to make vital improve-
tices are also an attractive employment option for ments in the delivery of healthcare.
many physicians because they may provide cer-
tain advantages over solo practice. For example, Penny L. Havlicek
Medicalization 737
See also Access to Healthcare; American Medical deviance is a matter of sinfulness gave way to the
Association (AMA); Equity, Efficiency, and view that deviant behavior is a violation of social
Effectiveness in Healthcare; Forces Changing norms and laws, that is, badness. Medicalization
Healthcare; Health Workforce; Managed Care; signifies the most recent shift, transforming the
Physicians; Quality of Healthcare
definition of deviance again, this time from bad-
ness to sickness.
Further Readings
The Power to Define Sickness
Casalino, Lawrence P., Kelly J. Devers, Timothy K.
Lake, et al. “Benefits of and Barriers to Large The concept of medicalization was introduced
Medical Group Practices in the United States,” during the second half of the 20th century when
Archives of Internal Medicine 163(16): 1958–64, Americans were registering rising distrust in and
September 8, 2003. disillusionment with the values being expounded
Medical Group Management Association. Performance by the leaders of most social institutions. Hence,
and Practices of Successful Medical Groups: 2008 the times were conducive to rejecting a socially
Report Based on 2007 Data. Englewood, CO: defined view of deviance in favor of a medical-
Medical Group Management Association, 2008. based perspective. Critics argued, and many
Reiboldt, J. Max, Craig W. Hunter, P. Todd DeWeese, observers agreed, that the prerogative to deter-
et al. Integration Strategies for the Medical Practice.
mine what is and what is not a medical problem
2d ed. Chicago: American Medical Association Press,
gives physicians tremendous power. The question
2006.
of whether this is more socially beneficial or det-
Tollen, Laura. Physician Organization in Relation to
rimental remains unsettled.
Quality and Efficiency of Care: A Synthesis of Recent
Talcott Parsons (1902–1979), an American,
Literature. New York: Commonwealth Fund, 2008.
Harvard University sociologist, is credited with
initiating discussion of the vital social role played
by physicians in differentiating between true sick-
Web Sites
ness and malingering. He based this proposition on
American Medical Association (AMA): the premise that social stability and continuity
http://www.ama-assn.org require that all members of society fulfill their
American Medical Group Association (AMGA): respective social roles. Because the “sick” role
http://www.amga.org offers the benefit of excusing a person from normal
Medical Group Management Association (MGMA): responsibilities, it is important to ensure that peo-
http://www.mgma.com ple do not take inappropriate advantage. By iden-
tifying what constitutes real illness, physicians are
in a position to grant patients a temporary exemp-
tion from their normal role responsibilities. By
Medicalization labeling symptoms as true illness, physicians are
granting the patient a period of “legitimated devi-
Medicalization is a process through which human ance.” Physicians then go on to restore the sick
problems come to be defined as medical problems. person to full health so that he or she can carry out
In brief, society considers certain behaviors to be the normal role expectations. Because physicians
deviant. But “deviance” is not inherent in the are willing to accept this weighty burden, Parsons
behavior; instead, it is the result of social judg- maintained that they should be generously
ments that shift over time in response to the ideas rewarded.
expounded by the social institution prevailing at Parsons’s model of the sick role depicted recov-
the time. For example, deviant behavior was seen ery from acute illness as the only acceptable resolu-
as sinful when religion was the predominant social tion to a period of legitimated deviance. Detractors
institution and in a position to define the nature pointed out that this portrayal meant that those
of human problems. As confidence in empirical who did not or could not get well were doomed to
explanations began to take hold, the view that being permanently labeled as deviants.
738 Medicalization
A number of observers have made the point that point of debate. A number of commentators have
having the power to determine whether the symp- taken the position that the medical profession has,
toms patients present with are, in fact, indicative in some instances, purposefully engaged in expand-
of a disease gives physicians undue power to act as ing its scope of control. Michel Foucault, for
moral arbiters. From time to time, the discovery of example, noted that early practitioners of psychi-
a newly identified disease reinvigorates the charge atry were particularly zealous in their efforts to
that physicians have too much power and that define the limits of acceptable social behavior.
patients’ complaints are too often dismissed as Thomas Szasz stated that psychiatrists were find-
illegitimate. The discovery of Lyme disease pro- ing evidence of mental illness in people who were
vides a vivid illustration. According to media simply rejecting the roles that society imposed on
reports, it was only through the efforts of one cou- them. He maintained that psychiatrists were
rageous woman that the disease was finally identi- guilty of trying to convince such people that their
fied. Because her symptoms were so common (i.e., behavior indicated that they were “sick,” and
headaches, body rashes, and flu-like conditions), they required medication to help them fit in the
she was diagnosed with various conditions from role or roles, often undesirable ones, that society
poison ivy to hysteria by the many physicians she had prescribed.
visited. The media reported that the physicians Similarly, the idea that women who resisted
denied the existence of this particular patient’s the limited range of social positions and roles
disease because it did not fit a recognized diagnos- dictated by society from the post–World War II
tic label. Not only was she repeatedly told that she period through the rebellious 1960s were likely to
was a hypochondriac, she was denied the benefits be the objects of such labels and treatment is, at
of the sick role as well as treatment. least in some circles, now a matter of conven-
The story, which received much media attention tional wisdom. Feminists argue that the medical
at the time, had the effect of bringing numerous profession continues today to impose its defini-
patients to physicians’ offices with similarly vague tion of the feminine ideal: They say that plastic
symptoms insisting that they, too, had Lyme dis- surgeons are defining our standards of beauty,
ease. When physicians did not find evidence of the both facial and in body shape, and that other
disease, many of these patients became convinced physicians are ready to prescribe a wide range of
that callous physicians were unwilling to treat them, pharmaceuticals—including weight-loss medica-
fueling the view that medicine’s power was certainly tions, mood-altering drugs, sleep aids, energy
excessive and probably socially dysfunctional. boosters, and so on—more to women than to
The question whether physicians should have men. The fact that some women demand such
the final say in determining whether a particular treatments they attribute to a distorted set of
set of symptoms is indicative of the existence of social values which are promoted by a wide range
disease—the essence of medicalization—continues of self-interested parties who benefit from the
to be contentious, particularly as groups of people medicalization of such common conditions as
who share some experience that they believe has aging-related changes.
caused them to experience a particular set of symp- Physicians’ motivations for actively promoting
toms insist that physicians identify those symp- medicalization, to the extent that they may have
toms as a disease or syndrome. Understanding the been doing so, have not yet been examined closely.
ramifications associated with the sick role helps Whether physicians are motivated by the promise
explain the persistent efforts on the part of many of increased income, as the representatives of
of those afflicted with various human problems to managed-care organizations have argued; or by
portray them as illnesses. greater social prestige and authority, as some social
scientists maintain; or are truly interested in
improving the lot of people who are not only
Physicians and the
plagued by pain and suffering but stigmatized as
Promotion of Medicalization
well, which is the position taken by spokespeople
Whether physicians are actively engaged in pro- for the medical profession, has not been the subject
moting and sustaining medicalization is another of much debate or investigation.
Medicalization 739
Eliot Freidson is one the few social scientists Medicalization and the Role
whose observations addressed the issue directly. of Other Interested Parties
He argued that physicians are not so much moti-
vated by the possibility of increased income as by The criticism aimed at the medical profession that
the opportunity to gain professional recognition it promotes the medicalization of routine human
and possibly have their names attached to the dis- problems has not had an ameliorating effect
covery of a new disease or syndrome. He pro- because the list of additional agents interested in
ceeded from the observation that medicine had promoting medicalization continues to expand.
been very successful in its efforts to define the Many members of the public afflicted with certain
scope of and monopolize medical work through conditions have been active in their efforts to aid,
medical licensure. That, he pointed out, effectively abet, and pressure medicine to define those condi-
prevents other health practitioners from minister- tions as sickness. One practical reason why
ing to patients’ complaints using treatments other patients would want to do this is that having a
than those approved by the medical profession. condition defined as an illness results in medical
Freidson coined the term professional dominance. insurance coverage. Another reason is that there
He argued that physicians behave in a dominant are certain conditions that members of the public
fashion in their interactions with anyone over want very much to see labeled as sickness to avoid
whom they can impose their authority, from the stigma attached to the alternative: Sickness
patients to other healthcare workers. Feminists indicates that the cause of the problem is biologi-
embraced Freidson’s observations on the role phy- cal and not the result of weakness of character—
sicians assigned to nurses—who are overwhelm- that is, it is sickness not badness.
ingly female—as handmaidens to physicians Attention deficit disorder, hyperactivity, and
It is worth noting that critics of medicine’s hyperkinesis are illustrative of this phenomenon.
power were most vocal during the same years that Some parents and teachers initially identified
society was registering especially high regard for socially disruptive behaviors as problematic and
the medical profession: during the post–World requested medications that will reduce the inci-
War II years until the end of the 1970s. Throughout dence of such behavior. Physicians must, of course,
this period, prestige surveys consistently accorded agree to diagnose the condition as an illness and
medicine the top rank compared with other occu- prescribe medications designed to control the
pations. Surveys documenting the level of trust behavior. The thrust of the criticism is that the
society was willing to accord particular social diagnosis is being too liberally applied. An impor-
institutions consistently found that medicine tant question that does not generally arise is
inspired more trust than other social institutions. whether diagnosing and medicating the child as
The decline in trust in the profession of medicine having a “minimal brain dysfunction”—that is, a
coincided with the rise of managed care during the sickness—is more or less damaging than determin-
1980s. The spokespeople for managed-care orga- ing that the child is a social deviant who willfully
nizations presented themselves as interested in misbehaves and deserves to be punished—that is,
protecting patients from physicians who, they said, that the child is bad.
were more interested in their own pocketbooks Further evidence that the medicalization of chil-
than their patients’ welfare. Thereby, in a few dren’s behavior is not waning is apparent in the
short years, the corporate sector succeeded at what discovery of new syndromes: “school refusal
social critics had been striving to accomplish for behavior,” for example, (i.e., skipping school),
several decades. which has recently been identified by some psy-
The charge that physicians engage in medical- chiatrists as a sign of an anxiety disorder requiring
ization lost much of its condemnatory power in medical treatment.
this atmosphere, given that a wide range of other Posttraumatic stress disorder (PTSD) is another
failings were also being attributed to the profes- example of a more or less successful effort to have
sion. Yet patients have generally said, and continue particular behaviors recognized as illness rather
to say, that their own physicians are wonderful but than badness. The designation allows those having
that they are the exception. difficulty readjusting to civil society after wartime
740 Medicalization
service in the military to receive the benefits that report suspected cases of child abuse when they
go along with the sick role—from the psychologi- examine children brought to their offices or, more
cal and emotional benefits that come with the likely, the emergency room. Medical treatment
extension of sympathy, to the greater understand- of the child is not at issue. However, some physi-
ing and tolerance of absence from work due to a cians resist reporting this form of deviance arguing
range of physical and psychological problems. that the children are likely to suffer further abuse
There are also instances of a less successful tran- when the abuser is threatened with legal sanctions
sition from badness to sickness as reflected, for and the removal of the child from the home.
example, in the social attitude toward alcoholism.
Many individuals who have this problem have been
Demedicalization
unwavering in their efforts to have society accept
the view that alcoholism is a disease. The Yale There is one well-known case of demedicalization—
School of Alcoholism Studies (which emerged in homosexuality. The first edition of the Diagnostic
the 1930s), now the Rutgers Center of Alcohol and Statistical Manual of Mental Disorders (DSM)
Studies (as of 1962)—neither of which has oper- published by the American Psychiatric Association
ated under the auspices of medical practitioners— (APA) in 1952, listed homosexuality as a “Sociopathic
have provided the main impetus for dissemination Personality Disorder.” It continued to be listed as a
of this definition. Physicians, generally, have been form of “sexual deviation” over the next two
less eager to define alcoholism as a disease; in part, decades even as the challenge from homosexual
no doubt, because alcoholism does not lend itself to activists, both within and outside the APA, gained
a traditional medical approach to either prevention momentum. In 1973, the APA Board of Trustees
or cure. Medical treatment of the health problems voted to adopt a new definition. As of that time,
brought on by alcoholism, though, is uncontested. only those homosexuals who are disturbed by their
The role played by the public health community condition are to be considered candidates for treat-
must be included in the discussion of medicaliza- ment. Many in the gay community welcomed the
tion because of its stance on the value of punish- change. Others pointed out that there was no coun-
ment versus therapeutic intervention in controlling terpart for the designation of “Homosexual-Conflict
certain behaviors. Members of the public health Disorder” for heterosexuals, as in “Heterosexual-
community not only oppose the use of legal sanc- Conflict Disorder.” Society has become more accept-
tions to reduce the prevalence of deviant behavior, ing of homosexuality and homosexual unions since
they also oppose treating people who engage in the early 1970s. Whether the APA’s decision con-
destructive and risky behavior on an individual tributed to the shift in social attitudes is not clear.
basis. They hold that control of such behavior
would be better addressed through population-
New Forces Promoting Medicalization
based solutions. Public health practitioners have
argued that the morbidity and mortality associated Although the term medicalization is now less
with violence, intravenous drug abuse, and other likely to be invoked, the process appears to be
forms of substance abuse should be viewed in proceeding at an accelerating rate along two
much the same way as other man-made diseases— related paths. One is the treatment of conditions
smoking-related illnesses, for instance—and treated that research indicates will lead to illness in the
accordingly. They point out that intervention at future and that can be identified using objective
the level of treating the individual who is suffering indicators of physical status. The second revolves
the consequences of engaging in risky behaviors around the possibility of enhancing the perfor-
comes too late. They maintain that more benign mance of persons who are healthy.
approaches, particularly public education, would Turning to the first path, medicine has been more
be far more effective. aggressive in recent years in lowering the cutoff that
There are also instances of medicalization being separates what is a normal reading from what
imposed on the medical profession, as illustrated requires attention for a range of physical indicators
by the legal mandate governing how physicians such as hypertension, cholesterol level, and diabe-
deal with child abuse. Physicians are required to tes. Physicians often strongly recommend lifestyle
Medicalization 741
changes, primarily more exercise and changes in Now that patients are increasingly directly
diet. Although this may be a form of medicalization, involved in requesting treatment for what they
it is not one that provides the benefits long associ- perceive to be unwelcome and avoidable physical
ated with the sick role. In fact, it requires a certain problems, direct-to-consumer advertising by
amount of sacrifice in giving up familiar patterns of pharmaceutical companies is a new force in con-
behavior that are not considered deviant. Whether vincing the public that their problems are actu-
society comes to define self-indulgent eating habits ally syndromes that can be successfully treated
and avoidance of exercise as deviant and requiring with prescription drugs. Some physicians say
some form of intervention (e.g., increased regula- that they feel pressured to prescribe medications
tion or taxation) besides physicians’ admonitions when there is no evidence that a person is
remains to be seen. The shift in social attitudes afflicted with the illness featured in the ads. Even
toward drinking and driving provides a good exam- when patients do experience some of the symp-
ple of society’s power to redefine what is acceptable toms being described in the ads, physicians often
versus unacceptable behavior, without physicians maintain that waiting to see whether the symp-
taking the leading role. toms diminish is preferable to reaching at once
Whether the health problems that result when for pharmaceuticals.
patients will not or cannot make the behavioral The second newly evolving medicalization path
changes that are intended to lower readings on revolves around the “heal or enhance” debate,
their blood pressure, low density lipids, and blood which has been limited to revelations about athletes,
sugar should be defined as syndromes is a matter of until recently, but is increasingly affecting the gen-
debate in the medical community. Obesity is a case eral public. Some physicians take the position that
in point. From the medical profession’s perspective, anything that helps patients is within the legitimate
defining what is and what is not a disease revolves scope of medical practice. Others argue that restor-
around questions of ethics and a consensus regarding function should not be confused with enhancing
ing best practices, not issues of social deviance. To function. The worry is that it is becoming more and
illustrate, the American Academy of Family Practice more difficult to draw the line between ethical and
(AAFP) declared, in 2004, that obesity is a disease; unethical practices. Is it ethical to prescribe stimu-
the American Medical Association (AMA), how- lants that can help enhance grades? Is it ethical to
ever, maintains that it is clearly a major health prescribe Alzheimer’s medications to enhance mem-
problem but not a disease. Those who favor defin- ory? Is “cosmetic neurology”—described by its main
ing obesity as a disease say that this will cause it to promoter as the modulation of “motor, cognitive,
be taken more seriously. Those who are opposed and affective systems”—an acceptable medical prac-
say that doing so will have the effect of diminishing tice? The demand for such enhancements is clearly
personal and social responsibility. growing where competitive pressure is greatest—
Ethics and best practices are also at issue in how that is, in professional athletics and advanced edu-
medicine should treat such touchy problems as cational training.
gender allocation surgery at birth, gender-based It is difficult to imagine what might replace the
selection of fetuses, treating women who have lost medicalization process that shifts badness to sick-
interest in sex with testosterone creams, and so on. ness, especially as it is increasingly accompanied
There is no denying the fact that members of the by the promise of an unrestrained potential to
public are demanding a wide range of interven- redefine a wide range of human problems as med-
tions and that there are growing numbers of will- ical problems, which people might then rid them-
ing providers. To illustrate, according to the selves of simply by taking a pill.
American Society for Aesthetic Plastic Surgery
(ASAPS), 11.5 million cosmetic procedures were Grace Budrys
performed in the United States in 2005. This is a See also Diagnostic and Statistical Manual of Mental
444% increase from 1997 to 2005. There were Disorders (DSM); Direct-to-Consumer Advertising
3.29 million Botox injections, making it the most (DTCA); Disease; Health; International Classification
popular procedure. By some estimates, this proce- of Diseases (ICD); Medical Sociology; Physicians;
dure has become a $15 billion business. Public Health
742 Medical Sociology
Further Readings and institutions, particularly hospitals and health-

Conrad, Peter. The Medicalization of Society: On the care networks; (d) the social patterns of health
Transformation of Human Conditions Into Treatable services; and (e) the international comparisons of
Disorders. Baltimore: Johns Hopkins University Press, healthcare delivery systems, particularly compar-
2007. ing the healthcare system of the United States with
Foucault, Michel. Madness and Civilization: A History that of Canada and the United Kingdom.
of Insanity in the Age of Reason. New York: Vintage
Press, 1965.
History
Freidson, Eliot. Professional Dominance. New York:
Atherton, 1970. Although a number of medical sociology articles
Hadler, Martin, “‘Fibromyalgia’ and the Medicalization appeared in the late 19th and early 20th centu-
of Misery,” Journal of Rheumatology 30(8): ries, the field is generally regarded as beginning in
1668–70, August 2003. 1951 with the publication of Talcott Parsons’s
Kuczynski, Alex. Beauty Junkies: Inside Our $15 Billion book The Social System. In his book, Parsons
Obsession With Cosmetic Surgery. New York: (1902–1979), the influential American, Harvard
Doubleday, 2006. University sociologist, presented a functionalist
Parsons, Talcott. The Social System. Glencoe, IL: Free theory of the “sick” role. He argued that patients
Press, 1951. who (a) do not intentionally cause their own ill-
Szasz, Thomas S. The Medicalization of Everyday Life: ness, (b) seek help from a physician, and (c) strive
Selected Essays. Syracuse, NY: Syracuse University to get well are entitled to relief from their normal
Press, 2007.
role responsibilities—a period of legitimated
Wolpe, Paul Root. “Treatment, Enhancement, and the
deviance. Those who do not follow these rules
Ethics of Neurotherapeutics,” Brain and Cognition
are engaging in deviant behavior and must be
50(3): 387–95, December 2002.
socially sanctioned. Otherwise, Parsons argued,
society risks social instability. As for physicians,
Parsons said that they bear heavy responsibility
Web Sites
for insuring that patients do not take advantage
American Academy of Child and Adolescent Psychiatry of the sick role. Accordingly, they deserve a high
(AACAP): http://www.aacap.org level of social reward in the form of status and
American Society for Aesthetic Plastic Surgery (ASAPS): income.
http://www.surgery.org Although Parsons’s theory of the sick role has
National Institute of Drug Abuse (NIDA): become a basic concept in medical sociology, other
http://www.nida.nih.gov sociologists have strongly criticized it. They point
out that the theory (a) fails to address the wide
variations in the way people view sickness and
define sick-role behavior; (b) does not take into
Medical Sociology consideration various types of diseases, such as
chronic diseases and mental illness; (c) is based on
Medical sociology is a large, substantive area a traditional, one-to-one interaction between a
within the general field of sociology. Using a patient and a physician, which frequently does not
sociological perspective, theories, and research occur; and (d) is based on a middle-class pattern of
methods, medical sociology is concerned with the behavior that fails to consider the sick role of
social causes and consequences of health and dis- lower socioeconomic classes.
ease. Some of the major areas that medical sociol- In the 1970s, medical sociology changed dra-
ogy studies include (a) the social aspects of health matically. Many medical sociologists suddenly
and disease, particularly health and illness behav- reversed their position and embraced a critical
ior and the role of the sick; (b) the social behavior theoretical perspective. They argued that physi-
of healthcare professionals and their patients, cians act in a dominant fashion in their interactions
particularly physician–patient interaction; with patients and other healthcare workers. This
(c) the social functions of healthcare organizations assessment captured society’s growing skepticism
Medical Sociology 743
regarding physicians’ social position, but it did not exclusive disciplinary jargon. Many medical soci-
have much practical impact on physicians. ologists now define themselves as health services
That changed during the 1980s with the emer- researchers or population health researchers.
gence of managed care. Managed-care spokespeo-
ple announced that they would not only eliminate
the inefficiencies associated with nonprofit-organi- Current Status and Future Direction
zational management but also protect patients
Today, medical sociology is a mature, objective,
from physicians who were primarily motivated by
and independent field of study and work. There
profit. The medical-sociological critique was no
are a large number of professional medical soci-
longer daring. A backlash against managed care
ologists conducting research and teaching in many
did not come until the mid-1990s, and by that time
countries, including the United States, Canada,
social confidence in medicine, if not in one’s own
Australia, Germany, Japan, and the United
physician, had been badly damaged.
Kingdom. Medical sociology is the third largest
section in the American Sociology Association,
System Goals and it is the largest section in the British and
German sociological associations. Most college
In retrospect, the medical-sociological contribution
and university sociology departments in the United
to understanding healthcare delivery was most
States offer introductory courses in medical soci-
clearly identified with the discipline of sociology
ology, and several universities have well-estab-
during the 1950s and 1960s when the work was
lished doctoral degree programs in medical
primarily theoretical. It is clear that medical-socio-
sociology. Through the decades, medical-sociology
logical observations reflected concern about the
concepts and research methodologies grounded in
quality of healthcare. The fact that medicine was
mainstream sociology have become integrated
delivered in private offices with little professional
into the larger health research enterprise. The
oversight meant that social control over quality
reverse is also true: Medical sociology continues
was a basic social concern. During the 1970s,
to expand but is doing so in recognition of
medical sociologists did the underlying work on
advances outside the discipline.
access or the availability of healthcare. This body
of work constitutes a major methodological contri- Grace Budrys
bution. By the 1980s, cost containment rose to the
forefront pushing medical-sociological work aside See also Access, Models of; Anderson, Odin W.;
in preference to medical economics. Computers; Disease; Health; Healthcare Organization
Theory; Health Surveys; Medicalization
Availability of Data and

Interdisciplinary Research
Further Readings
The introduction of computers during the 1980s
Bloom, Samuel W. The Word as Scalpel: A History of
had a radical effect on medical sociology and
Medical Sociology. New York: Oxford University
other disciplines involved in health services Press, 2002.
research. Internet technology permitted the gov- Brown, Phil, ed. Perspectives in Medical Sociology. 4th
ernment to collect and report statistics in a timely ed. Long Grove, IL: Waveland Press, 2008.
manner and make them publicly available. This, Cockerham, William C. Medical Sociology. 10th ed.
combined with the fact that healthcare had become Upper Saddle River, NJ: Pearson/Prentice Hall, 2007.
a central social concern, meant that an increasing Parsons, Talcott. The Social System. Glencoe, IL: Free
number of institutions, as opposed to individuals, Press, 1951.
were interested in analyzing health statistics for Timmermans, Stefan, and Steven S. Haas. “Towards a
the purpose of influencing policy. Organizations Sociology of Disease,” Sociology of Health and Illness
began employing researchers, who were expected 30(5): 659–76, July 2008.
to work as members of interdisciplinary teams and Wainwright, David, ed. A Sociology of Health.
produce clearly written position papers free from Thousand Oaks, CA: Sage, 2008.
744 Medical Travel
Web Sites traveled to India to receive hip-resurfacing treat-

European Society of Health and Medical Sociology ments, because the treatment was viewed as supe-
(ESHMS): http://www.eshms.org rior to hip replacement surgery but the procedure
Medical Sociology Section, American Sociological was not yet approved in the United States. The
Association (ASA): http://dept.kent.edu/sociology/ other subcategory—more expeditious access—
asamedsoc includes patients who live in countries with
Medical Sociology Study Group, British Sociological nationalized healthcare systems who may face
Association (BSA): http://www.britsoc.co.uk/medsoc months-long wait times for treatment at home and
who can receive immediate care in other countries
with the same or very similar procedures. (Seeking
more expeditious care can be viewed as an unfair
Medical Travel or selfish practice by others from the same com-
munity, who sometimes refer to the practice as
Medical travel refers to persons traveling outside line jumping.)
their home region in pursuit of healthcare that is Patients also travel for care in pursuit of lower
more accessible, of higher quality, or of lower costs. Elective procedures—that is, those not cov-
cost. It is a narrower term than medical tourism ered by insurance plans (e.g., cosmetic surgery)—
(also health tourism), which refers to consumers can involve significant out-of-pocket expenses, and
seeking health services of all kinds outside their so these procedures are an important driver of cost-
home region—including spa treatments and other based medical travel. The financial motivations for
wellness services—as well as the industries that comparison shopping can be even more substantial
cater to these consumers. The medical tourism for uninsured and underinsured patients who have
industry includes care providers and also related the financial resources to pursue care outside their
services such as intermediaries, concierges, travel communities’ safety nets. Such patients, particu-
specialists, and providers of room and board for larly those in need of major medical procedures,
medical travelers. Medical travel is distinct from have substantial financial incentive to seek out the
travel medicine, which refers to preventive medi- most cost-efficient care they can find, given their
cal care provided to consumers in preparation for comfort level with travel as well as the perceived
their planned travel (e.g., vaccinations for diseases competency and safety of the procedures and care
occurring in the destination area). providers. Hospitals in developing countries, which
have much lower operating costs, can provide some
procedures for 20% or less of the amount that pro-
Reasons for Medical Travel
viders in the United States would charge. This can
There are many reasons why patients travel for save uninsured patients tens or even hundreds of
medical care; most can be categorized into three thousands of dollars, enough to make medical
main areas: (1) access, (2) cost, and (3) quality. travel options enticing for a substantial proportion
Patients travel for access reasons if they are seek- of patients needing high-end care. Given the size of
ing care that they cannot receive in their own this cost differential, some insurers have also begun
community. Access may be subcategorized accord- providing plans—for U.S. employers with workers
ing to (a) patients who are seeking care that is not in states bordering Mexico—that require medical
provided in their home region versus (b) patients travel for nonurgent care.
who may be able to receive comparable care at The final category, quality, may similarly be
home but not in a timely fashion, and so they are broken down into several subcategories. One
seeking more expeditious care elsewhere. Seeking such segment comprises wealthy individuals from
care unavailable in one’s own community is prob- developing countries where there are few or no
ably the oldest form of medical travel; stories of modern healthcare systems. In addition to travel-
epic journeys to find a mystical healer or rare ing to other countries for major procedures, such
elixir are relatively common and date back many patients may also travel to receive a better stan-
centuries. A more modern example can be found dard of routine care. A second important segment
in the patients from the United States who have is patients pursuing cutting-edge healthcare—in
Medical Travel 745
particular, high-tech procedures that may only be Future Implications

available from a finite number of providers in the
The forecasts of future growth in medical travel
world and are perceived to be superior to the
vary considerably but, in general, predict that it
more readily available treatment options. Inbound
will continue to expand at a pace exceeding the
medical travel to major academic medical centers
broader growth in medical services worldwide. As
in the United States typically falls in this latter
healthcare costs continue to escalate, as pressures
category.
for greater transparency in quality and cost facili-
Because medical travelers often pay up front
tate performance comparisons, and as experiences
and in cash, most health systems regard these
with medical travel become more familiar, the
patients as a particularly desirable clientele. Some
range of and the opting for costly, nonurgent
developing countries, in particular, have come to
medical services on a global scale will grow.
view medical travelers as an important founda-
Further advances in technologies that support
tion for other types of economic development.
telemediated services will also facilitate the remote
Patients who come to a country for care may tend
provision of precare and aftercare, which may
to stay longer in that country than other kinds of
also foster the expansion of medical travel options
tourists do and, as a result, spend additional
in the coming years.
money in the local economy. Like tourists of
other types, once medical travelers have visited a Andrew N. Garman, Arnold Milstein,
country for the first time, they are also more and Matthew M. Anderson
likely to return. For these reasons, the govern-
ments of some countries have established orga- See also Access to Healthcare; Accreditation; Comparing
nized efforts to attract these patients to their Health Systems; Cost of Healthcare; International
private healthcare systems. Health Systems; Joint Commission; Quality of
Healthcare
Accreditation
Further Readings
Although access, cost, and quality all pose mea-
surement challenges, the quality of healthcare is a Bookman, Milica Z., and Karla R. Bookman. Medical
particularly complex and difficult construct on Tourism in Developing Countries. New York:
which to compare care providers internationally. Palgrave-Macmillan, 2007.
Different countries, and sometimes different Burkett, Levi. “Medical Tourism: Concerns, Benefits, and
regions within a country, often have very different the American Legal Perspective,” Journal of Legal
approaches to quality assurance and credential- Medicine 28(2): 223–45, April–June 2007.
ing, making meaningful comparisons across pro- Drager, Nick, and Cesar Vieira, eds. Trade in Health
Services: Global, Regional, and Country Perspectives.
viders very difficult. Providers who want to attract
Washington, DC: Pan-American Health Organization,
an international patient base need to demonstrate
2002.
quality via universally acceptable means, which
Forgione, Dana A., and Pamela C. Smith. “Medical
has led to substantial interest in pursuing interna-
Tourism and Its Impact on the U.S. Health Care
tionally recognizable accreditations. The most System,” Journal of Health Care Finance 34(1):
widely used hospital accreditation provider is 27–35, Fall 2007.
Joint Commission International, an international Herrick, D. “Medical Tourism: Global Competition in
program offered by the Joint Commission, based Health Care.” Washington, DC: National Center for
in the United States. Other providers, such as the Policy Analysis, November 2007.
International Organization for Standardization, Milstein, Arnold, and Mark Smith. “Will the Surgical
also offer accreditation programs primarily for World Become Flat?” Health Affairs 26(1): 137–41,
institutional, international, health services provid- 2007.
ers. Surgeons and other physicians can achieve Ramirez de Arellano, Annette B. “Patients Without
similar accreditation status by maintaining board Borders: The Emergence of Medical Tourism,”
certification in countries in which their interna- International Journal of Health Services 37(1):
tional patients either reside or feel confident. 193–98, 2007.
746 Medicare
U.S. Senate, Special Committee on Aging. The History

Globalization of Health Care: Can Medical
Tourism Reduce Health Care Costs? Hearings President Lyndon B. Johnson signed the Medicare
Before the Special Committee on Aging, U.S. Senate. program into law in 1965 as Title XVIII of the
109th Cong., 2d sess. (June 27, 2006): Serial No. Social Security Act. The Medicare program was
109–126. Washington, DC: Government Printing originally designed to provide health insurance to
Office, 2006. the aged.
Prior to its enactment, there were several key
moments in history that led up to the Medicare
Web Sites legislation. In 1935, the first federal government
American Medical Association (AMA): health insurance bill was introduced in the U.S.
http://www.ama-assn.org Congress. Later, in 1945, President Harry S
HealthCare Tourism International: Truman became the first sitting president to offi-
http://www.healthcaretrip.org cially endorse the idea of national health insur-
International Organization for Standardization (ISO): ance. In 1961, President John F. Kennedy
http://www.iso.org recommended to the U.S. Congress a health insur-
Joint Commission International (JCI): ance program for the elderly under Social Security,
http://www.jointcommissioninternational.org and in 1965 President Lyndon B. Johnson signed
Pan-American Health Organization (PAHO): Medicare into law.
http://www.paho.org Throughout the history of Medicare, there have
Travel Industry Association (TIA): been several major reforms to the program. When
http://www.tia.org first implemented in 1966, Medicare primarily
U.S. Office of Trade and Tourism Industries (OTTI): covered persons over the age of 65. In 1973,
http://tinet.ita.doc.gov Medicare eligibility was extended to people with
World Health Organization (WHO): http://www.who.int disabilities and those with ESRD. In 1976, health
maintenance organizations (HMOs) began to be
offered as a Medicare option. In 1983, the Medicare
Medicare program began reimbursing hospitals based on a
prospective payment system. In 1997, the
Medicare+Choice program was enacted and is
Medicare is a health insurance program for (a)
known today as Medicare Part C or the Medicare
people aged 65 or older, (b) people under age 65
Advantage plans. In 2003, President George W.
with certain disabilities, and (c) people at any age
Bush signed the Medicare Modernization Act
with end-stage renal disease (ESRD). It is the
(MMA) into law, establishing a voluntary, outpa-
nation’s largest health insurance program, cover-
tient prescription drug benefit program—known
ing nearly 44 million Americans. The Medicare
as Medicare Part D—that became available to
program is administered by the Centers for
Medicare beneficiaries in 2006. Under this law,
Medicare and Medicaid Services (CMS), and ben-
Medicare Advantage was also established, allow-
eficiaries may apply for Medicare benefits 3
ing private insurance companies to offer choices in
months before they reach 65 years of age. Almost
coverage to Medicare beneficiaries.
9 million individuals, or approximately 20% of
Medicare beneficiaries, receive their care through
Medicare’s Parts
the Medicare Advantage program, and more than
90% of beneficiaries receive prescription drug Medicare consists of four parts: A, B, C, and D.
coverage of some type. Medicare spending is a The original Medicare plan included Medicare
large component of the federal budget and national Part A (hospital) and Part B (medical). Medicare
health spending: In 2006, Medicare benefit pay- Part C is also called the Medicare Advantage
ments totaled $374 billion and accounted for plans (HMOs and preferred provider organiza-
12% of the federal budget. The spending on tions [PPOs]). Medicare Part D is for prescription
Medicare benefits is about 20% of the nation’s drug coverage. Medicare Parts B, C, and D are
total healthcare expenditures. optional. Most individuals either have Parts A and
Medicare 747
B, Part D and a Medigap (Medicare Supplemental Aged and Disabled, but it is often also called sup-
Insurance) policy, or Part C (which combines plementary Medicare or the medical insurance
Parts A and B) and Part D. program. Medicare Part B is medical insurance
Eligible individuals do not have to be retired to that helps cover physicians’ services and outpatient
get Medicare. Unlike Social Security, working care such as preventive services, including screen-
people can still receive full Medicare benefits at ing tests and vaccinations, diagnostic tests, some
age 65. People who are already receiving Social therapies, and durable medical equipment, such as
Security benefits are automatically enrolled in wheelchairs and walkers.
Medicare without an additional application. In addition to the monthly premium for Medicare
Part B, there is also a deductible; in 2008, this was
$135. This means that in 2008, a person with
Medicare Part A
Medicare was responsible for the first $135 of his
Most people do not pay for Medicare Part A or her Medicare approved Part B medical services
because they contributed to the Medicare Trust before Medicare Part B started paying for care.
Fund for 40 quarters. Medicare Part A is largely The deductible amount can change each year.
financed through hospital insurance taxes; it pro- People with the original Medicare plan also are
vides basic protection against the costs of inpatient responsible for some copayments or coinsurance
hospital and other institutional-provider care. for Medicare Part B services. The amount depends
Officially, this program is called the Hospital on the service but is 20% in most cases.
Insurance Benefits for the Aged and Disabled,
although it includes much more than just hospital
Medicare Part C
benefits. Medicare Part A not only helps pay for
inpatient hospital stays, but it also covers skilled A third Medicare program, Medicare Part C,
nursing care, home health care, and hospice care. expands managed-care options for beneficiaries
Unofficially, this program is sometimes called who are entitled to Part A and are enrolled in Part
basic Medicare or hospital insurance because the B. Medicare Part C was created under the Balanced
authorization for the program is Part A of Title Budget Act of 1997 and is also called Medicare
XVIII of the Social Security Act. Advantage. This program was formerly known as
Whereas most people do not pay a premium for Medicare+Choice. Since January 1, 1999, benefi-
Medicare Part A, they are responsible for a deduct- ciaries have had the option of choosing to receive
ible for inpatient hospital stays. The deductible is their health benefits through the traditional
the amount a person with Medicare must pay for Medicare fee-for-service program or to select a
healthcare before Medicare begins to pay. There managed-care plan certified under Medicare
was a deductible of $1,024 in 2008 for hospital Advantage. The payments Medicare makes to a
stays of up to 60 days, and additional costs for Medicare Advantage plan replace the amount that
longer stays. The costs are different for other Medicare would otherwise have paid under Parts
Medicare Part A services. Skilled-nursing facility A and B.
coinsurance, for example, is $128 per day for days There are several types of Medicare Advantage
21 through 100 for each benefit period. plans. A Medicare Advantage organization (MAO)
is a public or privately owned entity organized and
licensed by a state as a risk-bearing entity (with the
Medicare Part B
exception of provider-sponsored organizations
Medicare Part B is a voluntary program that receiving waivers) and is certified by the CMS as
covers the costs of physician and other healthcare meeting the Medicare Advantage contract require-
practitioner services, items, and supplies not cov- ments. A Medicare Advantage plan has health
ered under the basic program. It is financed benefits coverage—offered by an MAO under a
through monthly premiums from enrollees and policy or contract—that includes a specific set of
contributions from the federal government. health benefits offered at a uniform premium and
This program is more formally known as the uniform level of cost sharing to all Medicare ben-
Supplementary Medical Insurance Benefits for the eficiaries residing in the service area (or segment of
748 Medicare
the service area) of the plan. A Medicare Advantage a higher Medicare Part B premium. These amounts
plan may also provide a prescription drug benefit. change each year. The majority of beneficiaries
In 2008, 9.7 million beneficiaries were enrolled in pay only the standard Medicare Part B premium.
Medicare Advantage plans with the majority People can sign up for Medicare Part B at any-
(70%) in HMO plans. time during a 7-month period that begins 3 months
before the month they become eligible for Medicare.
This is called the initial enrollment period (IEP).
Medicare Part D People who do not take Medicare Part B when
Most recently, the Medicare program was they are first eligible may have to wait to sign up
expanded by the MMA of 2003 to include a pre- during a general enrollment period (GEP). This
scription drug benefit under a new Medicare Part period runs from January 1 through March 31 of
D of the Social Security Act. Beneficiaries entitled each year, with coverage effective July 1 of that
to Part A and enrolled in Part B, enrollees in year. Most people who do not take Medicare Part
Medicare Advantage and private fee-for-service B when they are first eligible will also have to pay
plans, and enrollees in Medicare Savings Account a premium penalty of 10% for each full 12-month
Plans are all eligible for the prescription drug ben- period they could have had Medicare Part B but
efit. The prescription drug benefit became avail- did not sign up for it, except in certain situations.
able to eligible individuals on January 1, 2006. In most cases, individuals will have to pay this
penalty for as long as they have Medicare Part B.
Most people covered by a group health plan
Premiums and Enrollment
based on current employment (their own or their
Most people do not have to pay a monthly charge spouse’s) can delay enrolling in Medicare Part B
(premium) for Medicare Part A because they or without a penalty. These individuals get a special
their spouse paid Medicare or Federal Insurance enrollment period. They can enroll in Medicare
Contributions Act (FICA) taxes while they were Part B at anytime while they are still covered by
working. This is the tax withheld from a person’s their employer or union group health plan based
salary, or that an individual pays from their self- on current employment, or during the 8 months
employment income, that funds the Social Security following the month the employment ends or the
and Medicare programs. When people pay these group health plan coverage ends, whichever is
taxes on their earnings, it is called Medicare- first. Most people who sign up for Medicare Part
covered employment. If a person and his or her B during a special enrollment period do not pay
spouse did not pay Medicare taxes while they higher premiums.
were working or did not work long enough (usu- People who choose Medicare Part B usually
ally 10 years or 40 quarters in most cases) to have the premium automatically taken out of their
qualify for premium-free Part A, he or she may monthly Social Security or Railroad Retirement
still be able to get Medicare Part A by paying a payment. Federal government retirees may be able
monthly premium. In 2008, the Part A premium to have the premium deducted from their retire-
was $233 for people having 30 to 39 quarters of ment check.
Medicare-covered employment, or $423 for those People can choose to get Medicare healthcare
who are not otherwise eligible for premium-free coverage in several ways. Which Medicare plan
hospital insurance and have fewer than 30 quar- people choose may affect their costs, benefits, and
ters of Medicare-covered employment. convenience, and their physician, hospital, and
Qualifying beneficiaries can choose whether or pharmacy choices. Nonetheless, no matter how
not to enroll in Medicare Part B medical insurance. people choose to get their Medicare healthcare,
Those who enroll are responsible for a monthly they are still enrolled in the Medicare program.
premium for Medicare Part B, which was $96.40 The original Medicare plan is available nation-
in 2008. Starting January 1, 2007, some people wide; it is also known as “fee-for-service.” People
with higher annual incomes—more than $80,000 in the original Medicare plan may go to any physi-
if filing an individual federal income tax return or cian, specialist, hospital, or other healthcare pro-
more than $160,000 if married, filing jointly—pay vider who accepts Medicare. However, there are
Medicare 749
other plans besides the original Medicare plan that who has Medicare Part A, or Part B, or both Part
people can choose to get their Medicare health A and Part B is eligible to join a Medicare drug
coverage. plan and must enroll in a plan to get Medicare
prescription drug coverage. However, people who
live outside the United States or who are incarcer-
Medigap Insurance
ated may not enroll and are not eligible for cover-
A Medigap policy is a health insurance policy sold age. The CMS contract with private companies
by private insurance companies to fill the “gaps” offering Medicare prescription drug plans to
in coverage under the original Medicare plan, negotiate discounted prices on behalf of their
including the deductibles, coinsurance, and copay- enrollees. People may also receive Medicare drug
ments mentioned above. Some Medigap policies coverage through a Medicare Advantage plan or
also provide benefits that Medicare does not other Medicare plan, if they are enrolled in one.
include such as emergency healthcare when travel- Some employers and unions may provide Medicare
ing outside the United States. The insurance com- prescription drug coverage through employer/
panies that sell these policies must follow federal union group plans to their retirees. The drug ben-
and state laws that protect people with Medicare. efit is offered through stand-alone prescription
The Medigap policy must be clearly identified as drug plans (PDPs) and Medicare Advantage pre-
Medicare Supplement Insurance. scription drug (MA-PD) plans, such as HMOs
A Medigap policy only works with the original that cover all Medicare benefits, including drugs.
Medicare plan. If an individual joins a Medicare Generally, there are two types of enrollment
Advantage plan or other Medicare plan, then the periods when people can sign up for Medicare
Medigap policy cannot pay any deductibles, copay- prescription drug coverage: (1) the IEP is for 7
ments, or other cost sharing under the Medicare months starting 3 months before the month they
plan. In all states except Massachusetts, Minnesota, become entitled to Medicare; (2) the annual coor-
and Wisconsin, a Medigap policy must be one of dinated election period is from November 15 to
12 standardized plans (A–L) so that people can December 31 each year. During this period, a per-
compare them easily. Each plan has a different set son who is not enrolled in a Medicare drug plan
of benefits. The benefits in any Medigap plan A to can choose to enroll.
L are the same for any insurance company. It is People who do not enroll when they are first
important for individuals to compare Medigap eligible may have to pay a penalty to enroll later.
policies because the costs vary. Most people who wait until after the end of their
In most Medicare Advantage plans, members IEP to join a Medicare drug plan will have their
usually get all their Medicare-covered healthcare premiums go up 1% of the national base premium
through that plan. The plan may offer extra bene- for every month they waited to enroll. These indi-
fits such as Medicare prescription drug coverage as viduals will usually have to pay this penalty as long
well as coverage for vision, hearing, dental, or as they have Medicare prescription drug coverage.
health and wellness programs. If a plan offers a The costs of prescription drug benefits vary
network of healthcare providers and hospitals, depending on the plan. Plans must provide a stan-
people may very often have to use only that panel dard level of coverage, but they may offer more
of providers. However, it is important to note that coverage or additional drugs, usually at a higher
people who join a Medicare Advantage plan are monthly premium. In most cases, for coverage in
still in the Medicare program and still receive all 2008, people paid a monthly premium that varied
their regular Part A and Part B services. Additionally, for different plans, a deductible, and a copayment
beneficiaries in a Medicare Advantage plan still or coinsurance. Once a Medicare beneficiary spent
have Medicare rights and protections. $4,050 out of pocket for covered drug costs during
2008, they paid 5% of their drug costs for the rest
of the calendar year. This is called catastrophic
Medicare Prescription Drug Benefits
coverage, and it could take effect even sooner in
All people with Medicare now have the option to some plans. All these amounts can change each
join a plan that covers prescription drugs. Anyone year.
750 Medicare Part D Prescription Drug Benefit
Medicare Part D plans vary in benefit design, Cassel, Christine K. Medicare Matters: What Geriatric
covered drugs, and utilization management tools, Medicine Can Teach American Health Care: With a
such as prior authorization, quantity limits, and step New Preface. Berkeley: University of California Press/
therapy. The CMS established minimum require- Milbank Memorial Fund, 2007.
ments for Medicare Part D plan formularies to help Marmor, Theodore R. The Politics of Medicare. 2d ed.
ensure that plans do not offer formularies that dis- New York: Aldine de Gruyter, 2000.
criminate against or discourage the enrollment of Medicare Payment Advisory Commission. Report to
certain types of beneficiaries. Enrollment in Medicare Congress: Promoting Greater Efficiency in Medicare.
Washington, DC: Medicare Payment Advisory
drug plans is voluntary, with the exception of dual-
Commission, 2007.
eligible (people in both Medicare and Medicaid) and
Moon, Marilyn. Medicare: A Policy Primer. Washington,
certain low-income beneficiaries who are automati-
DC: Urban Institute Press, 2006.
cally enrolled in a prescription drug plan if they do
Pauly, Mark V. Markets Without Magic: How
not choose a plan on their own. Competition Might Save Medicare. Washington, DC:
Many people with limited income and resources AEI Press, 2008.
will get extra help paying for prescription drugs. The Peltz, Marlene C., ed. Medicare and Medicaid: Critical
extra help is available to people with Medicare who Issues and Developments. New York: Nova Science,
have an income below 150% of the federal poverty 2007.
level and limited resources. Resources also are U.S. Department of Health and Human Services Centers
counted for the person and a spouse, if living for Medicare and Medicaid Services. Medicare and
together. The resource limits in 2007 were $11,710 You. Baltimore: Centers for Medicare and Medicaid
for an individual and $23,410 for a married couple. Services, 2008.

The Medicare program continues to fulfill the Centers for Medicare and Medicaid Services (CMS):
vision of President Johnson’s Great Society by http://www.cms.hhs.gov
furnishing healthcare services for the elderly as Commonwealth Fund:
well as for persons with disabilities and ESRD. http://www.commonwealthfund.org
The program serves tens of millions of Americans Henry J. Kaiser Family Foundation (KFF):
each year by providing essential healthcare cover- http://www.kff.org
age. However, there is growing concern over Medicare: http://www.medicare.gov
Medicare’s rising costs and questions about the My Medicare Matters, National Council on Aging:
ability of the program to sustain itself over time. http://www.mymedicarematters.org
The public policy debate concerning the direction Robert Wood Johnson Foundation (RWJF):
and solvency of the nation’s Medicare program http://www.rwjf.org
will be an increasingly important topic of discus-
sion in the future.
Raymond J. Swisher
Medicare Part D
See also Centers for Medicare and Medicaid Services Prescription Drug Benefit
(CMS); Health Insurance; Managed Care; Medicaid;
Medicare Part D Prescription Drug Benefit; Medicare
On December 8, 2003, President George W. Bush
Payment Advisory Commission (MedPAC)
signed into law the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003, or
MMA. This legislation was the most significant
Further Readings expansion of the nation’s Medicare program since
Bishop, Harold M., Jenny M. Burke, Paul T. Clark, et al. its inception in 1965. The MMA provides seniors
CCH Medicare Explained. Riverwoods, IL: CCH, and individuals with disabilities with voluntary
2008. prescription drug coverage, referred to as Medicare
Medicare Part D Prescription Drug Benefit 751
Part D. The new coverage began on January 1, (The national base premium was $27.35, for
2006. Until the MMA, Medicare did not provide 2007). The individual will have to pay this penalty,
coverage for outpatient prescription drugs. in addition to the premium, for as long as he or she
The Medicare prescription drug benefit is vol- has Medicare prescription drug coverage.
untary insurance that covers both brand name and Moreover, one may have to wait until the next
generic prescription drugs at participating pharma- annual coordinated election period, November 15
cies. All Medicare beneficiaries are eligible for this to December 31, to enroll. The enrollment will be
coverage, regardless of income level and financial effective from January 1 of the following year.
resources, health status, or current prescription However, if a person has other drug coverage that
expenses. Individuals enrolled in Medicare Part A is at least as good as the Medicare prescription
(hospital insurance), Medicare Part B (medical drug coverage, called creditable prescription drug
insurance), or both Part A and Part B are eligible coverage, the penalty will not apply.
for Medicare Part D. To obtain prescription drug
coverage, a Medicare beneficiary must enroll in a
Coverage and Costs
Medicare prescription drug plan.
The Centers for Medicare and Medicaid Services Medicare drug plans are not all the same. Plans vary
(CMS), the U.S. federal agency that administers the based on costs, which drugs are covered, and which
Medicare program, contract with private compa- pharmacies are in the network. Like other insur-
nies offering Medicare prescription drug plans and ance, if an individual joins a Medicare drug plan, in
negotiate discounted prices on behalf of Medicare most cases he or she will pay monthly premiums,
beneficiaries. Individuals may also receive Medicare which vary by plan, and a yearly deductible. They
drug coverage through Medicare Advantage plans will also pay a part of the costs of the prescriptions,
or another Medicare plan, if they are enrolled in including a copayment or coinsurance. Costs will
one. Some employers and unions may also provide vary depending on the specific Medicare drug plan.
Medicare prescription drug coverage to their retir- Some plans offer more coverage and additional
ees through employer/union group plans. drugs for a higher monthly premium.
There may be a point during the year when a
Medicare beneficiary will be paying 100% coin-
Enrollment
surance, called the coverage gap. However, there
Generally, there are three periods of time when are some Medicare drug plans that do not have a
individuals can sign up for Medicare prescription coverage gap or that pay for some drugs during the
drug coverage. The IEP is 7 months long, starting gap. Once the total out-of-pocket costs paid by a
3 months before the month of becoming entitled beneficiary reach a set amount ($3,850, in 2007),
to Medicare. Second, there is an annual coordi- the plan will pay all but 5% or a small copayment
nated election period from November 15 through for the rest of the year. This is called catastrophic
December 31 each year. During the annual coor- coverage. All plans must offer this catastrophic
dinated election period, individuals who are not coverage. The CMS sets the standard premium,
enrolled in a Medicare drug plan may enroll, and deductible, and copayment amounts every year.
individuals who are already in a Medicare drug These are minimum requirements for drug plans
plan may drop or switch plans. The change will be offering basic coverage.
effective from January 1 of the following year. As already noted, all individuals with Medicare
Third, there are special situations that entitle indi- can get prescription drug coverage. This is true
viduals to a special enrollment period, such as an regardless of their income level and financial
involuntary loss of creditable prescription drug resources, health status, or how much they pay for
coverage or a change of permanent residence out prescriptions. Moreover, many individuals with
of the plan’s service area. limited income and resources will get extra help
In most cases, if an individual does not join a paying for their prescription drugs. Individuals
plan during the IEP, his or her premium will with the lowest incomes will pay no premiums or
increase 1% of the national base premium deductibles and only have a small or no copay-
for every full month he or she waits to enroll. ments. And individuals with slightly higher incomes
752 Medicare Payment Advisory Commission (MedPAC)
will have a reduced deductible and pay a little See also Centers for Medicare and Medicaid Services
more out-of-pocket (15%) coinsurance. (CMS); Cost of Healthcare; Health Insurance;
Medicare; Pharmaceutical Industry;
Pharmacoeconomics; Prescription and Generic
Covered Drugs and Participating Pharmacies Drug Use
Medicare Part D–covered drugs are defined as (a)

drugs available only by prescription, used and Further Readings
sold in the United States, and used for a medically
accepted indication; (b) biological products; (c) Fincham, Jack E. The Medicare Part D Drug Program:
insulin; and (d) vaccines. The definition also Making the Most of the Benefit. Sudbury, MA: Jones
includes medical supplies associated with the and Bartlett, 2007.
injection of insulin (i.e., syringes, needles, alcohol IMS Health. Medicare Part D: The First Year. Plymouth
Meeting, PA: IMS Health, 2007.
swabs, and gauze). Certain drugs or classes of
McAdams, David, and Michael Schwarz. “Perverse
drugs, or their medical uses, are excluded by law
Incentives in the Medicare Prescription Drug Benefit.”
from Medicare Part D coverage.
Inquiry 44(2): 157–66, 2007.
Not all Medicare Part D–covered drugs are
Stuart, Bruce C., Becky A. Briesacher, Jalpa A. Doshi,
included by each drug plan. Each plan has a for-
et al. “Will Part D Produce Savings in Part A and
mulary or list of covered drugs. Plans’ formularies Part B? The Impact of Prescription Drug Coverage on
must include a range of drugs to ensure that indi- Medicare Program Expenditures.” Inquiry 44(2):
viduals with different medical conditions can get 146–56, 2007.
the treatment they need. A plan’s formulary may
not include every drug that a beneficiary takes.
However, in most cases, a similar drug that is safe
Web Sites
and effective will be available.
Medicare requires plans to have convenient AARP: http://www.aarpmedicarerx.com
pharmacies for individuals to choose from. Each Center for Medicare Advocacy:
company offering a Medicare drug plan will have http://www.medicareadvocacy.org/FAQ_PartD.htm
a directory of pharmacies that work with the plan. Medicare: http://www.medicare.gov
Generally, a beneficiary must use one of the phar- National Council on Aging:
macies listed in this directory for the plan to cover http://www.mymedicarematters.org
their prescriptions. However, some plans will Pharmaceutical Research and Manufacturers of America
allow individuals to use a pharmacy that is not in (PhRMA): http://www.phrma.org
the plan’s network for a higher cost. Plans cannot
require the use of mail-order pharmacies, but they
may offer them as an option, many times at a
reduced cost to the beneficiary. Medicare Payment Advisory
Commission (MedPAC)
Future Implications
The CMS estimate that 39 million individuals— The Medicare Payment Advisory Commission
more than 90% of all Medicare beneficiaries—have (MedPAC) is a small, independent, federal agency
prescription drug coverage. Of these individuals, that advises the U.S. Congress on issues affecting
approximately 24 million have coverage through the Medicare program. Established by the Balanced
the Medicare Part D program. As the population Budget Act of 1997, the commission monitors the
ages and more individuals join the Medicare pro- Medicare program, reviews its policies, conducts
gram, Medicare Part D prescription drug coverage studies, and makes recommendations to Congress.
will become an increasingly important part of the MedPAC combines the functions of two prior
nation’s healthcare delivery system. government agencies: the Prospective Payment
Assessment Commission (ProPAC) and the
Todd Stankewicz Physician Payment Review Commission (PPRC).
Medicare Payment Advisory Commission (MedPAC) 753
Commissioners and Staff Members including staff members from various congressional
committees and the Centers for Medicare and
MedPAC is composed of 17 commissioners and
Medicaid Services (CMS), healthcare researchers,
approximately 35 professional staff members. The
medical providers, various beneficiary advocates,
commissioners, who are appointed by the U.S.
and professional associations.
Comptroller General and the head of the U.S.
General Accountability Office (GAO), serve 3-year
terms (subject to renewal) on a part-time basis. Publications
Appointments are staggered to maintain continuity:
MedPAC publishes a variety of documents, includ-
Every year approximately five or six commissioners
ing reports, data books, congressional testimony,
end their appointments and new commissioners are
contractor reports, comment letters, Medicare
appointed. The commissioners come from various
basics, and payment basics. Its specific recommen-
geographic regions, and they bring a wide array of
dations to the U.S. Congress and supporting
experience and expertise. Currently, the commis-
analyses are published in two annual reports,
sioners include actuaries, lawyers, physicians, and
which are issued in March and June of each year.
policymakers.
These have included consideration of Medicare
The commission’s professional staff members
payment policy and promoting greater efficiency
include an executive director as well as various
in Medicare. At the request of Congress, the com-
policy analysts, research assistants, administrative
mission also publishes reports on a variety of
staff, and consultants. Its staff members prepare
other Medicare-related subjects.
analyses of proposed regulations, write issue briefs,
The commission publishes a yearly data book
and contribute to the preparation of congressional
that provides statistical information on a variety of
testimony. Furthermore, they provide technical
Medicare topics (e.g., national healthcare and
support to the staffs of congressional committees
Medicare spending, Medicare beneficiary demo-
through memos and briefings.
graphics, and dual-eligible beneficiaries). It is fre-
quently called on to testify before Congress and to
Purpose submit reports on various Medicare issues. MedPAC
The commission’s statutory mandate is quite publishes various reports that have been produced
broad. In addition to advising the U.S. Congress under contract for them by outside authors. The
on payments to private health plans participating commission often submits formal comments on pro-
in the Medicare program and to providers in posed regulations issued by the Secretary of the
Medicare’s traditional fee-for-service program, Department of Health and Human Services (HHS)
the commission also analyzes access to care, qual- and on various Medicare-related reports to Congress.
ity of care, and other issues affecting Medicare. It also publishes Medicare Basics for the public (e.g.,
Medicare benefit design, Medicare Advantage
benchmarks, and payment compared with the aver-
Public Meetings
age Medicare fee-for-service spending) and Medicare
The commission holds seven formal public meetings Payment Basics (e.g., ambulatory surgical centers
per year in Washington, D.C. At these meetings, the payment system and clinical laboratory services
commission’s professional staff members present payment system), both of which provide brief over-
their research and research regarding policy issues views of various Medicare topics.
for the commissioners to discuss, and the commis- All its publications are available on the commis-
sion’s reports and specific recommendations to the sion’s Web site.
U.S. Congress are approved. Time for public com-
ment is always provided. Each meeting’s agenda
Future Implications
and briefs, as well as the transcripts from the meet-
ings, are posted on the commission’s Web site. MedPAC is in a unique position to influence pol-
Commissioners and professional staff members icy making for the nation’s Medicare program. In
also seek input on Medicare issues through informal the past few years, the commission’s recommen-
meetings with individuals interested in the program, dations have had substantial impact, and the U.S.
754 Mental Health
Congress feels obligated to weigh its recommen- complete state of mental and physical well-being,
dations carefully. The commission’s reports and and not simply the absence of disease. This defini-
testimony make important contributions to fed- tion emphasizes the positive features of mental
eral legislation. In the future, with the growing well-being. Good mental health is associated with
number of elderly people and the rising costs of positive family, community, and school or work
Medicare, the commission’s recommendations involvement, as well as with a supportive group of
will continue to be highly valued. friends.
In contrast, mental illness usually is associated
Vikrant Vats with the absence of one or more of these positive
involvements. Mental illness can be characterized
(CMS); Health Insurance; Medicare; Payment by problems in one’s thinking, emotions, behav-
Mechanisms; Public Policy; Regulation; U.S. iors, or any combination of these three. The
Government Accountability Office (GAO) American Psychiatric Association (APA) has devel-
oped a classification system for mental disorders
based on these characteristics, published as the
Further Readings Diagnostic and Statistical Manual of Mental
Lubell, Jennifer. “MedPAC: Can’t We All Get Along. Disorders (DSM).
Agency Examines Ways Docs, Hospitals Compete,” The most common mental disorders among
Modern Healthcare 37(36): 8–9, September 10, 2007. adults in the United States are depression and
Medicare Payment Advisory Commission. A Data Book: anxiety, each of which affects about 10% of
Healthcare Spending and the Medicare Program. the population. Much less common are bipolar
Washington, DC: Medicare Payment Advisory disorder—a combination of depression and mania,
Commission, 2007. which affects about 4% of adults—and schizophre-
Medicare Payment Advisory Commission. Report to the nia, which affects about 1% of the adult popula-
Congress: Promoting Greater Efficiency in Medicare. tion. Both can lead to disabilities, and both bipolar
Washington, DC: Medicare Payment Advisory disorder and schizophrenia are known to have a
Commission, 2007. genetic basis, at least in some population groups.
Medicare Payment Advisory Commission. Report to the About 25% of adults have a mental disorder
Congress: Medicare Payment Policy. Washington,
within a 1-year period, and about 50% will have a
DC: Medicare Payment Advisory Commission, 2008.
mental disorder in their lifetime. About 6% of
Neigh, Janet E. “MedPAC Examining Medicare Hospice
adults become seriously disabled as a result
Benefit Reimbursement System,” Caring 27(1):
of mental illness. Less is known about the rates of
60–61, January 2008.
specific mental illnesses in children and adoles-
cents. However, about 20% of youths suffer from
Web Sites one or more disorders, and 9% to 13% of them
are seriously disabled. Soon, national data will be
available on the rates of specific disorders in this
population.
Medicare Payment Advisory Commission (MedPAC):
http://www.medpac.gov
U.S. Government Accountability Office (GAO): Historical Overview
http://www.gao.gov
U.S. House of Representatives: http://www.house.gov Because mental illness has not been well under-
U.S. Senate: http://www.senate.gov stood in the past, the history of mental illness and
care is characterized by misunderstanding and
exclusion. These can lead to stigmatization, by
which a person or a family is blamed for the men-
Mental Health tal illness and deliberately excluded from social
groups, community activities, and work. Only
More than 50 years ago, the World Health recently has mental illness been truly recognized
Organization (WHO) defined mental health as a as a treatable illness from which one can recover.
Mental Health 755
In the American colonial period, people who had mental illnesses that led to serious disabilities.
had mental illness were called “the insane” and Although effective programs were developed for
were cared for by their families or in local alms- both adults and youths, these programs were not
houses. Around the time of the American broadly implemented. In 1992, President George
Revolution, a system of state mental hospitals was H. W. Bush signed federal legislation creating the
constructed. The first of these facilities, Eastern Substance Abuse and Mental Health Services
State Hospital, was built near Williamsburg, Administration (SAMHSA) with the mission of
Virginia, shortly before the Revolution. Usually, improving both mental health and substance use
these facilities were located in rural areas because care throughout the nation.
it was thought that persons with mental illness With the dawning of the 21st century, a new
would benefit from good air and the quiet atmo- awareness has developed that effective care is
sphere of a rural setting. available, that one can recover from mental illness,
After World War I, it became clear that a large and that one who has had a mental illness can lead
number of potential recruits had been excluded a happy and productive life in the community. This
from military service because of mental illness. It new approach has been heralded by representa-
also became clear that battle fatigue, suffered by tives of the mental healthcare community and
soldiers who had experienced combat, was a form broadly embraced by many Americans.
of mental illness. As a result, in the early 1930s, Many successes in mental health have been
the Veterans Administration created a system of achieved, in large measure due to the development
general hospitals that also provided psychiatric and growth of an effective mental health consumer
care. In the early 1940s, a system of general hospi- movement in parallel with the rapid growth of the
tals in local communities was created, many of family movement. Many American communities
which offered psychiatric care, and in the 1950s, a have access to (a) an affiliate of Mental Health
large number of private psychiatric hospitals were America, representing consumers; (b) an affiliate
founded, principally in urban areas. of the National Alliance for Mental Illness, repre-
In 1949, President Harry S. Truman signed leg- senting both families and consumers; and (c) the
islation creating the National Institute of Mental Federation of Families for Children’s Mental
Health (NIMH). In 1954, the drug chlorpromaz- Health, representing both families and children.
ine (sold under the trade names of Largactil and
Thorazine) was approved in the United States for
Recent Reports
psychiatric treatment. It was hailed as a wonder
drug to treat severe mental illness. With the advent Several recent reports will likely have a major
of drug therapy, the nation’s state mental hospitals effect on the future of mental healthcare in the
began to empty, a process later called deinstitu- United States.
tionalization. However, many of the former inpa- More than 200 years after the first U.S. Surgeon
tients of the mental hospitals became homeless, General took office in 1798, the first-ever Mental
were placed in nursing homes, or were even incar- Health: A Report of the Surgeon General was
cerated in jails or prisons. issued in 1999. This report examined the scientific
In 1963, President John F. Kennedy signed fed- foundation for current mental illness care practices
eral legislation creating a national system of com- and identified opportunities for care improvement.
munity mental health centers, which would be Significantly, the scientific foundations of mental
available throughout the nation. It was estimated health clinical and services research was found to
that 1,500 of these facilities would be required to be quite robust. The report identified the integra-
serve the entire American population. More than tion of mental health with general healthcare as
800 facilities were built before President Ronald the step forward needed most in the near term,
Reagan ended federal funding for the program in with the goal that the two systems become one and
1981. treat both mind and body at the same time.
From 1980 to the end of the 20th century, the In 2002, slightly more than 25 years after
mental healthcare field strove to provide effective President Jimmy Carter convened the first
care in local communities for public clients who President’s Commission on Mental Health,
756 Mental Health
President George W. Bush convened the President’s psychologists, social workers, psychiatric nurses,
New Freedom Commission on Mental Health. The marriage or family therapists, and clinical men-
new commission met for a year and then issued a tal health counselors. Typically, these providers
report titled Achieving the Promise: Transforming see clients either in the practitioner’s office or in
Mental Health Care in America in 2003. The an outpatient clinic or community mental health
report identified six major goals for the improve- center.
ment of mental healthcare in America: (1) The remaining 5% to 6% of the American
Americans understand that mental health is essen- population who receive care for mental illness are
tial to overall health; (2) mental healthcare is con- seen only by a general, medical physician. This
sumer and family driven; (3) disparities in mental pattern is particularly pronounced for children,
health services are eliminated; (4) early mental who likely are seen only by their pediatricians, and
health screening, assessment, and referral to ser- for elderly persons, who likely are seen only by
vices are common practice; (5) excellent mental their personal physicians. Most primary-care phy-
healthcare is delivered and research is accelerated; sicians are not adequately trained to recognize and
and (6) technology is used to access mental health- treat the full spectrum of mental illnesses.
care and information. About one fourth of those who experience a
In 2005, the prestigious national Institute of mental disorder each year suffer from a serious
Medicine (IOM) issued a study titled Improving mental illness such as schizophrenia and suffer the
the Quality of Health Care for Mental and greatest consequences in their loss of community
Substance Use Conditions. This landmark study participation. Many of these people are homeless
provided a plan for achieving the goals outlined by and jobless because of their illnesses. Frequently,
the President’s New Freedom Commission on they receive their only mental healthcare through a
Mental Health. A new set of “care rules” was state mental health agency, sometimes in a state
identified to improve care quality. These rules pro- mental hospital or local, outpatient, mental health
moted (a) better provider-consumer information clinic.
exchange, (b) more stable care relationships, and Each year, many other Americans have a range
(c) a more central role for consumer input regard- of mental health problems with symptoms that are
ing care. Care quality was determined to relate to not severe enough to qualify as mental illnesses.
six factors: (1) safety, (2) efficiency, (3) effective- Only a very small percentage of this group seeks or
ness, (4) equitability, (5) timeliness, and (6) per- receives care. Often, when care is sought, the first
son-centeredness. (For the latter, IOM identified point of contact is a company employee assistance
the consumer’s input as the “true north” of the program, many of which offer both mental health
healthcare system.) Finally, four key strategies and substance use care services, or a school or col-
were recommended to bring about necessary sys- lege health service.
tem changes: (1) financing reform, (2) training of If so many youths and adults have mental ill-
providers, (3) implementation of care that has a nesses, why do so few receive care? In a word,
sound scientific basis, and (4) better use of infor- stigma, which can lead to the rejection of care for
mation technology and performance measures. As fear that other family members, neighbors, fellow
with each of the earlier reports, it was strongly employees, and friends will find out. Many people
recommended that the integration of mental health interpret seeking care as a sign of weakness and fear
and general healthcare be a high priority. that it will have negative effects in the future, such
as diminished job prospects or the loss of friends.
Stigma can also manifest through negative manage-
Who Receives Care?
rial, boardroom, and legislative decisions about
At least half of those who experience a mental funding for mental healthcare. It is well-known, for
disorder each year do not receive any care at all. example, that insurance benefits for mental illnesses
Among the 10% to 12% of the American popu- provide less annual and lifetime coverage than for
lation who do receive mental healthcare, about physical disorders. This differential has spawned
half (5–6%) actually see a mental health spe- major efforts by national mental health leaders
cialist. These specialists include psychiatrists, to seek parity for mental health benefits in both
Mental Health 757
private and public insurance plans. In its most essential components, particularly in the most
extreme forms, stigma manifests as discrimination rural areas and the poorest urban areas.
against people with mental illness.
Some progress has been made in addressing the
Care Includes a Broad Range of
stigma of mental illness. Depression, anxiety, and
Modern, Psychotropic Medications
even schizophrenia show up on some television
shows as part of a character’s story line. Well- Medications are now available for virtually all
known national figures have disclosed their own the major mental illnesses. Yet many people do
illnesses: Tipper Gore, the wife of the former vice not receive modern medications because they lack
president Al Gore, and Mike Wallace, a longtime the financial resources to pay for them. Even
anchor on the popular investigative television when more effective, modern formulations are
newsmagazine show 60 Minutes, both have dis- available, older medications—some developed as
cussed their bouts with depression. And the popu- long ago as 50 years—are used because they cost
lar author Danielle Steel has written a gripping less. Some newer medications have also given rise
account of the bipolar disorder suffered by her to concerns about secondary effects, particularly
eldest son. National organizations have also mobi- metabolic changes that can lead to diabetes and
lized to combat stigma. As a result, the stigma heart disease.
associated with mental illness has diminished, but
it has not yet been extinguished.
Care Has Become More
Consumer and Family Centered
Recent Improvements in Care
A quarter century ago, mental healthcare pro-
In the past quarter century, there have been viders made virtually all the decisions about the
changes in the way Americans view mental health nature of mental healthcare and its duration. Now,
and the way mental illness is treated. Many of consumers and family members help define the
these changes are positive steps, though others objectives and the content of care. Yet a chasm
have introduced new societal problems. The main frequently exists—between the provider and con-
changes are discussed briefly below. sumer perspectives and between the consumer and
family perspectives—that can diminish the effec-
tiveness of care.
Care Has Moved From
Institutions to the Community
Debate Over Forced Treatment Continues
There are about 250,000 fewer psychiatric beds
today compared with 25 years ago. Community- In the past, this debate focused on inpatient
based care has expanded dramatically. Yet many commitment. Now, it focuses on outpatient com-
persons have been left behind. Witness the dra- mitment in community settings. Some community
matic growth in mental illness among the homeless members and professionals favor outpatient com-
as well as among the less affluent segments of mitment or court-determined and directed outpa-
American society. tient care if clients do not follow recommended
treatment practices. Many consumers oppose it as
an infringement on personal rights. This debate
Care Is Better Integrated
has fostered the development of creative alterna-
Into Overall Support Systems
tives. For example, advance directives are similar
It is now widely understood that those with the to a living will in that a person makes his or her
most severe mental illnesses require care systems wishes known in advance and appoints a personal
that span mental health, overall health, rehabilita- representative to reflect these views of patient care
tion, and social support services in the community. in subsequent proceedings. It may be useful to
At the heart of such systems are case managers view forced outpatient commitment as a measure
who work to achieve better community integration of system failure in that it generally occurs only
for their clients. Yet many of these systems lack when prior care has not been adequate.
758 Mental Health
Disparities in Mental members allowed and expected to take on a greater

Healthcare Have Been Identified role in the direct management of mental disease.
The use of new technologies will likely become an
It has been known for decades that racial, eth-
even more important vehicle for delivering mental
nic, gender, and age disparities exist in the occur-
healthcare. Currently, telecommunication, computer,
rence of mental illnesses and in mental healthcare
and Internet technologies are being linked to offer
services. Yet it is only recently that these disparities
“care at a distance.” Several thousand Web sites
have been recognized as national policy concerns.
now offer interpersonal psychotherapy, expanding
As a result, mental health providers and systems
the scope of mental health care services, much as the
will need to learn to adapt themselves to a broader
telephone expanded healthcare providers’ ability to
diversity of clients and develop a heightened level
help their patients in the past. Rapid advances also
of sensitivity to cultural and biological differences.
are being made in voice-activated automatic-re-
sponse systems and in the application of artificial-
Integration of Mental and
intelligence systems to real-world problems. As a
Physical Healthcare Services Has Begun
result, it is now possible to receive care and guidance
Until as recently as a decade ago, mental health- through a computer program without human inter-
care and physical healthcare systems operated in vention. Other automated systems are being devel-
separate, parallel worlds. With approximately 5% oped to monitor—at home, in real time—and report
to 6% of the American population receiving men- physical symptoms to healthcare providers. As these
tal healthcare only from general physicians, there noninterpersonal technologies become more perva-
is an urgent need to open a dialogue on better sive, new concerns are likely to arise about how and
ways to integrate the two fields. It is now realized, when human intervention in the mental healthcare
for example, that financial incentives, training, process is appropriate or even essential.
and new system configurations will be needed. A Also very promising will be the development of
similar dialogue has started between the mental new genetic treatments over the next 5 to 10 years
health and substance use care fields. for biologically based mental disorders. To date,
Other issues also will need to be addressed. As virtually no genetic interventions are recommended
more effective community care systems are built in or implemented in the mental health field. Now
the short-term future, they will need to consider that the basic human genome has been mapped,
(a) the role that the faith-based community can this situation may change radically as genetic inter-
play in prevention and early intervention, (b) the ventions are developed for mental disorders that
potential role of private-public partnerships, have a genetic basis.
(c) the need for effective linkages with the human
service community, and (d) the need for effective Ronald W. Manderscheid
outreach to those who are disenfranchised or sub- See also Access to Healthcare; Ambulatory Care;
jected to discrimination. Moreover, the new com- Diagnostic and Statistical Manual of Mental
munity systems must have the capacity to respond Disorders (DSM); Disability; Disease; Epidemiology;
to disasters, which can have major effects on men- Mental Health Epidemiology; Public Health
tal health and well-being similar to those experi-
enced after the 9/11 terrorist attacks in New York
and Washington, D.C. Further Readings
In the distant future, several other trends can be American Psychiatric Association. Diagnostic and
anticipated to emerge or strengthen. One trend Statistical Manual of Mental Disorders. 4th ed.
that is likely to affect mental healthcare is the Washington, DC: American Psychiatric Association,
move toward consumer- and family-centered care. 2000.
Consumers and family members will seek and Center for Mental Health Services. Mental Health,
receive more responsibility for health and health- United States, 2004. Edited by R. W. Manderscheid
care. Already, consumer-operated and peer- and J. T. Berry HHS Pub. No. (SMA)-06–4195.
supported mental health services have become Rockville, MD: Substance Abuse and Mental Health
more common, with individuals and family Services Administration, 2006.
Mental Health Epidemiology 759
Committee on Crossing the Quality Chasm: Adaptation statistical sampling methods, interviewer scales,
to Mental Health and Addiction Disorders. and appropriate analytical tools and collect detailed
Improving the Quality of Health Care for Mental and information on specific medical diagnoses that can
Substance-Use Conditions: Quality Chasm Series. be generalized to a defined national population.
Washington, DC: National Academies Press, 2006. This combination of resources has enabled research-
New Freedom Commission on Mental Health. Achieving ers to measure the magnitude of mental health
the Promise: Transforming Mental Health Care in disorders in the United States’s population. In gen-
America. Final Report. HHS Pub. No. (SMA)-03–3832. eral terms, researchers now estimate that about one
Rockville, MD: U.S. Department of Health and
quarter of the nation’s adult population has a diag-
Human Services, 2003.
nosable mental disorder in any 1-year period of
U.S. Department of Health and Human Services. Mental
time and that the lifetime expectation is that about
Health: A Report of the Surgeon General. Rockville,
1 in 2 adults will suffer from these disorders. For
MD: U.S. Department of Health and Human Services,
children and adolescents, the 1-year figure is about
Administration, Center for Mental Health Services,
1 in 5. For any other medical disorder (e.g., heart
National Institutes of Health, National Institute of disease, diabetes, hepatitis), these figures would be
Mental Health, 1999. considered signs of a public health crisis.
Some Basic Concepts of Epidemiology

Web Sites
To understand epidemiology, several key concepts
are critical. Two important basic concepts are the
prevalence and the incidence of disease. Prevalence
Centers for Disease Control and Prevention (CDC),
Mental Health Work Group: http://www.cdc.gov/
refers to the total number of disease cases in a
mentalhealth
period of time for a defined population. This
Federation of Families for Children’s Mental Health period of time can be 1 day in length, called point
(FFCMH): http://www.ffcmh.org prevalence, or 1 year in length, called period
Mental Health America (MHA): http://www.nmha.org prevalence. Incidence refers to the number of new
National Alliance for Mental Illness (NAMI): disease cases occurring during a period of time for
http://www.nami.org a defined population, either point incidence or
National Institute of Mental Health (NIMH): period incidence, as differentiated above.
http://www.nimh.nih.gov A major goal of epidemiology is to measure both
New Freedom Commission on Mental Health: the prevalence and the incidence of a disease. By
http://www.mentalhealthcommission.gov definition, the ratio of incidence to prevalence will
Substance Abuse and Mental Health Services always be 1 or less. The higher this ratio, the greater
Administration (SAMHSA): http://www.samhsa.gov the turnover in the diseased population. For exam-
ple, depression has both a high incidence and a high
prevalence, which means that there is considerable
turnover in the population with this disease and
Mental Health Epidemiology that many persons with this disease recover in a
relatively short period of time. In contrast, schizo-
Mental health epidemiology is the study of the phrenia has a very low prevalence and even lower
prevalence and incidence of mental health disor- incidence. This means that there is a very low turn-
ders. This entry defines basic epidemiology conover in this population and that persons with this
cepts and describes the historical development of disease have it for a long period of time.
mental health epidemiology in the United States. To measure a disease’s period prevalence, mea-
In conclusion, it outlines some of the promising sures of the number of disease cases at Time 1
new directions mental health epidemiology will and Time 2 are required. Period prevalence is the
likely take in the future. sum of these two figures (i.e., point prevalence
Only in the past 30 years have public health and plus incidence). Remember that the period preva-
health services researchers been able to combine lence is always equal to or greater than the period
760 Mental Health Epidemiology
incidence. By extension, it should be noted that Beginning of the Modern Era

point prevalence can be viewed as the sum of the
disease cases at the beginning of a day plus the The beginning of the modern era of mental health
number of new incident cases over the course of epidemiology can be traced to a famous study
the day. conducted in Stirling County, New York, in 1952.
Period incidence also requires measurement at At that time, Stirling County was rural, with a
two time points. Period incidence means that a total population of about 20,000 persons. More
person does not have the disease at Time 1 but than 1,000 male and female adult heads of house-
develops the disease between Time 1 and Time 2. holds were interviewed for the study, and the
By extension, point incidence means that a person American Psychiatric Association’s new Diagnostic
did not have the disease at the beginning of the and Statistical Manual of Mental Disorders
day but developed the disease over the course of (DSM-1) was used for the first time. Two psychia-
the day. trists reviewed the interview ratings. The purpose
Frequently, sociodemographic factors such as of the study was to examine the relationship
age, gender, race or ethnicity, and place of resi- between sociocultural disintegration and specific
dence are examined in relation to a disease. From mental disorders. Lifetime prevalence was esti-
such analyses, for example, Hollingshead and mated at 57% for all DSM-1 disorders measured,
Redlich were able to determine that the preva- and current prevalence was estimated to be 90%
lence of mental illness was 8 times as large in the of the lifetime rate.
lowest social class as compared with the highest An equally famous study from this period is the
social class. Midtown Manhattan Study conducted in 1954.
The study population included 175,000 adults
between the ages of 20 and 59 who resided in
Early Work in Mental Health Epidemiology Midtown Manhattan. Of this number, 1,660 were
Beginning in 1840, the U.S. superintendent of the interviewed. Two psychiatrists reviewed the rat-
census began to collect information, as part of ings. The purpose of the study was to examine the
the nation’s decennial census of population, on relationship between stress indicators and mental
the number of persons living in households who impairment. Unlike the Stirling County Study, the
were “insane or idiotic.” Similar data were col- Midtown Manhattan Study developed an overall
lected on persons residing in state mental hospi- measure of mental disorders and ratings for several
tals. The sum of these two numbers provides a symptom groups rather than ratings for specific
very primitive, early estimate of the prevalence of disorders. Current prevalence was estimated at
mental illness in the United States. This procedure 81.5% for mild to incapacitated impairment. No
was continued until 1900 with progressive refine- lifetime prevalence figure was provided.
ment in the diagnostic categories. Both of these studies contributed significantly to
After that time, specific questions on mental ill- the understanding of how to conduct mental
ness were no longer asked of the household popu- health epidemiological fieldwork. However, both
lation, but data were collected more frequently on also had considerable limitations. Both were sur-
state mental hospitals. Over time, the data col- veys conducted in small geographical areas, and
lected from state mental hospitals, treated preva- both were focused on the noninstitutionalized
lence, became the surrogate for total community population. Persons with mental illness who resided
prevalence—that is, the sum of the community and in psychiatric hospitals at the time of the studies
hospital figures. These hospital data were reported were not counted.
by the U.S. Public Health Service in a publication It should be noted that the newly formed
series called Patients in Mental Institutions. As National Institute of Mental Health (NIMH) was
additional types of hospitals—Veterans Adminis developing psychiatric case registers at about the
tration Medical Centers, general community hos- same time the Stirling County and Midtown
pitals, and private psychiatric hospitals—were Manhattan studies were being conducted. A psychi-
developed in the 1930s and later, their figures were atric case register is a continuous recording of all
also added to these data collections. persons who present for mental health treatment
from a defined geographical area, together with The ECA project was widely acclaimed at the
detailed treatment data. A case register is a very time it was reported to the field, and its results were
valuable tool for understanding the precise patterns used broadly for policy, clinical, and financial
of care provided to persons with specific disorders. analysis. To the present time, this study has pro-
The most notable of these psychiatric case registers vided the only annual incidence figures for specific
were for the states of Maryland and Hawaii and for diagnoses that have ever been collected on a
Monroe County, New York. The two state case national basis. Problems of individual recall were
registers were discontinued at the end of the 1960s, noted in the lifetime prevalence figures; hence, they
and the Monroe County case register was discon- have received relatively little attention by the field.
tinued at the end of the 1980s.
Current Generation of Work
A Landmark National Study
Almost a decade after the ECA fieldwork was
From the time of the Stirling County and Midtown completed, a new study, the National Comorbidity
Manhattan studies until the early 1980s, work Survey (NCS) was undertaken between 1990 and
was underway at NIMH and in the mental health 1992 on a national probability sample of more
research field to improve the measurement of spe- than 8,000 persons, 15 to 54 years of age, from
cific mental disorders using interview techniques. the household population. NIMH supported this
At the same time, the specification of mental dis- new study. This effort was the very first to assess
orders was refined with the release of the second mental illness in a national probability sample. It
and third generation of the Diagnostic and was also the first effort to use the World Health
Statistical Manual of Mental Disorders (DSM-II Organization’s Composite International Diagnostic
and DSM-III). From these efforts came the Instrument (CIDI), based on the DSM-III-R and
Diagnostic Interview Schedule (DIS). The DIS was administered by lay interviewers. Fourteen differ-
the first field survey instrument that could be ent psychiatric disorders were assessed. Annual
administered solely by a lay interviewer and from prevalence figures were similar to those reported
which specific mental illness diagnoses could be from the ECA, with almost 30% of respondents
derived, with further clinical review. having a mental illness. Lifetime prevalence was
The DIS became the basic survey instrument for reported to be almost 50%. Equally important,
the epidemiological catchment area (ECA) project more than half of all the persons with a lifetime
conducted in 1983 under the leadership of NIMH. disorder had a history of three or more comorbid
This survey project was conducted among persons disorders. Of those with a disorder in the past
18 years of age and older in five geographic areas year, less than 20% received any care; for those
across the nation: (1) New Haven, Connecticut; with a lifetime disorder, the percentage receiving
(2) Baltimore, Maryland; (3) St. Louis, Missouri; any treatment was less than 40%.
(4) Durham, North Carolina; and (5) Los Angeles, A broad range of mental health issues have been
California. The purpose of the study was to pro- explored by researchers using NCS data, which are
duce lifetime and annual prevalence estimates for publicly available; numerous scientific articles
specific mental disorders and to produce estimates have been published from it. However, NCS did
of the incidence of these disorders for a 1-year not include a scale for schizophrenia, and it did not
period. The national estimates were produced collect incidence data.
using the 1980 population figures, even though the In 2001 and 2002, the same set of NCS respon-
data were collected in 1983. Annual period preva- dents was reinterviewed. NIMH and the Center
lence was estimated to be 28.1% for all disorders, for Mental Health Services supported this effort.
and separate estimates were provided for specific The reinterview study is called NCS-2. This study
disorders. A very important finding from this was conducted to examine the course of mental
study was that only about 15% of the adult popu- disorders, as well as the relationship between pri-
lation received any mental healthcare, and only mary mental disorders and secondary substance
6% received care from a mental health provider use disorders. From this study, the framework of
such as a psychiatrist or psychologist. the “window of opportunity” has been developed.
762 Mental Health Epidemiology
This framework points to opportunities to inter- mental health epidemiology is also developing the
vene between the onset of a primary mental disor- capacity to make accurate, state-level estimates,
der and the onset of a secondary substance use which will be very useful for state and local health
disorder to prevent the latter. planners, various departments of state govern-
At the same time, an NCS-R (Replication) ment, and state policymakers.
prevalence survey was carried out on a new The future will likely hold many changes for the
national probability sample of 10,000 respon- field of epidemiology in general and for mental
dents, 18 years of age and older, using a revised health epidemiology in particular. Some of the
CIDI based on DSM-IV. More than 32% of the anticipated changes are outlined below.
respondents had a disorder in a 1-year period, and
more than 57% had a lifetime disorder.
Electronic Health and Personal Health Records
Currently, the results from a parallel study of
10,000 adolescents, called the NCS-A (Adolescents), A process is already underway to implement
are being analyzed. Once reported, this study will electronic health records (EHRs) and personal
be the first national effort to collect detailed preva- health records (PHRs) in the United States.
lence information on a national probability sample Comprehensive EHRs will contain detailed con-
of adolescents, 12 to 17 years of age. tinuous information on a person’s health status
and the healthcare he or she receives. PHRs will
translate this information into action steps that
Some Related National Work
consumers will be able to take to improve their
In 2006, funding was provided by the Center for health status and the quality of their care, as well
Mental Health Services to add mental health ques- as to engage in self-care activities.
tions to the Behavioral Risk Factor Surveillance The EHRs and PHRs will provide an entirely
System (BRFSS), operated by the U.S. Centers for new source of data for mental health epidemiol-
Disease Control and Prevention (CDC). The ogy. These electronic files will be universal. They
BRFSS is composed of 51 parallel, state telephone will be continuous records. And they will contain
surveys of samples of adults and is conducted each detailed information on the full range of a person’s
year. The mental health questions added to the comorbidities. The implication is that traditional
BRFSS were the first eight items from the Physician epidemiological-survey data collections will be
Health Questionnaire (PHQ-8), which provide a replaced by continuous data collection from these
measure of depression. Unlike all earlier mental electronic files.
health epidemiology efforts, the BRFSS is capable To facilitate this outcome, it will be essential to
of producing direct state estimates in addition to ensure that very high-quality information is entered
national estimates. In this first effort, 38 states into these EHRs and PHRs, using the very best
added the mental health questions. Initial results instruments available. The VistA EHR developed
will be available from the Center for Mental by the U.S. Department of Veteran Affairs for
Health Services. military veterans has already demonstrated how
In 2007, the BRFSS work was extended by add- this might be accomplished. More effort needs to
ing the K-6, a measure developed in the NCS to be spent on ensuring comparable data standards in
assess whether an adult respondent has serious men- EHRs and PHRs for items and scales measuring
tal illness. These results will be released in 2008. mental health epidemiology.
Promising New Directions Improved Knowledge Base

As indicated above, mental health epidemiology in Two types of scientific advances hold consider-
the United States has steadily progressed from able promise for the future of mental health epide-
small, local studies using inconsistent nonstan- miology. First, with the decoding of the human
dardized measures to sophisticated, national prob- genome and the development of large-scale popu-
ability samples using internationally recognized lation samples of DNA, it will be possible to deter-
and validated research instruments. The field of mine genomic patterns for persons with particular
disorders. Some mental disorders, such as schizo- prevalence of 25% may not be taken seriously as a
phrenia and depression, are already known to public health crisis because of stigma and because
have genetic components, at least in specific popu- of unfounded beliefs about persons with mental
lation subgroups. As this knowledge is developed, illness and the care they receive.
it will need to be incorporated into mental health Major national efforts are underway to combat
epidemiology. stigma against persons with mental illness. These
Second, major efforts are currently underway to efforts take the form of educational campaigns,
develop what is called personal medicine. Stated discussions with family members and consumers,
simply, this is an effort to match care uniquely to and engaging people in mental health initiatives.
a particular individual. Hence, rather than a gen- With an annual prevalence of 25% and a lifetime
eral drug formulary for a psychotropic medication, prevalence of 50%, virtually every family in the
the formula would be prepared specifically for nation has one or more members who experience
each individual. Clearly, how each patient responds mental illness.
to a medication could be used to develop an The second and related issue is privacy or con-
entirely new classification system for mental disor- fidentiality. Because of work and social discrimina-
ders: Instead of relying on a series of questions to tion, persons with mental illness are very reluctant
identify a particular disorder, drug responsiveness to share information about their illness or care.
could be used for this purpose. These wishes for privacy need to be respected, and
strong standards of confidentiality need to be
enforced. And healthcare providers, insurers,
Enlightened Consumers
employers, and other institutions all need to be
As the mental health consumer movement con- held to a very high and strict standard in this
tinues to evolve in the United States, consumers area.
will be able (a) to better recognize the signs and Those engaged in mental health epidemiology
symptoms of mental illness, (b) to understand and need to recognize these issues and address them
evaluate the quality of care they receive, and (c) to head-on. To address stigma, they need to consider
engage in self-help activities. This is all part of a mental illness in the general context of all illnesses.
major transformation effort to promote true recov- Past research on comorbidity is a very positive
ery and independence. As this evolution pro- movement in this direction. With regard to confi-
gresses, consumers and the providers who serve dentiality, researchers need to ensure that epide-
them may become less willing to participate in miological data are not released inappropriately,
national or state mental health epidemiology sur- particularly as the nation moves into the era of
vey efforts. They will also want to know and EHRs and PHRs.
understand how the results from such research can
be applied directly to their own care and recovery. Ronald W. Manderscheid
Hence, future research efforts will need to include See also Diagnostic and Statistical Manual of Mental
new components that address these concerns and Disorders (DSM); Disease; Epidemiology; Forces
interests. Changing Healthcare; Mental Health; National
Institutes of Health (NIH); Public Health
Stigma and Privacy
The mental health field has two preeminent Further Readings
concerns that need to be addressed on an ongoing Center for Mental Health Services. Mental Health,
basis. The first is stigma based on the ideas that (a) United States, 2004. Edited by R. W. Manderscheid
people feign mental illness and are really laggards, and J. T. Berry. HHS Pub. No. (SMA)-06–4195.
(b) mental health treatment doesn’t work, and (c) Rockville, MD: Substance Abuse and Mental Health
mental health treatment is too expensive. Although Services Administration, 2006.
these contentions are not true, they color any Eaton, William W., and Larry G. Kessler, eds.
debate about mental health issues from the U.S. Epidemiology Field Methods in Psychiatry. New
Congress to a local community group. A 1-year York: Academic Press, 1985.
764 Meta-Analysis
Hollingshead, August B., and Frederick C. Redlich. results of each study are shown, making it obvious
Social Class and Mental Illness: A Community Study. if all the studies agree or not. For example, if some
New York: Wiley, 1958. studies find that an intervention or experimental
Oakes, J. Michael, and Jay S. Kaufman, eds. Methods in group is worse than the control group, and other
Social Epidemiology. San Francisco: Jossey-Bass, 2006. studies find it better, the disagreement can be seen
Prince, Martin, Robert Stewart, Tamsin Ford, et al., eds. at a glance.
Practical Psychiatric Epidemiology. New York: The term meta-analysis was coined by the
Oxford University Press, 2003. American statistician Gene V. Glass while he was a
Susser, Erza, Sharon Schwartz, Alfredo Morabia, et al.
faculty member at the University of Colorado at
Psychiatric Epidemiology: Searching for the Causes of
Boulder in 1976. However, the practice actually
Mental Disorders. New York: Oxford University
originated before 1976 as many meta-analyses
Press, 2006.
were published earlier. The use of meta-analysis in
Tsuang, Ming T., and Mauiricio Tohen, eds. Textbook
in Psychiatric Epidemiology. 2d ed. New York:
clinical medicine was systematically developed in
Wiley-Liss, 2002.
the United Kingdom by the Cochrane Collaboration,
an international group of thousands of volunteers
founded in 1993 and named after the British
Web Sites epidemiologist Archibald “Archie” L. Cochrane
(1909–1988). The Cochrane Collaboration is an
American College of Epidemiology: international, not-for-profit organization that pro-
http://acepidemiology.org
duces and maintains systematic reviews of health-
care interventions, doing their meta-analysis in a
standard way. These meta-analyses are published
electronically in the Cochrane Database of Syste
http://www.apha.org
matic Reviews, which are published many times a
http://www.cdc.gov/brfss
year and can be easily updated.
National Comorbidity Survey and Replication: Meta-analysis consists of (a) a systematic search of
http://www.hcp.med.harvard.edu/ncs the literature, identifying studies by predefined crite-
National Institute of Mental Health (NIMH): ria; (b) extracting numerical results from each study
http://www.nimh.nih.gov for the experimental and control subjects, on various
Office of the National Coordinator on Health outcomes and their difference; plus (c) the calculation
Information Technology: http://www.hhs.gov/healthit of parameters reflecting their statistical confidence
Society for Epidemiologic Research: (e.g., standard deviation and sample size).
http://www.epiresearch.org
The Meta-Analytic Method
Administration (SAMHSA): http://www.samhsa.gov
To conduct a meta-analysis, a researcher conducts
a literature search to find all the studies that meet
certain predefined qualitative and quantitative
Meta-Analysis inclusion or exclusion criteria. This is often com-
puter based, with each search term and database
Meta-analysis, a tool developed to summarize the used listed. As computer searches often miss impor-
findings from randomized clinical trials (RCTs), tant articles and reports, hand searches are also
can be used by many scientific fields, including necessary, including searching the bibliography in
health services research, to statistically combine each journal article to identify other applicable
data from many individual studies. A meta-analysis studies. If possible, the translations of the relevant
adds up the results for each participant in the foreign-language articles should be acquired.
experimental group and in the control group of all It is vital that all studies in the meta-analysis
the relevant studies and presents an easily under- meet reasonable criteria; otherwise there is the
stood summary; it also provides a visual depiction potential for bias. Meta-analysis is no better than
of the outcome, a forest diagram, in which the the studies that go into it. If there is bias in even a
Meta-Analysis 765
few studies, it will translate into bias in the meta- the mean of the control group divided by their
analytic summary. Sometimes, one will see a meta- pooled standard deviation.
analysis with rather exacting criteria for the Many outcomes are inherently qualitative, for
selection of studies. This may defeat the purpose of example, living versus dead or having a disease
a meta-analysis because having very exhaustive versus not having a disease. For qualitative or dis-
inclusion criteria excludes studies that do not fit continuous data, the effect size for an intervention-
with the researcher’s preconceptions. For this rea- control comparison is primarily expressed as the
son, the Cochrane Collaboration always includes a difference between the percentages with and with-
list of excluded studies. The criteria for study out an event in the experimental group and the
inclusion should be simple and straightforward control group using indices such as odds ratios, risk
and capture all the well-controlled studies in a ratios, or risk differences to provide a measure of
field. One can then examine some of the minor the differences. Inherently qualitative outcomes
methodological differences across studies by sensi- should be dealt with as such. Here, researchers
tivity analysis and meta-regression to see if they do would generally prefer using a continuous variable,
make a difference. but sometimes it is useful to supplement with a
It is not appropriate to statistically evaluate a dichotomous variable. Dichotomizing data should
participant’s measure twice, as if it were for differ- be done using predefined criteria. An advantage of
ent subjects. Each participant should be counted dichotomous data is that information from each
only once. To demonstrate this double publication individual subject can often be extracted (i.e., the
redundancy, investigators may initially report on results stem from real participants) from the obser-
the first 20 subjects and, in another article, report vations of individual subjects rather than conducted
on a total of 60 subjects that include the original on summary statistical parameters. This approach
20 subjects. Clearly, the same participants counted is inherently meaningful to researchers, whereas a
twice or more will amplify any finding. In addi- change of abstract continuous units may not be.
tion, bias is introduced when undue weight is given The statistical methods for analyzing qualitative
to the findings of groups reporting their data in data are essentially a stratified or fold contingency
multiple publications as opposed to those report- table. Epidemiologists have been using these statis-
ing their findings in only one source. tical methods for many years.
Some researchers perform multiple statistical Studies often present a vast amount of data
analyses and stress the most favorable outcome. obtained through the use of various rating scales,
For meta-analysis, predefined systematic numeri- measurement instruments, and statistical tech-
cal information should be extracted from each niques, which makes it difficult to compare the
study. results as they are expressed in a wide variety of
units. In meta-analytic statistics, the control group
mean or average is subtracted from the interven-
The Statistics of Meta-Analysis tion or experimental group mean and then divided
by the pooled group standard deviation, a process
Effect Size
that is similar to the notion of percentage change
The effect size is the magnitude of the difference scores. As a result, the data are expressed in uni-
between the intervention or experimental groups form units. This allows researchers to focus their
and the control groups, regardless of the sample attention on the hypothesis they are examining
size. This is different from the statistical signifi- rather than be distracted by the many different
cance, which is defined as the probability that such units among studies.
a finding may happen by chance, leading to the
rejection of the null hypothesis. Statistical signifi-
Statistical Methods
cance is dependent, in part, on the sample size, so
studies with a large number of subjects may yield Most meta-analysis uses standard statistical
a highly significant result. The effect size of a con- techniques for continuous data and the Mantel-
tinuous variable is frequently expressed as the Haenszel model, or some variant thereof, for dis-
mean, or average, of the experimental group minus continuous data. Because continuous data possess
766 Meta-Analysis
more power than discrete data, continuous data important to perform a sensitivity analysis by ana-
are preferred, when available, to derive the effect lyzing the same data set with different assump-
size. The sample size, mean, and standard deviations, often with 5 to 10 alternate examinations.
tions can be easily extracted from RCTs as well The blinding and randomization or other method-
as many other types of published studies. ologies protect against bias. Sensitivity analysis is
Unfortunately, many reports provide the sample recalculation of the meta-analysis under different
size and means for the assorted groups but do not assumptions. Frequently researchers will drop a
report the standard deviations (or standard error certain type of study to determine if the other stud-
of the mean) that are needed for effect size calcula- ies produce the same results as the total, thereby
tions. Standard deviation or its equivalent should demonstrating that the overall results are not an
always be reported. Sometimes, standard devia- artifact of a given type of study. A sensitivity
tions can be computed from the results of the sta- analysis can be done by using a different choice in
tistical test presented. Part of meta-analysis is the deciding which studies to include, or a different
calculation of variance in standard units. Meta- outcome measure. However, the problem with
analyses can be done with fixed (assuming each dropping studies is the loss of statistical power.
study to have a fixed effect size) or random models A metaregression differs in that it includes all
(not assuming this). Generally, random models put the studies but examines whether there is a system-
more emphasis on the smaller studies. atic difference between one or another moderator
variable. The moderator variables could be con-
tinuous or dichotomous (i.e., the meta-analytic
Consistent Results
equivalent of analysis of variance or analysis of
One of the major objectives of meta-analysis is covariance). The moderator variables are not ran-
to demonstrate, when studies are combined, that domly assigned nor are they usually blinded. Many
the findings are consistently homogenous. When biases could affect moderator variables. The same
consistent findings are present, some studies will cautions that apply when imputing cause from
be clearly statistically significant whereas others statistical correlation analysis apply to a meta-re-
may have strong nonsignificant trends in the same gression as it is an exploratory technique.
direction, which summates the essential agree-
ment, because the results are similar.
The Graphic Inspection of Results
The quintessence of meta-analysis is the inspection
Sensitivity Analysis and Meta-Regression
of the data. Thus, this method generates a visual
The pattern and consistency of results across all or numeric illustration of each study in the context
studies is vital. For example, if there are several of all the others. A review of the actual data gives
small-sample, positive RCTs and many large- the analytical reader a feel for the data. When the
sample, negative trials, it is likely that the smaller results from several studies are converted into
studies were deviations or wishful thinking. If the similar units, a simple inspection of a graph or
results between individual studies are highly dis- table quickly displays which trials have dissimilar
sonant, it is erroneous to conclude that the overall outcomes from the majority. Such disparate out-
effect is statistically significant. Rather, the pru- comes can also be examined by a variety of statis-
dent conclusion is that some studies show inter- tical parameters. For example, a researcher can
vention effects and others do not, which requires calculate a statistical index of homogeneity,
the researcher to explain this discrepancy. It is whereby he or she can remove the most discrepant
preferable to appraise studies by a priori criteria study from the analysis, recalculate, and in so
for methodological precision and then examine if doing reveal that all but one study in the data set
there is a similar effect size in the more rather than are homogenous. If two studies are discrepant,
less rigorous studies. then the researcher can remove both from the
There are many arbitrary assumptions that can study and again recalculate the parameters of sta-
go into a meta-analysis, involving how to classify tistical homogeneity, and so on. When there are a
studies and the exact criteria for inclusion. It is number of blinded studies, the interpretation of
Meta-Analysis 767
efficacy is usually straightforward, particularly underlying them. To minimize this bias, research-
when the results are not statistically significant. A ers recommend including all reasonable-quality
few biased studies mixed in with valid studies studies as well as search reports of symposia, meet-
might produce a significant difference. In inter- ing presentations, relevant Web sites, exhibits, and
preting the results of the meta-analysis, it is impor- other available unpublished data; they also recom-
tant to examine the effect size and its significance, mend contacting investigators and funding sources
as well as the consistency of the results. The con- for data and, if necessary, obtaining data using the
fidence interval or standard deviation and sample Freedom of Information Act.
size provide a bridge to inspect uncertainty in the One safeguard is to calculate the number of
same units. participants whose negative results (hypothetically
hidden in a file drawer) would convert a positive
meta-analysis to a negative one (the fail-safe num-
Meta-Analysis Versus Narrative Reviews
ber). It seems likely that the file drawer issue is also
Narrative reviews of scientific findings are often a problem for narrative reviews as they generally
based on clinical wisdom and can be highly sub- do not seek to consider all relevant studies.
jective: The author of a narrative review may
accept the results of studies without any critical
assessment. The author may summarize several Omnibus Methods
highly publicized references in support of a certain Meta-analysis does not simply count the number
position, even reporting redundant data, but the of studies that display a significant difference,
reader may discover that many of the quoted stud- average their means not weighted by sample size,
ies are inadequately controlled. The author selec- or add up the p values. These methods, which are
tively chooses what studies to mention and selects referred to as omnibus or vote-counting methods,
what aspects to mention or omit, as well as giving have many methodological problems. The results
his or her opinion as to what the bottom line is. obtained by adding p values can be excessively
Additionally, limited evidence from controlled influenced by a few disparate studies, as shown by
studies failing to find a big difference is often various researchers using simulation models.
interpreted as finding the opposite result. But an
area that is not studied does not imply the oppo-
site of the hypothesis, only insufficient studies. Implications
Ideally, the researcher should carefully consider A large literature on meta-analysis has developed
each individual study before coming to any conover the years, documenting the extensive experi-
clusions. However, when there are many con- ence and the methodological and statistical issues
trolled studies, the individual researcher often associated with it. The most important aspect of a
cannot remember all the results. Thus, a meta- meta-analysis, no matter how technically excellent,
analysis can often provide a more meaningful is no better than the soundness of the judgment that
summary than a narrative review. goes into the selection of the studies and their inter-
pretation so that they make sense mechanistically.
The File Drawer Problem Although meta-analysis has been traditionally
used to summarize RCTs and genetic studies, it can
One of the most important drawbacks in meta- also be used to summarize various health services
analysis is the “file drawer” problem. Researchers research studies, case-controlled studies, observa-
have found that positive findings are much more tional studies, or even uncontrolled studies that
likely to be published than negative findings. And use a common methodology. Knowledge of the
positive findings are more likely to be printed in data provides some empirical benchmarks to help
more prestigious journals. Estimates can be made distinguish empirical findings from the results of
according to assumptions about such a pattern. An dogma, wishful thinking, or political pressures.
example of such estimates is the funnel plot, which
is often included in a meta-analysis. However, John M. Davis, Chunbo Li,
such plots are no better than the assumptions and Stefan Leucht
768 Midwest Business Group on Health
See also Benchmarking; Causal Analysis; Cochrane, Background

Archibald L.; Cohort Studies; Cross-Sectional Studies;
Evidence-Based Medicine (EBM); Measurement in Established in January 1980 by a small group of
Health Services Research; Randomized Controlled large, Midwest employers, the nonprofit MGBH
Trials (RCTs) has grown to include more than 80 major employ-
ers responsible for more than 2 million covered
lives in 11 states. These employers collectively
Further Readings spend more than $2.5 billion annually on their
employees’ healthcare benefits. Over the years, the
Egger, Matthias, George Davey Smith, and Douglas G.
coalition’s mission has also broadened and
Altman, eds. Systematic Reviews in Health Care:
expanded. Initially, it was mainly concerned with
Meta-Analysis in Context. 2d ed. London: BMJ, 2003.
Higgins, Julian P. T., Simon G. Thompson, Jonathan J.
ways to lower and control the costs of healthcare;
Deeks, et al. “Measuring Inconsistency in Meta-
today, it also addresses the quality, safety, and
Analysis,” British Medical Journal 327(7414): value of healthcare.
557–60, September 6, 2003.
Lipsey, Mark W., and David B. Wilson. Practical Meta-
Membership
Analysis. Thousand Oaks, CA: Sage, 2001.
Petitti, Diana B. Meta-Analysis, Decision Analysis, and The MBGH is primarily funded through employer
Cost-Effectiveness Analysis: Methods for Quantitative membership dues. Membership is for a 12-month
Synthesis in Medicine. 2d ed. New York: Oxford period with dues based on the employer’s number
University Press, 2000. of U.S. workers. Public and nonprofit employers
Stangl, Dalene K. and Donald A. Berry, eds. Meta- receive a 50% discount off their membership
Analysis in Medicine and Health Policy. New York: dues. Specifically, the coalition has four member-
Marcel Dekker, 2000. ship categories: (1) business members, which are
Sutton, Alexander J., and Julian P. T. Higgins. “Recent for-profit organizations (e.g., Bank of America,
Developments in Meta-Analysis,” Statistics in Caterpillar, and Ford Motor Company); (2) pro-
Medicine 27(5): 625–50, February 28, 2008.
vider members, which are community-based
healthcare provider organizations such as hospital
systems (e.g., Advocate Health Care, Alexian
Web Site
Brothers Hospital Network, and Carle Clinic
Cochrane Collaboration: http://www.cochrane.org Association); (3) nonprofit and government mem-
bers, which include academic, research, and gov-
ernment organizations (e.g., the Federal Reserve
Bank of Chicago, the state of Illinois, and the
Midwest Business University of Chicago); and (4) associate mem-
Group on Health bers, which include providers of healthcare and
medical products or consulting and management
The Chicago-based Midwest Business Group on services (e.g., Abbott Laboratories, Deloitte, and
Health (MBGH) is a leading regional healthcare Johnson and Johnson Health Services).
coalition of major private and public employers.
The MBGH works with its member employers to
help them control and lower their healthcare costs
and obtain more value for their healthcare benefit The MBGH is governed by a board of directors,
dollars. As an organization, the coalition offers its which consists of the president, chief executive
members a wide variety of health benefit, educa- officer, and secretary of the coalition and
tional seminars; networking opportunities; initia- 18 board members. The board members are
tives and demonstration projects; and group elected from the various member employers.
purchasing programs. The MBGH is also a mem- A professional staff of six individuals—the
ber of the National Business Coalition on Health president, vice president, director of projects
(NBCH). and communications, director of operations,
Midwest Business Group on Health 769
membership and administration coordinator, and (c) determining what information consumers want
projects coordinator—manages the coalition. to know about their physicians; and (d) studies of
employer adoption of value-based benefit strate-
gies and the correlation of benefit incentives to
Products and Services
changes in employee behavior.
The MBGH provides three types of services to its In 2003, the MBGH’s initiative on the cost of
member employers: (1) learning network pro- overuse, underuse, and misuse of healthcare gained
grams, (2) health benefit purchasing groups, and national attention with its estimate that about
(3) health benefits and quality initiatives. These 30% of all direct healthcare outlays are the result
services help member employers connect and learn of poor quality of care. In 2007, the MBGH,
from each other as well as obtain various products working with two pharmacist associations, initi-
and services. ated Taking Control of Your Health, a diabetes
The coalition’s learning network programs management demonstration project. The project
include the following: (a) monthly learning network uses specially trained pharmacists to conduct indi-
meetings; (b) an annual conference; (c) employer, vidual meetings with employees to help educate,
health, roundtable discussions; (d) health system motivate, and empower them to better manage
user groups; (e) benchmark survey services; and their diabetes. In 2008, the coalition received a
(f) monthly, Medicare, employer forum telephone grant from the National Business Group on Health
calls. The employer, health, roundtable discussions (NBGH) to expand the program.
address pharmacy benefits, consumer-directed
health plans (CDHPs) and consumerism, union ben- Amy L. Sulkin
efits, and wellness and health management issues.
See also Cost Containment Strategies; Cost of Healthcare;
To help its member employers obtain competi-
Employee Health Benefits; Health Insurance; Health
tive rates, superior services, performance evalua- Insurance Coverage; Leapfrog Group; National
tions, and performance guarantees, the MBGH has Business Group on Health (NBGH); Pacific Business
established an affiliate, the Midwest Health Group on Health (PBGH)
Purchasers Foundation (MHPF), which provides
various health benefit purchasing groups. The
foundation helps coalition member employers
Further Readings
(a) enroll their workers in several Chicago health
maintenance organizations (HMOs), (b) obtain Butterfoss, Frances Dunn. Coalitions and Partnerships in
pharmacy services (e.g., retail, mail, and specialty Community Health. San Francisco: Jossey-Bass, 2007.
drugs), (c) obtain health promotion and risk man- Camillus, Joseph A., and Meredith B. Rosenthal.
agement services, (d) obtain disease management “Health Care Coalitions: From Joint Purchasing to
services (e.g., acute-care counseling, and high-cost Local Health Reform,” Inquiry 45(2): 142–52,
case management), (e) obtain audit services to Summer 2008.
examine the performance of third-party adminis- Midwest Business Group on Health. Reducing the Costs
of Poor-Quality Health Care Through Responsible
trators (TPAs) and health plans, (f) manage
Purchasing Leadership. Chicago: Midwest Business
Medicare Part D services, and (g) implement and
Group on Health, 2003.
manage incentive programs and products.
Midwest Business Group on Health. Employers’
The MBGH undertakes a large number of
Readiness to Adopt Value-Based Benefit Strategies.
health benefit and quality initiatives. Specifically, Chicago: Midwest Business Group on Health, 2008.
the coalition develops and supports various initia-
tives that test healthcare measurement tools and
improve community health. Some of its recent ini-
tiatives include (a) an employee self-report tool Web Sites
that analyzes the impact of chronic disease on pro- Midwest Business Group on Health (MBGH):
ductivity; (b) measuring the costs of overuse, http://www.mbgh.org
underuse, and misuse of healthcare and the role National Business Coalition on Health (NBCH):
of purchasers in addressing these problems; http://www.nbch.org
770 Milbank Memorial Fund
The fund addressed controversial issues of

Milbank Memorial Fund health policy between 1926 and 1935. In 1926, for
example, it helped organize the consortium of
For most of its history, the Milbank Memorial foundations to finance a Committee on the Costs
Fund has collaborated with decision makers in the of Medical Care (CCMC). Research reports by the
public and private sectors to use the best available committee’s staff are landmarks in the history of
evidence and experience in making policy for health services research. In 1932, however, most of
healthcare and population health. Its founders, the physician members of the CCMC refused to
Elizabeth Milbank Anderson—who provided the sign its final report because it recommended the
endowment in increments between 1905 and prepayment of healthcare and the reorganization
1921—and Albert G. Milbank—who led the of physicians into large group practices dominated
board from 1905 until his death in 1949— by specialists.
dedicated the fund to devising effective policy to Kingsbury and his staff at the fund advocated
improve the well-being of people, especially those including these recommendations, as well as fund-
with low incomes. ing to expand access to health services, in the
Social Security Act of 1935. The fund seconded
two employees to the staff of the cabinet-level
History
committee that drafted what became the Social
The fund’s history can be divided into five seg- Security Act. This advocacy increased antagonism
ments: (1) 1905 to 1920, (2) 1921 to 1936, (3) toward the fund among critics of the CCMC
1937 to 1961, (4) 1961 to 1989, and (5) 1990 to report in organized medicine. Several medical soci-
the present. From 1905 until Elizabeth Milbank eties recommended that physicians advise mothers
Anderson’s death in 1920, the Memorial Fund to boycott Borden’s condensed milk—an ingredi-
Association, as it was then called, worked with ent in infant formula—because stock in that com-
officials of government and charitable agencies pany accounted for a substantial percentage of the
that served the poor in New York City. Notable fund’s assets. In 1935, the board of the fund fired
projects included constructing public baths on Kingsbury but reaffirmed its commitment to
models devised by health officials in Europe; increased access to health services.
increasing children’s access to health and related During the next quarter century, the fund main-
services; and demonstrating the feasibility of a tained this commitment but through projects and
“home hospital,” residences, and health services publications that avoided controversy. Its chief
for families, one or more members of which had executive from 1937 to 1961, Frank Boudreau,
tuberculosis. was a public health physician who had joined the
Between 1921 and 1936, the fund and its allies new social medicine movement as an official of the
in government and medicine addressed major League of Nations. He led the fund in conducting
issues in improving access to appropriate health- and commissioning policy-related research on
care and related services. Its first chief executive, nutrition, fertility and birth control, and mental
John A. Kingsbury, a veteran manager in city gov- health. The fund convened annual conferences
ernment and charitable organizations, organized addressed and attended by researchers and policy-
multiyear demonstrations of new methods of inte- makers. In the 1950s, fund staff helped inform
grating services provided by the government and policy on substituting community for institutional
charities in New York City, Syracuse, and rural care of the mentally ill and facilitated the establish-
Cattaraugus County, New York. The fund ment of the Population Council.
appointed a technical board of prominent health The fund chose not to prioritize activities related
experts to advise and evaluate these projects. This to policy between 1961 and 1989. Alexander
board produced a periodic bulletin evaluating the Robertson, chief executive from 1961 to 1967,
work of the demonstrations and commissioned a managed a fellowship program in social medicine
book about each of them. The bulletin, published for young academic physicians from North and
continuously since 1923, is now the Milbank South America. His successor from 1967 to 1977,
Quarterly. Leroy Burney, accorded priority to the reform of
Minimum Data Set (MDS) for Nursing Home Resident Assessment 771
higher education for public health. The next chief care. The fund continues to publish the Milbank
executive, Robert H. Ebert—1978 to 1984 and Quarterly and occasional reports and copublishes a
1988 to 1989—organized a fellowship program in book series with the University of California Press.
clinical epidemiology; several of its alumni became
leaders in the field subsequently called evidence- Daniel M. Fox
based health research and practice. Sidney Lee, See also Committee on the Costs of Medical Care
1984 to 1988, mounted projects to improve the (CCMC); Health Insurance; Health Services Research
health of migrant and seasonal workers and their Journals; Public Health; Public Policy
families.
In the 1960s, the Milbank Quarterly became,
and has remained, a highly regarded, international Further Readings
journal of research on health services and policy Ameringer, Carl F. The Health Care Revolution: From
and on population health. The fund was desig- Medical Monopoly to Market Competition. Berkeley:
nated an operating foundation under 1967 amend- Milbank Memorial Fund/University of California
ments to the Internal Revenue Code on the basis of Press, 2008.
the Quarterly and miscellaneous reports. Cassel, Christine K. Medicare Matters: What Geriatric
Since 1990, however, the fund has used its regu- Medicine Can Teach American Health Care. Berkeley:
latory status as an operating foundation to col- Milbank Memorial Fund/University of California
laborate with many decision makers in the public Press, 2007.
and private sectors to bring the best available evi- Daly, Jeanne. Evidence-Based Medicine and the Search
dence to bear on policy and practice. A new chair- for a Science of Clinical Care. Berkeley: Milbank
man, Samuel L. (Tony) Milbank (1990 to present), Memorial Fund/University of California Press, 2005.
and two presidents, Daniel M. Fox (1990–2007) Fairchild, Amy L., Ronald Bayer, and James Colgrove.
and Carmen Hooker (2007 to present), led this Searching Eyes: Privacy, the State, and Disease
restoration of what had been the fund’s mission Surveillance in America. Berkeley: Milbank Memorial
during its first half century. Fund/University of California Press, 2007.
Fox, Daniel M. “The Significance of the Milbank
Memorial Fund for Policy: An Assessment at Its
Future Implications Centennial,” Milbank Quarterly 84(1): 1–23, 2006.
The fund currently prioritizes responsiveness to its
constituents, who are mainly decision makers but
Web Site
also include researchers who are able to inform
policy in the United States and other countries. Milbank Memorial Fund: http://www.milbank.org
The fund’s largest program since the early 1990s
has been its partnership with the Reforming States
Group (RSG). The RSG is a voluntary association
of senior officials of the legislative and executive Minimum Data Set (MDS)
branches of government from each of the states, for Nursing Home
from most Canadian provinces, and recently,
from Australia, England, and Scotland. Its mem- Resident Assessment
bers assist one another to acquire and assess evi-
dence and experience that could improve policy The provision of appropriate care in nursing
for healthcare and population health. facilities requires comprehensive knowledge of
In addition to its work with the RSG, the fund residents’ strengths, weaknesses, and problems.
and its constituents have recently addressed issues As one feature of the Omnibus Budget
that include (a) public health law reform, (b) the Reconciliation Act of 1987 (OBRA 87), the U.S.
adequacy of the income available to retirees over Congress sought to ensure the availability of such
the next generation, (c) the importance of global information by mandating a national resident
health issues for American foreign and security assessment system, including a uniform set of
policy, and (d) improving long-term and palliative items and definitions for assessing all residents in
772 Minimum Data Set (MDS) for Nursing Home Resident Assessment
nursing facilities in the United States. The need for personal-care area, as well as basic demographic
uniform resident assessment in long-term care had factors. Other domains covered in the MDS
been long recognized. A 1986 study by the include (a) decision making; (b) behavioral prob-
national Institute of Medicine (IOM) focused on lems; (c) symptoms, diagnoses, and conditions;
how to improve nursing home regulation and (d) social interaction and regulations; (e) skin
identified uniform resident assessment as a corner- care needs; and (f) services received. Newest of
stone of any effort to improve quality. Indeed, this all were data elements about the residents’ life-
recommendation, along with a host of others in long behavioral styles and preferences, as well as
the Institute’s report, formed the basis for many of documentation of the existence and type of an
the nursing home reform provisions in OBRA 87, advance directive.
requiring each certified nursing facility to conduct
a comprehensive, accurate, standardized, repro-
Field Testing
ducible assessment of each resident’s functional
capacities. As with all research instruments, extensive field
In 1988, the Health Care Financing Admini testing and reliability testing were undertaken.
stration (HCFA) (now the Centers for Medicare Numerous sets of independent reliability trials
and Medicaid Services [CMS]) contracted with were undertaken during the development pro-
the Research Triangle Institute, the Hebrew cesses. The results of these reliability studies
Rehabilitation Center for the Aged, Brown clearly demonstrated that when MDS data are
University, and the University of Michigan to gathered in a research context, it is possible to
develop and evaluate a uniform resident assessment obtain reliability levels that make the data useful
system. The resident assessment instrument that for research purposes. The MDS items met tradi-
emerged was designed as a minimum data set tional standards of good reliability in key areas of
(MDS) of items, definitions, and response catego- functional status such as cognition, activities of
ries aimed at providing a comprehensive assess- daily living (ADL) performance, continence, and
ment. In addition, the resident assessment protocols disease diagnoses.
(RAPs), which are part of the resident assessment Development of reliable data on the functional
instrument (RAI), provide guidelines for more in- status of nursing home residents is a task that
depth assessment of 18 conditions that affect the largely defies traditional approaches to measure-
functional well-being of nursing home residents ment. Nursing home residents are a special popu-
(e.g., falls, urinary incontinence, cognition difficul- lation and present special measurement challenges.
ties, and use of restraints). Most nursing home residents have some level of
cognitive impairment and exhibit behavior changes.
The abilities and status of many nursing home
Development of the Instrument
residents with physical or cognitive impairments
In developing the RAI, more than 60 prior vary throughout the day and over time. Still others
assessment instruments that had been developed have communication difficulties that impede tradi-
for screening, admission, and research purposes tional research interview interactions. These char-
were reviewed for comprehensiveness and to acteristics seriously limit the effectiveness of simple
identify common domains, items, definitions, “point in time” estimates of a resident’s status, no
responses, and scoring patterns. These were used matter how well standardized, and argue against
to develop multiple instrument drafts, all of relying on a single informant, which is the usual
which underwent extensive review by literally approach with research instruments. For these rea-
hundreds of experts representing all the profes- sons, the assessment approach incorporated in the
sions that work with nursing home residents. MDS relies on the input of multiple individuals
The resulting instrument contains more than who interact with the resident throughout the
300 data elements, many of which measure the course of the day or night.
traditional domains of functioning, personal- As part of an evaluation of the national imple-
care activities, and the amount of “hands-on” mentation of the MDS, the quality-of-health status
and supervision time associated with each and the resident assessment information in the
Minimum Data Set (MDS) for Nursing Home Resident Assessment 773
residents’ charts before and after the implementa- Computerized Data

tion of the MDS was addressed. Research nurses
To facilitate ongoing quality monitoring and case-
extracted data from a sample of more than 2,000
mix reimbursement for both Medicare and state
nursing home residents in more than 250 ran-
Medicaid programs, the Centers for Medicare and
domly selected facilities in 1990 and again in
Medicaid Services (CMS) mandated the comput-
1993. The analyses revealed that, in 1990, accu-
erization of all MDS data in 1998. Since then, all
rate information was available in 68% of the items
MDS assessments are computerized and transmit-
in the patients’ records, whereas in 1993, that
ted to a national repository maintained by CMS.
average had climbed to 84%. Although accuracy
These data are used (a) by state regulators charged
levels from records sampled from participating
with inspecting nursing homes to ensure compli-
nursing homes varied considerably in the 10 states
ance with the Medicare and Medicaid conditions
studied, in all cases there was an improvement in
of participation, (b) by Medicare and some state
data accuracy associated with the introduction of
Medicaid programs to differentially pay facilities
the MDS.
as a function of the acuity of their residents, and
The most recent reliability study of the MDS
(c) to create quality measures that are publicly
compared the assessments performed by facility
reported on national Web sites to assist individu-
nurses—on between 25 and 30 residents from
als and their families in selecting a nursing home.
more than 250 facilities located in 10 states—with
Furthermore, nursing facility management—as a
those undertaken by research nurses uniformly
stimulus to guide and initiate internal quality
trained by a team of researchers. Of the more than
improvement efforts—increasingly uses MDS data
100 items evaluated, almost all revealed high levels
on residents’ acuity, pattern of services use, and
of reliability, although there was substantial inter-
quality.
facility variation that suggests that some facilities
departed from the standard approach. These find-
ings are consistent with studies finding substantial
Use for Policy, Regulatory,
disagreement between selected MDS items in resi-
and Quality Improvement
dents’ charts and research data collected about the
same residents. The MDS is being extensively used for policy,
regulatory, and quality improvement purposes.
The new measure of resident case-mix, which is
Clinical Scales
being used to reimburse facilities differentially
The utility of the MDS for clinical and research (Resource Utilization Groups–III), is based on
applications has been further enhanced by the the MDS. State regulators inspecting nursing
development of concise and clinically meaningful homes also use the MDS in residents’ charts to
scales summarizing the functioning of individual determine whether the residents assessed as
residents. For example, the Cognitive Performance potentially having selected care needs are getting
Scale, which replicates the mini-mental-status the relevant services. Finally, drawing on the con-
exam at an accuracy of nearly 90%, has been cepts of statistical quality improvement, quality
developed from items in the MDS. Similarly, an indicators are being developed as benchmarks
ADL scale that captures the hierarchy of ADL against which nursing homes can compare their
performance has been formulated and a new mea- quality of performance.
sure of “social engagement” developed, which is The impact of the nationally mandated MDS for
one of the first efforts to quantify a qualitative U.S. nursing home resident assessment has been
aspect of the personal and social interactions of an profound. The MDS has also been adopted in
individual in a nursing home. Other summary other nations. As of 2008, the MDS has been
measures of items in the MDS include measures of translated into 20 languages (e.g., French, Spanish,
mood, behavioral disruption, medical instability, Italian, Swedish, German, Chinese, Japanese, and
and more refined aspects of cognitive and execu- Korean). Canada and Iceland have adopted a
tive functioning, including qualitative features of version of the MDS as the basis for reforming
dementia. their own nursing home programs and to institute
774 Minimum Data Set (MDS) for Nursing Home Resident Assessment
case-mix reimbursement and quality management positive impact on the quality of care for nursing
programs. Finland, Germany, Italy, and Switzerland home residents.
have instituted experiments in large geographic
areas. An international organization, the InterRAI, Vincent Mor
has been formed with the express purpose of shar- See also Activities of Daily Living (ADL); Centers for
ing experiences in implementing the MDS as (a) a Medicare and Medicaid Services (CMS); Long-Term
clinical-care-planning tool, (b) an administrative Care; Nursing Home Quality; Nursing Homes;
information system for management decisions, and Quality of Healthcare; Skilled-Nursing Facilities;
(c) a basis for policy analysis of a nation’s health- Vulnerable Populations
care system.
Further Readings
Future Changes
Arling, Greg, Robert L. Kane, Christine Mueller, et al.
The original, national Institute of Medicine (IOM) “Explaining Direct Care Resource Use of Nursing
recommendations suggested that the MDS not be Home Residents: Findings From Time Studies in Four
static. In keeping with that suggestion, CMS com- States,” Health Services Research 42(2): 827–46,
missioned an early redesign of the initial instru- April 2007.
ment, and this was implemented in 1996. Nearly Committee on Nursing Home Regulation, Institute of
a decade later, CMS has announced that it will be Medicine. Improving the Quality of Care in Nursing
introducing a major redesign of the MDS (Version Homes. Washington, DC: National Academy Press,
3.0) in 2009. This new instrument has the benefit 1986.
of many years of additional research on the utility Dellefield, Mary Ellen. “Implementation of the Resident
of various measures of quality, functional perfor- Assessment Instrument/Minimum Data Set in the
mance, and clinical-care needs. It also has bene- Nursing Home as Organization: Implications for
fited from considerable additional research Quality Improvement in RN Clinical Assessment,”
focused on capturing the “voice” of the residents’ Geriatric Nursing 28(6): 377–86, November–
December 2007.
experiences and quality of life. Changes from the
Lee, Feng-Ping, Carol Leppa, and Karen Schepp. “Using
earlier versions include a focus on directly inter-
the Minimum Data Set to Determine Predictors of
viewing the residents and an emphasis on their
Terminal Restlessness Among Nursing Home
quality of life in addition to their quality of care.
Residents,” Journal of Nursing Research 14(4):
This means that facility staff will first attempt to 286–96, December 2006.
directly ask residents questions about their expe- Mor, Vincent. “A Comprehensive Clinical Assessment
rience in the home, with all the associated Tool to Inform Policy and Practice: Applications of
problems of response acquiescence, residents’ the Minimum Data Set,” Medical Care 42(4): III50–
unwillingness to complain, and cognitive impair- III59, April 2004.
ment difficulties. Whereas earlier versions of the Mor, Vincent, Katherine Berg, Joseph Angelelli, et al.
MDS appeared to underestimate the prevalence of “The Quality of Quality Measurement in U.S.
psychosocial problems, it is likely that new diffi- Nursing Homes,” Special issue 2, Gerontologist 43
culties will arise with the revised version. 37–46, April, 2003.
Nonetheless, in keeping with the spirit of the Zimmerman, David R. “Improving Nursing Home
original recommendation, resident assessment Quality of Care Through Outcome Data: The MDS
instruments must be dynamic, reflecting the Quality Indicators,” International Journal of
changing context of nursing home care and the Geriatric Psychiatry 18(3): 205–257, March 2003.
case-mix of the patients served.
In many ways, the introduction of the MDS has
catapulted the nursing home industry into the Web Sites
information age. It is possible, given the implemen- Centers for Medicare and Medicaid Services (CMS),
tation of the MDS, that the goals of the IOM rec- Nursing Home Quality Initiatives: http://www.cms.hhs.
ommendations may be reached and that ongoing gov/NursingHomeQualityInits/20_NHQIMDS20.asp
comprehensive assessment may actually have a InterRAI: http://www.interrai.org
Moral Hazard 775
taken by the agent, which is not observable by the

Moral Hazard principal. Adverse selection, on the other hand, is
known as a “hidden type” or “hidden informa-
Moral hazard arises in implicit and contractual tion” problem where the principal cannot observe
relationships in which one party behaves differ- the characteristics of the agent before entering into
ently because of the relationship, and these actions an implicit or explicit contract, and the agent
improve one party’s utility but have a negative makes decisions about the relationship that benefit
consequence for the other party. In healthcare, him or her but are costly to the principal.
moral hazard is most commonly associated with
insurance, where the purchase of health insurance
induces an increase in the likelihood of a loss cov-
Health Insurance
ered by the insurance policy, the size of the loss, Moral hazard in health insurance can occur in
or both the likelihood and size of the loss. two basic ways. Ex ante moral hazard occurs
when an insured individual takes less preventive
care than he or she would take if the individual
Asymmetric Information
did not have insurance, and these preventive-care
Moral hazard arises because of asymmetric infor- efforts would reduce the likelihood or size of a
mation between the two parties. When one party, loss covered by the insurance policy. The second
the agent, has more information than another type of moral hazard occurs ex post, when an
party, the principal, in a relationship, the agent individual demands more healthcare services when
can take actions that are not observable to the covered by an insurance policy than he or she
principal and that benefit the agent but are costly would demand if the individual paid the full cost
to the principal. If the information and actions of healthcare. The evidence that ex post moral
were perfectly observable to both parties, the hazard exists in health insurance is quite strong.
agent would be unlikely to take these actions. For Although there has been less evidence in support
example, an individual without auto insurance of ex ante moral hazard, it is gaining attention in
may take many precautions to prevent his or her the health insurance market.
car from being stolen: He or she may only park Ex ante moral hazard includes the actions taken
the car in security-monitored parking lots, install by an insured individual prior to contracting an
a security system, and make certain that no valu- illness or disease that increase the probability of
ables are left in plain sight in the car. If this indi- contracting the illness or increase the cost of medi-
vidual purchases an auto insurance policy that cal care covered by health insurance once the ill-
fully insures against theft, the individual may not ness is contracted. Examples of ex ante moral
take any of these precautions—he or she may park hazard include a lack of preventive care, for exam-
in high crime areas, not use a car security system, ple, an unhealthy diet, sedentary lifestyle, and
and leave valuables in plain sight in the car— other health behaviors that increase the likelihood
because the individual knows that the insurance of obesity and chronic health conditions such as
company will reimburse him or her if the car is heart disease and diabetes. Through healthy-life-
stolen. As the insurance company cannot monitor style behaviors such as a healthy diet and physical
how the individual safeguards the car against exercise, an individual can reduce the risk of these
theft, these actions benefit the individual; it takes chronic conditions. The theory of ex ante moral
less time and effort not to use these safeguards, hazard suggests that individuals who have insur-
but by not taking these actions, he or she increases ance will invest in fewer healthy-lifestyle behaviors
the chance that the car will be broken into or sto- than those without health insurance because they
len. In economic terms, this increases both the do not bear the full cost of their unhealthy-lifestyle
likelihood of a loss occurring and the size of the behaviors when covered by insurance.
loss, if a loss occurs. Ex post moral hazard takes place after a loss
Although both moral hazard and adverse selec- occurs—in healthcare, this means after an indi-
tion arise because of asymmetric information vidual becomes ill. Without health insurance cov-
between parties, moral hazard is a “hidden action” erage, an individual will purchase healthcare
776 Moral Hazard
services up to the point where the marginal cost of services or more expensive services than necessary.
these services is equal to the marginal private ben- A shift to capitation removes the financial incen-
efit obtained from these services. Health insurance tive to provide more than necessary care. Instead,
coverage reduces the marginal cost of these ser- the provider is incentivized to provide efficient
vices that is paid by the consumer. Therefore, with services to treat an illness, aligning the provider’s
health insurance coverage, the consumer still pur- incentives with the health insurer rather than the
chases services up to the point where his or her enrollee, thereby reducing the extent of ex post
private marginal cost of these services equals his moral hazard.
or her marginal private benefit. However, in that Solutions to mitigate ex ante moral hazard need
the consumer’s marginal private cost is reduced, to incentivize enrollees to obtain preventive care
the quantity of services consumed is higher. As the by reducing the financial and nonfinancial costs of
generosity of a health insurance policy increases, taking preventive actions or by increasing the mar-
ex post moral hazard also increases, because the ginal costs of failing to take preventive actions.
consumer bears a smaller proportion of the cost of Health insurers may fully cover the costs of immu-
care. In the most extreme case where an insurance nizations, for example, to encourage enrollees to
policy fully covers the cost of medical care and the obtain them.
consumer has no out-of-pocket costs, the con-
sumer uses medical care up to the point where he
or she obtains almost no marginal benefit from Future Implications
these services, even though the full cost of care is The U.S. federal government and private health
still paid by the insurer. insurers alike have been promoting consumer-di-
rected health plans (CDHPs)—high-deductible
Solutions health plans with health savings accounts—as a
mechanism to control increasing healthcare costs.
Health insurers use a combination of mechanisms CDHPs directly target ex post moral hazard.
targeted at the demand for care (i.e., mechanisms These plans shift a greater proportion of the risk
that are targeted at consumers or enrollees) and to the consumer and, by increasing the consumer’s
the supply of care (i.e., mechanisms targeted at cost, require him or her to share the burden.
healthcare providers) to mitigate ex post moral CDHPs give the consumer an incentive to search
hazard. Demand-side mechanisms shift some of for and obtain the most efficient healthcare ser-
the risk originally borne by the insurer to the vices. For CDHPs to be successful, however, both
enrollee through deductibles and coinsurance. prices and information on the quality of care must
Shifting risk to the enrollee increases the mar- be transparent and publicly available so that con-
ginal cost of care consumed by the enrollee. sumers can compare across both treatments and
Although increasing enrollee cost sharing miti- healthcare providers to identify the most efficient
gates moral hazard, the trade-off is a reduction in method and provider of care. Although the nation’s
risk spreading, which is an inherent purpose of healthcare industry is improving the dissemina-
health insurance. tion of information on the quality of healthcare
Supply-side mechanisms are strategies that tar- through Web sites such as Hospital Compare,
get providers, including financial incentives such information is not yet easily available to all con-
as reimbursement strategies and nonfinancial sumers. For example, not all consumers have
incentives such as the use of gatekeeper primary access to or know how to use the Internet.
care physicians, second opinions, prior authoriza- Furthermore, solutions to mitigate moral hazard
tion, and review of usage. The use of capitated must be balanced with trade-offs that increase the
per-member-per-month compensation rather than risk borne by the individual consumer. The nation’s
per-unit fee-for-service reimbursement is one solu- healthcare industry is still searching for the opti-
tion that has been used to reduce moral hazard. mal combination of risk spreading and moral
Fee-for-service reimbursement aligns the financial hazard.
incentives of the healthcare providers with the
enrollees, incentivizing the delivery of more Tricia J. Johnson
Morbidity 777
See also Adverse Selection; Capitation; Consumer- determine the resources needed and consumed for
Directed Health Plans (CDHPs); Healthcare Markets; treatment.
Health Economics; Health Insurance; Payment
Mechanisms; RAND Health Insurance Experiment
Overview
Morbidity or illness greatly affects an individual’s
Further Readings as well as a population’s quality of life. When try-
Arrow, Kenneth J. “Uncertainty and the Welfare ing to define or measure the factors that cause
Economics of Medical Care,” American Economic some individuals to be unhealthy, it is important
Review 53(5): 941–73, December 1963. to also understand the concept of health. The
Manning, Willard G., and M. Susan Marquis. “Health determinants of health have been acknowledged
Insurance: The Tradeoff Between Risk Pooling and by the World Health Organization (WHO) to
Moral Hazard,” Journal of Health Economics, 15(5): include (a) the social and economic environment,
609–639, March 1996. (b) the physical environment, and (c) the person’s
Newhouse, Joseph P. “Reconsidering the Moral Hazard- individual characteristics and behaviors. As the
Risk Avoidance Tradeoff,” Journal of Health leading causes of illness and death have shifted
Economics 25(5): 1005–1014, September 2006. from infectious diseases to chronic diseases, there
Pauly, Mark V. “The Economics of Moral Hazard: has been much work to better understand the
Comment,” American Economic Review 58(3 pt. 1): social determinants of health and the causes of
531–37, June 1968. morbidity. Some commonly used indicators of a
Zweifel, Peter, and Willard G. Manning. “Moral Hazard
population’s health include the presence of child
and Consumer Incentives in Health Care,” in A. J.
abuse, poverty, youth suicide, alcohol-related traf-
Culyer and J. P. Newhouse, eds. Handbook of Health
fic fatalities, teenage drug use, depression; social
Economics, Vol. 1A. Amsterdam: Elsevier, North-
networks and social capital.
Holland, 2000.
Measures of Morbidity
Web Sites
Since the mid-1800s, conditions affecting health
Hospital Compare: http://www.hospitalcompare.hhs.gov status began to be measured in a routine and sys-
RAND Health Insurance Experiment: tematized manner in the United States. As a result,
http://www.rand.org/health/projects/hie incidence and prevalence rates have been used to
measure the presence and rate of illnesses or con-
ditions that interfere with a population’s well-be-
ing. The incidence rate is also known as the
Morbidity cumulative incidence or the number of new cases
of a disease or condition, and the prevalence rate
The term morbidity comes from the Latin word refers to the number of existing cases of a disease
morbidus, meaning a condition of being unhealthy or condition in a population.
or having a disease or an illness. Today, morbidity The incidence rate can be calculated and used
refers to an illness, disease, or disability. It also whenever a condition (physical or mental health
includes the burden caused by a health condition related) has a defined diagnosis. Incidence rates
or the state of poor health. Morbidity is often can also provide a measure of the risk of acquiring
measured using the incidence or prevalence rates a particular condition. An example of the inci-
of a disease in a population. Public health and dence rate of diabetes in a city of 141,000 residents
health services researchers study the incidence with 535 new cases of diabetes in 2008 would
rates of diseases to determine trends. For example, require the following calculation: 535/141,000 =
the incidence rate will show whether a specific 0.00379 or 3.8 per 1,000 population. Given that
disease is increasing or decreasing in a population. the incidence rate of diabetes was 0.4%, if an indi-
In contrast, the prevalence rate will show the vidual was a member of that population he or she
overall burden of a disease, which may be used to had a 0.4% chance of getting diabetes. It should be
778 Morbidity
cautioned that extrapolating population data to of years of life lost prematurely and the disability of
individuals can be misleading because individual a population. As a result, mortality and morbidity
risk factors and behaviors vary widely. are combined into a single measurement.
The second common measure of morbidity is QALY is another method of measuring the bur-
prevalence. For example, if a researcher was inter- den of disease by taking into account not only the
ested in the prevalence of breast cancer among quantity of years lived but also the quality of life.
women in a given city with 141,000 residents and Each year of perfect health is rated as 1.0 and
there were 5,076 cases of breast cancer during death is rated as 0. QALYs are often used in cost-
2008, the prevalence rate would be calculated as utility analyses to measure the effectiveness of
follows: 5,076/141,000 = 0.036 or 36 per 1,000 specific medical interventions. Regarding the use
population. Because prevalence also measures the of QALYs, there have been several debates as to
total number of existing cases of a condition in a whether some years should actually be rated with
population, it can be used to determine the burden negative numbers, because some conditions might
of that disease on society. In other words, knowing be viewed as worse than death. Furthermore, it is
that 36 residents per 1,000 population, or 5,076 difficult to define what is “perfect health.”
residents currently have breast cancer can give
some guidance as to the demand for healthcare
The Compression of Morbidity
services as well as the public health programs that
should be provided. Due to the increasing recognition of the growing
By examining the incidence and prevalence burden of disease, there is now a greater emphasis
rates, the trends and patterns in the distribution of on the compression of morbidity, that is, reducing
diseases can be studied. From this information, the number of years that individuals are affected
decisions can be made in terms of resource distri- by chronic diseases. The goal of the compression
bution and planning efforts for prevention and of morbidity is to keep populations disease free
treatment. for as long as possible. The objective of the com-
In addition to the morbidity associated with pression of morbidity is to decrease the number of
specific conditions, it is important to be aware that years that an individual suffers from disease at the
in many populations, especially the elderly, there same time maximizing his or her life span. It has
will be multiple morbidities (comorbidities) pres- been suggested that aging-related morbidity can
ent at the same time. Thus, comorbidities must be reduced through healthier lifestyles.
also be taken into account to understand the full
burden of disease.
The Global Burden of Disease
In one of the most comprehensive research proj-
Measures of Disease Burden
ects ever undertaken to look at the global burden
Measures of morbidity, which generally include of disease, the WHO identified the most impor-
quality of life or years of life lost due to an increase tant risk factors that are the causes of disability,
in morbidity, are difficult to quantify. However, disease, and death in the world today. Globally,
several measures of morbidity have been devel- the top 10 risks are (1) being underweight;
oped that combine the concepts of the number of (2) having unsafe sex; (3) having high blood pres-
years lived with the quality of those years. The sure; (4) using tobacco; (5) consuming alcohol;
two most commonly used measures are the dis- (6) having unsafe water, sanitation, and hygiene;
ability-adjusted life year (DALY) and the quality- (7) having iron deficiency; (8) having indoor
adjusted life year (QALY). smoke from solid fuels; (9) having high choles-
The DALY was developed by the Global Burden terol; and (10) being obese.
of Disease study by the WHO as a means of estimat- In developing countries, such as those in sub-
ing the burden of disease in various parts of the Saharan Africa, being underweight is the major
world. This study not only looked at life expectancy cause of disease burden; this condition also affects
tables but also factored in the burden of injuries, hundreds of millions of the poorest people through-
risk factors, and diseases. DALYs combine the effect out the world. On the other hand, in developed
Mortality 779
countries the leading risks of disease are tobacco Segui-Gomez, Maria, and Ellen J. MacKenzie.
use, alcohol consumption, high blood pressure, “Measuring the Public Health Impact of Injuries,”
high cholesterol, and obesity. A disturbing finding Epidemiologic Reviews 25(1): 3–19, 2003.
from this report was the conclusion that the world
is living more dangerously than ever before. In
Web Sites
regard to health, this is because the poor have few
choices in their lives, and those not limited by pov- Centers for Disease Control and Prevention (CDC):
erty who do have choices make the wrong choices http://www.cdc.gov
concerning their health behaviors and activities. National Center for Health Statistics (NCHS):
Future Implications
Measuring and understanding the determinants of
morbidity are key to ensuring the health and vital- Mortality
ity of a population. As the leading causes of mor-
bidity and mortality in developed countries shift Mortality is simply defined as death, and it is the
from infectious to chronic diseases, appropriate end result of life. A mortality rate is the propor-
health planning must be undertaken. Additionally, tion of deaths in a given place over a specified
in developing countries, the urgent need to stem period of time. The numerator includes the num-
the rise in infectious diseases is paramount to ber of persons who died in a given geographic
decrease the burden of morbidity and improve the area over a period of time, and the denominator is
quality of life. the total population in the same geographic area.
James C. Hagen The mortality rate is generally reported as a pro-
portion of deaths per 1,000, 10,000, or 100,000
See also Acute and Chronic Diseases; Centers for Disease individuals. In health services research, mortality
Control and Prevention (CDC); Disease; Emerging rates are often used as general indicators of the
Diseases; Epidemiology; Infectious Diseases; Mortality; health and well-being of groups and populations.
Quality-Adjusted Life Years (QALYs)
Overview
Further Readings Mortality rates are based on death data that come
from vital statistics registries. Vital statistics
Fries, James F. “Frailty, Heart Disease, and Stroke: The include all the prominent life events: births, mar-
Compression of Morbidity Paradigm,” American riages, divorces, and deaths. The registration of all
Journal of Preventive Medicine 29(5 Suppl. 1):
these life events is required in the United States,
164–68, December 2005.
and state health departments compile vital statis-
Gordis, Leon. Epidemiology. 4th ed. Philadelphia:
tics summaries on deaths. The primary source of
Saunders-Elsevier, in press.
death information in the United States is the stan-
Lopez, Alan D., Colin D. Mathers, Majid Ezzali, et al.,
dardized death certificate, which is kept by indi-
eds. Global Burden of Disease and Risk Factors.
Washington, DC: World Bank and Oxford University
vidual state health departments and is completed
Press, 2006. by physicians or coroners at the local level. The
Michaud, Catherine M., Christopher J. L. Murray, and major components of the death certificate include
Barry R. Bloom. “Burden of Disease: Implications for personal identifiers, demographic information,
Future Research,” Journal of the American Medical and the manner and cause of death.
Association 285(5): 535–39, February 7, 2001.
Mokdad, Ali H., James S. Marks, Donna F. Stroup, et al.
Mortality Rates and Ratios
“Actual Causes of Death in the United States, 2000,”
Journal of the American Medical Association 291(10): There are many types of mortality rates and
1238–45, March 10, 2004. ratios, for example, the crude mortality rate,
780 Mortality
age-standardized mortality rate, disease-specific The Case Fatality Rate

mortality rate, and infant mortality rate. Each
The case fatality rate is a measure of how severe
type of mortality rate and ratio has its specific
a disease is and is usually reported as a percentage.
uses and limitations. The following are the most
The case fatality rate is calculated by taking the
common types of mortality rates.
number of deaths from a specific cause after the
onset of the disease (i.e., after diagnosis) during a
The Crude Mortality Rate specified period of time divided by the number of
cases of the disease, multiplied by 100. This “rate”
A crude mortality rate represents a rough esti-
illustrates the percentage of individuals who die
mate of mortality and is seldom used because it
from a specified disease within a certain time after
does not take into account the variations in a
diagnosis.
group’s or population’s age composition. The
crude mortality rate is calculated by taking the
total number of deaths during a 1-year period The Proportional Mortality Ratio (PMR)
divided by the total population midyear for a
specified geographic area. The rate is usually pre- The PMR is a measure of the proportion of
sented as deaths per 100,000 individuals. Crude deaths from a specific disease compared with all
mortality rates can sometimes be misleading. For deaths. The PMR is calculated by taking the total
example, a developed country may have a higher number of deaths from a certain disease over a
crude mortality rate than a developing country specified period of time divided by the total num-
because of the increased number of elderly who ber of deaths from all causes in the identical period
may die in a given year. Therefore, mortality rates of time. The PMR does not measure the risk of
generally should be standardized to reflect this dif- dying from a specific disease: The proportions
ference in population characteristics. change as a result of increases or decreases in the
mortality rates of other diseases.
The Age-Standardized Mortality Rate

The Maternal Mortality Rate
An age-standardized mortality rate is deter-
mined by taking the number of deaths in a specific The maternal mortality rate is calculated by
age cohort occurring during 1 year divided by the dividing the number of deaths from childbearing
midyear population of the specific age cohort. The causes during 1 year over the total number of live
derived rate is usually presented in terms of deaths births during the identical year. This proportion is
per 1,000 or 100,000 individuals. Age-specific usually reported as deaths per 100,000. The
rates are refinements on the crude mortality rates. maternal mortality rate measures the number of
Note that, in putting a limitation on age, the same mothers who die giving birth.
restriction must be applied to both the numerator
and denominator, so that every individual in the The Infant Mortality Rate
denominator group will be at risk for entering the
numerator group. The infant mortality rate is an overall measure
of infant deaths. The numerator for this death rate
is the number of children under the age of 1 who
The Disease-Specific Mortality Rate die over a 1-year period, and the denominator is
The disease-specific mortality rate is specified the total number of live births during the same
for a certain disease, such as tuberculosis or HIV/ year. The result is typically multiplied by 1,000 to
AIDS. The numerator in this rate is the number of calculate a rate of infant deaths.
deaths from a specific cause or disease and the
denominator is the total population at midyear.
The Perinatal Mortality Rate
Again, these rates are usually expressed in terms of
annual mortality figures from a specific cause per The perinatal mortality rate measures the num-
1,000 or 100,000 individuals. ber of infant deaths occurring around the period of
Mortality 781
birth. The perinatal mortality rate is calculated by entire population, the YPLLs for all individuals are
taking the number of fetal deaths and the number added together for a specific cause of death. YPLLs
of infants under 1 week of age who die during a can be used to compare the causes of premature
period of a year divided by the total number of live deaths.
births plus the total number of fetal deaths in the
same year. This rate is typically expressed as
deaths per 1,000. Sources of Mortality Data
There are several sources of mortality data that
are available to health services researchers.
The Neonatal Mortality Rate
Information from death certificates is aggregated
The neonatal mortality rate is calculated by in comprehensive mortality databases and is
dividing the total number of children under 28 reported by various federal agencies. Data may
days old who die during a particular year by the also be collected by agencies at the time of death
number of live births during the same year. This for the purposes of issuing survivor benefits.
rate is usually multiplied by a factor of 1,000. Researchers may need this information on mortal-
ity and the cause of death to calculate a variety of
mortality rates, to assess survival rates for a dis-
The Fetal Mortality Rate
ease of interest, or to verify deaths in a multisite
The fetal mortality rate is calculated by dividing clinical trial.
the number of fetal (unborn infant) deaths during
a particular year by the total number of live births
plus fetal deaths during the identical year. This The Morbidity and Mortality
rate is usually multiplied by a factor of 1,000. Weekly Report (MMWR)
The MMWR is published weekly by the U.S.
Centers for Disease Control and Prevention (CDC).
The Standardized Mortality Ratio (SMR)
This publication originated from the National
The SMR is used to examine the differences in Quarantine Act, passed by the U.S. Congress in
death rates between what is observed and what is 1878, requiring American Consuls to file reports
expected. It is calculated by dividing the number of on conditions abroad and on vessels bound for
individuals who die per year by the number of U.S. ports. From these reports, the surgeon general
individuals expected to die during the same year of the U.S. Public Health Service (PHS) prepared
multiplied by 100. An SMR of less than 100 indi- weekly abstracts for transmission to PHS officers,
cates that the observed deaths are less than what is collectors of customs, and state and local health
expected, a value of 100 shows that the number of authorities. The format, content, and sponsoring
expected deaths is equal to the number of observed government agencies have changed over the years
deaths, and an SMR of more than 100 demon- until, in 1961, the CDC published its first issue of
strates that observed deaths are greater than what MMWR. The MMWR is the only regular weekly
is expected. periodical published in the United States that doc-
uments morbidity from all 50 states and 5 territo-
ries and mortality from 121 cities that represent
The Years of Potential Life Lost (YPLL)
one third of the nation’s population.
The YPLL is a mortality index that has been
used increasingly in recent years. It indicates the
The National Death Index (NDI)
number of “years lost” as a result of an early
death. It is calculated by first subtracting an indi- The NDI was created in 1981 by the National
vidual’s age at death from a standard age of life Center for Health Statistics (NCHS) in response to
expectancy (generally, 65 years old). The smaller a growing need for a national source of mortality
the subtrahend, the larger is the number of years of data. The NDI is compiled from death certificate
potential life lost. This calculation yields the YPLL data received from all 50 state health departments.
for one individual. To calculate YPLL for the It is particularly useful to verify large numbers of
782 Mortality
deaths. The NDI is considered to be the gold stan- (b) estimates on causes of deaths and the global
dard of death databases; however, it is available burden of disease, and (c) statistics on life expec-
only to researchers in medical and health sciences tancy. Mortality rates can be compared and con-
research for statistical purposes. There is a cost trasted across nations as much of the WHO data
associated with the NDI data and suitable projects collected are universally standardized. For example,
must be approved by NCHS, which necessitates the cause of death information is reported for all
additional time as the review and approval of proj- countries using International Classification of
ects may take several months. Diseases (ICD) codes.
The Death Master File (DMF) Future Implications

The DMF is compiled and maintained by the Mortality data play an important role in health
U.S. Social Security Administration (SSA) and is services research studies because it provides a gen-
only one of several mortality databases available eral indication of a population’s health as well as
to the public: For small studies, where the verifi- the trends and patterns in the leading causes of
cation of only a few deaths is necessary, Web death. As the demographics of populations shift,
searches may be quickly and easily completed at mortality data will continue to be used to examine
no cost. SSA data depend on an individual having the demand and need for specific healthcare ser-
a Social Security number, and the death must vices. Mortality rates are also used as one measure
have been reported to the SSA. The DMF con- of the quality of care provided by healthcare insti-
tains only basic information on each decedent. tutions and systems.
However, once the verification of death has been
confirmed, researchers can then procure the death Joseph D. Kubal
certificates from the appropriate state agencies. See also Centers for Disease Control and Prevention
The cause of death information also can be (CDC); Disease; Epidemiology; Health; Morbidity;
acquired from the SSA. Mortality, Major Causes in the United States; Public
Health; Quality of Healthcare; World Health
Organization (WHO)
The Beneficiary Identification and
Records Locator Subsystem (BIRLS)
The BIRLS is a death database maintained by Further Readings
the U.S. Department of Veterans Affairs (VA). Black, William C., David A. Haggstrom, and H. Gilbert
This database was created in the 1970s as an Welch. “All-Cause Mortality in Randomized Trials of
update to a manual system designed to collect Cancer Screening,” Journal of the National Cancer
information for veterans’ benefit programs. The Institute 94(3): 167–73, February 2002.
majority of BIRLS records are of veterans whose Gordis, Leon. Epidemiology. 4th ed. Philadelphia:
survivors applied for death benefits. The inclusion Saunders-Elsevier, 2008.
of a veteran’s death record depends on the submis- Manton, K. G., Igor Akushevich, and Julia Kravchenko.
sion of a copy of the individual’s death certificate Cancer Mortality and Morbidity Patterns in the U.S.
to the VA. This database has two major limita- Population: An Interdisciplinary Approach. New
tions: First, it only contains data on U.S. veterans, York: Springer, 2009.
and second, it is only available to VA researchers. Mathers, Colin D., and Dejan Loncar. Updated
Projections of Global Mortality and Burden of
Disease, 2002–2030: Data Sources, Methods, and
The World Health Organization Results. Geneva, Switzerland: World Health
Organization, 2005.
(WHO) Mortality Statistics
Zupan, Jelka, and Elisabeth Ahman. Neonatal and
The WHO statistics include mortality informa- Perinatal Mortality: Country, Regional, and Global
tion from WHO member states around the globe. Estimates. Geneva, Switzerland: World Health
WHO collects and distributes data on (a) mortality, Organization, 2006.
Mortality, Major Causes in the United States 783
Web Sites disease (CIHD). Death rates decreased steadily

Centers for Disease Control and Prevention (CDC): from 1968 to 1981, but the decrease has begun to
http://www.cdc.gov slow. An increasing number of people survive their
National Center for Health Statistics (NCHS): first heart attack.
http://www.cdc.gov/nchs The mortality declines have been attributed to
Social Security Administration (SSA): http://www.ssa.gov prevention efforts as well as to improvements in
World Health Organization (WHO): http://www.who.int medical care. There have been substantial decreases
in the prevalence of some of the major cardiovas-
cular risk factors such as smoking, elevated total
cholesterol, and high blood pressure. Advances in
Mortality, Major Causes medicine have led to a revolution in the treatments
for established heart disease, with major break-
in the United States throughs in evidence-based medical and surgical
techniques, including the use of coronary artery
For decades, heart disease, cancer, and stroke bypass grafting, coronary angioplasty, and stents.
have been the top three leading causes of death in Despite overall declining trends, heart disease mor-
the United States. Deaths from heart disease, can- tality is still a disparate burden on minority popu-
cer, and stroke together account for almost 60% lations.
of all deaths in the nation. The prevalence of these
three major diseases has important implications
for the delivery, organization, and exploitation of Risk Factors
healthcare services. It also guides public health Extensive research has identified both the major
policy and programmatic efforts at the national, and contributing risk factors associated with an
state, and local levels. Mortality trends, risk fac- increased risk of developing CHD, but their exact
tors, and the prevention of each disease are dis- significance and prevalence have not been precisely
cussed below. determined. Some of these risk factors are modifi-
able, whereas others are not. The risk of develop-
ing CHD is directly proportional to a person’s
Heart Disease
number of risk factors as well as to the level of
Heart disease is the leading cause of mortality in each risk factor.
the United States with about 700,000 deaths Major nonmodifiable CHD risk factors include
occurring annually, accounting for approximately age, male gender, and heredity, including race. The
29% of all deaths in the nation. Heart disease, also children of parents with heart disease are more
known as cardiovascular disease, encompasses a likely to develop the disease. African Americans,
number of abnormal conditions, including coro- who tend to have more severe high blood pressure
nary heart disease (CHD) and hypertension (high than Whites, have a higher risk of heart disease.
blood pressure), that affect the heart and its blood The risk of heart disease is also higher among
vessels. CHD is the most common type; it leads to Mexican Americans, American Indians, native
hardening and narrowing of the arteries, making it Hawaiians, and some Asian Americans than among
harder for blood to reach the heart. It can lead to Whites. Major modifiable risk factors include
angina (chest pain or discomfort), myocardial smoking, high blood cholesterol, high blood pres-
infarction (heart attack), congestive heart failure, sure, physical inactivity, obesity and being over-
or arrhythmia (abnormal heart beat). weight, and having diabetes mellitus. Additional
factors contributing to CHD risk include stress
and excessive alcohol intake.
Mortality Trends
Mortality rates for CHD rose in the United
Prevention
States during the period from 1949 to 1967 and
have been declining since, particularly for acute Taking steps to prevent and control the known
myocardial infarction and chronic ischemic heart risk factors can reduce the occurrence of CHD.
784 Mortality, Major Causes in the United States
Additionally, knowing the signs and symptoms of deaths occurred in 2003, when there were 369
a heart attack, calling for emergency medical ser- fewer cancer-related deaths than in 2002. From
vices, and immediately going to a hospital are 2003 to 2004, the number of recorded cancer
crucial to positive outcomes. People who have had deaths decreased by 1,160 in men and by 1,854 in
a heart attack can also work to reduce their risk of women. Compared with the peak rates in 1990 for
future attacks. men and 1991 for women, the cancer death rate in
Despite our greater understanding of the risk 2003 was 16.3% lower for men and 8.5% lower
factors of CHD, the prevalence of both obesity and for women.
diabetes in the U.S. population has increased over Among men, most of the increase in cancer
the past 25 years, with approximately 34% of death rates prior to 1990 was attributable to lung
adults aged 20 and over being obese. The rising cancer. Since 1990, the age-adjusted lung cancer
prevalence of obesity and diabetes may reverse the death rate in men has been decreasing. Death rates
decline in CHD-related deaths. Aggressive public from prostate and colorectal cancers have also
health programs to control these risk factors are decreased. Among women, lung cancer is currently
urgently needed. the most common cause of cancer death, with the
death rate more than twice what it was 25 years
ago. Breast cancer death rates were constant from
Cancer 1930 to 1990 but have since decreased by about
24%. The death rates for stomach and uterine
Cancer is the second leading cause of mortality in
cancers have decreased steadily since 1930; col-
the United States with about 500,000 deaths
orectal cancer death rates have been decreasing for
occurring annually, accounting for approximately
more than 50 years.
23% of all deaths. Cancers, also called malignant
Overall, cancer incidence rates are higher in
neoplasms, include a large group of diseases in
men than in women. Among men, African
which abnormal cells divide without control and
Americans have the highest incidence followed by
can invade healthy body tissues. Cancer cells can
Whites, Hispanics, Asian Americans/Pacific
spread to other parts of the body through the
Islanders, and American Indians/Alaskan Natives.
blood and lymph systems. There are more than
Racial differences in cancer incidence among
100 different types of cancer. Lung cancer is the
women are less pronounced; White women have
most common cause of cancer-related deaths in
the highest incidence rates followed by African
the United States for both men and women, result-
Americans, Hispanics, American Indians/Alaskan
ing in approximately 157,000 deaths each year.
Natives, and Asian Americans/Pacific Islanders.
Among men, prostate cancer mortality is second,
Overall, cancer death rates are higher for men
followed by colon and rectum cancer. In women,
than for women in every racial and ethnic group.
lung cancer, breast cancer, and colon and rectum
African American men and women have the high-
cancer are the leading types of fatal cancers.
est rates of cancer mortality. Death rates for
Among women, breast cancer is the most common
myeloma and cancers of the prostate, larynx,
cancer and the second most common cause of
stomach, oral cavity, esophagus, liver, small intes-
cancer death, with approximately 40,000 deaths
tine, colon and rectum, lung and bronchus, and
per year.
pancreas are all higher in African American men
than in White men. Death rates for African
American women are also higher than for White
Mortality Trends
women for myeloma and cancers of the stomach,
Whereas the rates for other major chronic dis- cervix, esophagus, larynx, uterus, small intestine,
eases have decreased substantially since 1950, pancreas, colon and rectum, liver, breast, urinary
cancer-related death rates showed a steady increase bladder, gallbladder, and oral cavity. Although
until the 1990s. The death rate from all cancers cancer death rates are higher in African American
combined has decreased by 1.6% per year since men and women than for their White counter-
1993 for men and 0.8% per year since 1992 for parts, the cancer death rate is declining faster for
women. The first decline in the number of cancer African Americans than for Whites.
Mortality, Major Causes in the United States 785
Risk Factors ischemic attack (TIA) is defined clinically by the

A number of cancer risk factors have been iden- temporary nature of the associated neurological
tified, including increasing age, family history of symptoms, which last less than 24 hours by the
cancer, environmental factors, and lifestyle factors. classic definition. Recognition of a TIA is crucial
As with heart disease, some of the risk factors are because it is an important predictor of future isch-
modifiable and others are not. Perhaps the most emic events.
recognized and preventable cancer risk factor is Regardless of the cause, an interrupted blood
tobacco use. Research clearly indicates that tobacco supply to the brain results in cell damage and neu-
use is a major cause of cancer-related deaths. It has rological injury. Consequently, functions con-
been estimated that cigarette smoking accounts for trolled by the affected area of the brain, such as
85% of all lung cancers in smokers. Another risk speech, movement, and memory, may be lost. The
factor is postmenopausal obesity, which is associ- outcome depends on the location and extent of
ated with breast cancer due to the conversion of the brain area damaged. A small stroke may result
adipose tissue to estrogen. A lack of vitamins B in only minor problems such as weakness of an
and D may also be a risk factor for breast, pros- arm or leg. Larger strokes may result in paralysis
tate, and colon cancers. on one side of the body or loss of the ability to
speak. Some people suffer transient loss of func-
tion and recover completely from strokes. More
Prevention than two thirds of survivors, however, experience
some type of residual disability as well as emo-
To lower the risk of developing cancer, the
tional problems.
American Cancer Society recommends (a) avoid-
Strokes can occur at any age. However, the risk
ing tobacco products, (b) consuming a diet rich in
of having a stroke more than doubles for each
fruits and vegetables and low in saturated fats, and
decade a person lives beyond the age of 55.
(c) exercising moderately and maintaining a healthy
Nearly 75% of all strokes occur in people over
weight. Specifically, the society recommends eating
the age of 65. Stroke death rates are higher for
five or more serving of fruits and vegetables a day,
African Americans than for Whites, even at
which may protect against cancers of the mouth
younger ages.
and pharynx, esophagus, lung, stomach, and colon
and rectum. It recommends that adults engage in
at least moderate physical activity for 30 minutes Mortality Trends
or more on 5 or more days a week.
Overall, stroke mortality declined steadily from
1950 through the mid-1970s, then increased.
During 1979 to 1989, stroke mortality declined
Stroke
one third more rapidly than the other 10 leading
Stroke is the third leading cause of mortality in the causes of death. Recent data, however, suggest that
United States; about 160,000 stroke deaths occur there is a slowing of the decline in stroke
annually, accounting for approximately 7% of all mortality rates. For the period 1968 to 2005, the
deaths. Stroke, sometimes referred to by the older decrease in stroke mortality rates appears to be
term cerebrovascular accident (CVA), occurs due due to improving survival rates rather than from a
to interrupted blood flow to an area of the brain. decline in the incidence of stroke.
This may be caused by an arterial blockage or rup- The constant morbidity rates combined with
ture. Hence, stroke is classified into two major constant rates of high blood pressure highlight the
types: ischemic (blockage) or hemorrhagic (rup- need for improved prevention to reduce the num-
ture). Ischemic stroke can occur due to thrombosis, ber of strokes. For several decades, the southeast-
embolism, or systemic hypoperfusion. Hemorrhagic ern United States has had the highest stroke
stroke can result from intracerebral hemorrhage mortality rate in the nation and has been described
or subarachnoid hemorrhage. Approximately as the “stroke belt.” It is not clear what factor or
80% of strokes are due to ischemic cerebral infarc- factors contribute to the higher incidence and mor-
tion and 20% to brain hemorrhage. A transient tality from stroke in this region.
786 Mortality, Major Causes in the United States
Risk Factors Intersecting Risk and Prevention Pathways

Some of the risk factors for stroke are non- Although heart disease, cancer, and stroke are
modifiable, such as age, gender, and race. The risk separate diseases, they have many overlapping
of stroke increases with age. Males are more sus- risk factors and prevention pathways. Obesity,
ceptible overall to having a stroke, but women physical inactivity, and tobacco use as well as high
aged 35 to 44 are also susceptible—possibly due to blood cholesterol, high blood pressure, and diabe-
pregnancy and oral contraceptive use—as are tes are risk factors for heart disease, some cancers,
women over age 85. One’s family history, environ- and stroke. For example, cigarette smokers are
ment, and lifestyle also influence the risk of having more likely to develop heart disease than are non-
a stroke. smokers, smokers have a much higher incidence of
Modifiable risk factors for stroke include high lung cancer than nonsmokers, and smoking
blood pressure, smoking, diabetes, asymptomatic approximately doubles a person’s risk for stroke.
carotid stenosis, atrial fibrillation, and hyperlipi- Responding to public health campaigns, millions
demia. Blood pressure, especially systolic blood of Americans have changed their eating habits,
pressure, increases with age. Isolated high systolic reducing saturated fat in their diets and lowering
blood pressure (more than 160 mmHg) is an their serum cholesterol levels. Fewer adults are
important risk factor for stroke in the elderly. smoking cigarettes. More people with hypertension
Smoking causes reduced blood vessel distensibility are being treated to control their high blood pres-
leading to increased arterial wall stiffness. Smoking sure. And millions of people exercise during their
is also associated with increased fibrinogen levels, leisure time. These changes in lifestyle have signifi-
increased platelet aggregation, decreased high- cantly contributed to the decline in heart disease,
density lipoprotein (HDL) cholesterol levels, and cancer, and stroke deaths. At the same time, how-
increased hematocrit. Diabetes is a risk factor for ever, a large number of people continue to be physi-
atherogenesis and leads to obesity, high blood cally inactive and are overeating, gaining weight,
pressure, and hypercholesterolemia. Hyperlipidemia and becoming obese. In addition, these three dis-
also contributes to atherogenesis and, hence, eases may all occur at any age from childhood to
stroke. In older persons, congestive heart failure is adulthood. And many adolescents and teenagers are
an important risk factor for stroke. Other factors engaging in unhealthy behaviors such as smoking.
that may be risk factors for stroke include obesity, Further reducing major risk factors such as high
physical inactivity, poor nutrition, alcohol abuse, blood pressure, high blood cholesterol, tobacco
drug abuse, sickle-cell anemia, hormone replace- use, diabetes, physical inactivity, and poor nutri-
ment therapy, and oral contraceptive use. tion could eliminate much of the incidence of heart
disease and stroke as well as some cancers.
Prevention Determining effective prevention measures and
therapy is increasingly important for both under-
To prevent the occurrence of stroke, regular
standing past disease trends and planning future
adult screening for high blood pressure at least
preventive and therapeutic strategies.
every 2 years is recommended for appropriate
management, evaluation, and treatment. Memoona Hasnain and Grace Male
Appropriate control of high blood pressure for
patients with Type 1 or 2 diabetes significantly See also Cancer Care; Disease; Epidemiology;
reduces their incidence of stroke, whereas blood International Classification of Diseases (ICD); Life
glucose control has been proven to be less effec- Expectancy; Mortality; Preventive Care; Public Health
tive. The long-term use of anticoagulants such as
aspirin and warfarin, especially for individuals
with atrial fibrillation, has been shown to decrease Further Readings
stroke mortality. Patients with coronary disease Baker, Daryll M. Stroke Prevention in Clinical Practice.
and hyperlipidemia should be managed with sta- London: Springer, 2008.
tins to lower the risk of stroke. Last, patients who Columbus, Frank H. Trends in Cancer Prevention. New
smoke should be encouraged to stop. York: Nova Science, 2007.
Multihospital Healthcare Systems 787
Edlow, Jonathan A. Stroke. Westport, CT: Greenwood U.S. hospitals. The vast majority of the systems,
Press, 2008. 299, or 81%, were not for profit. Of the remain-
Fang, Jing, Michael H. Alderman, Nora L. Keenan, et al. ing systems, 65 were investor-owned (for-profit)
“Declining U.S. Stroke Hospitalization Since 1997: and 5 were government-owned organizations.
National Hospital Discharge Survey, 1988–2004,”
Neuroepidemiology 29(3–4), 243–49, 2007.
Heron, Minino A. “Deaths: Leading Causes for 2004,” Horizontally and Vertically
National Vital Statistics Reports 56(5): 1–95, Integrated Systems
November 20, 2007.
Multihospital healthcare systems are often differ-
Jemal, Ahmedin, Rebecca Siegel, Elizabeth Ward, et al.
entiated as being either horizontally integrated or
“Cancer Statistics, 2008,” CA: A Cancer Journal for
vertically integrated systems. The term horizon-
Clinicians 58(2): 71–96, March–April 2008.
tally integrated system refers to groups of similar
Marmot, Michael G., and Paul Elliott. Coronary Heart
Disease Epidemiology: From Aetiology to Public
organizations providing similar services (e.g., two
Health. 2d ed. New York: Oxford University Press,
or more community hospitals). The primary goal
2005. of developing a horizontally integrated system is
Pampel, Fred C., and Seth Pauley. Progress Against generally to capture the market for a particular
Heart Disease. Westport, CT: Praeger, 2004. service within a specific geographic location.
Tierney, Edward F., Edward W. Gregg, and K. M. These types of multihospital systems tend to be in
Venkat Narayan. “Leading Causes of Death in the close geographic proximity to one another.
United States,” Journal of the American Medical Vertically integrated systems attempt to link dif-
Association 295(4): 383, January 25, 2006. ferent levels of healthcare services (e.g., primary
care, acute care, and postacute care) together to
move toward providing full service delivery. Such
Web Sites multihospital systems may include the ownership
of managed-care organizations, for example, that
American Cancer Society (ACS): http://www.cancer.org
can serve as feeders to the inpatient facilities. This
American Heart Association (AHA):
type of multihospital system can be dispersed
http://www.americanheart.org
National Cancer Institute (NCI): http://www.cancer.gov
across a wide geographic area (e.g., in different
National Center for Health Statistics (NCHS):
states). Most multihospital healthcare systems in
http://www.cdc.gov/nchs the United States are vertically integrated.
National Heart, Lung, and Blood Institute (NHLBI):
http://www.nhlbi.nih.gov Reasons for System Integration
National Institute of Neurological Disorders and Stroke
(NINDS): http://www.ninds.nih.gov There are a number of reasons cited regarding
National Stroke Association: http://www.stroke.org the benefits—to an autonomous, freestanding
hospital—of joining a multihospital healthcare
system. One of the primary goals of integrating
into multihospital systems is to achieve economies
Multihospital Healthcare of scale and scope in delivering healthcare. In
theory, when hospitals integrate into a system,
Systems they can take advantage of significant cost savings
in organizational operation. These economies can
Multihospital healthcare systems are defined as be achieved in a variety of ways. First, multihospi-
two or more hospitals owned, leased, sponsored, tal systems may be able to reduce costs by receiv-
or contract managed by a central organization. ing volume discounts on the purchase of services
They are also sometimes referred to as hospital and supplies. Second, equipment and service costs
chains. In 2006, the American Hospital Association can be reduced by eliminating overlap and dupli-
(AHA) reported a total of 369 multihospital cation. Third, administration costs can be reduced
healthcare systems in the United States. These sys- by centralizing functions such as marketing, legal,
tems contained 2,755 hospitals, nearly 56% of all human resource management, and planning.
788 Multihospital Healthcare Systems
A second perceived benefit of systems integra- funded by federal tax dollars. The fiscal year 2008
tion is the spreading of financial risk. In theory, budget for the Veterans Health Administration
members of multihospital systems are better able to (VHA), which runs hospitals and other health
absorb the financial impact of a turbulent health- facilities, was in excess of $36 billion, which rep-
care environment than are freestanding hospitals. resents more than 40% of the VA’s total annual
Third, multihospital systems help hospitals pro- budget. The VHA operates 153 medical centers
vide better-coordinated patient care. In a vertically and 724 community-based outpatient centers
integrated system, for example, it may be possible across the nation and employs more than a quar-
to provide a full array of patient care services with- ter of a million people.
out having to refer the patient to an outside pro- The operation of the VA as a system is one
vider. Such a system can provide the continuum of example of successful integration. According to
care from primary care through inpatient care to Phillip Longman, VA hospitals have moved from
postacute or long-term care. being some of the worst healthcare providers in the
A fourth factor cited as being a benefit of inte- nation to some of the very best. The benefits
gration is increased administrative efficiency. By derived from running the VA with systemwide
centralizing many administrative functions, it is standards of care, safety, and quality improvement
possible to standardize many processes, including have been substantial and have occurred in a rela-
planning, marketing, human resource manage- tively short time frame.
ment, and quality improvement strategies.
Finally, all the benefits listed above can be
enhanced through the development of an inte- Future Implications
grated, systemwide information system. The abil- The general trend in the percentages of hospitals
ity to have current, accurate information on all integrated into multihospital healthcare systems—
phases of the system’s operation enhances its abil- over the 5 most recent years for which AHA data
ity to both respond and be proactive to enhance are available—indicates an increase. The percent-
success. age of hospitals in systems has risen from less than
The empirical evidence on whether such benefits 46% to nearly 55% between 2001 and 2005.
have actually been achieved is not clear. Although Although the evidence is mixed on whether
some multihospital systems report reductions in multihospital healthcare systems deliver the poten-
operational costs, in general, such claims of gains tial benefits noted earlier, it is apparent that they
seem exaggerated. The most recent data available offer some advantages. As the healthcare environ-
indicate, for example, that the average total cost ment continues to remain turbulent, autonomous
per occupied hospital bed is higher in multihospi- freestanding hospitals will feel pressure to band
tal systems than in autonomous freestanding hos- together with other institutions to ensure their
pitals. Vertically integrated systems owning survival.
managed-care organizations do seem to have lower
costs than systems without such ownership. This Ralph Bell
may indicate that a useful gatekeeper function is
See also American Hospital Association (AHA);
being performed by the systems’ health mainte-
Competition in Healthcare; Healthcare Financial
nance organizations (HMOs). Management; Healthcare Markets; Healthcare
Organization Theory; Health Economics; Hospitals;
U.S. Department of Veterans Affairs (VA)
The Veterans Administration
One of the largest vertically integrated multihospi-
tal systems in the nation is operated by the Further Readings
Veterans Administration (VA). Its mission is to Bazzoli, Gloria J., Stephen M. Shortell, and Nicole L.
provide a full array of healthcare services to U.S. Dubbs. “Rejoinder to Taxonomy of Health Networks
military veterans. The veterans healthcare system and Systems: A Reassessment,” Health Services
is headed by the undersecretary of health and is Research 41(3 pt. 1): 629–39, June 2006.
Multihospital Healthcare Systems 789
Evans, Melanie, and Vince Galloro. “Growth Amid Signs Weil, Thomas P. Health Networks: Can They Be the
of Strain: Our Annual Hospital Systems Survey Solution? Ann Arbor: University of Michigan Press,
Indicates a Strong Bottom Line Overall, but 2001.
Operating Margins Beginning to Erode,” Modern
Healthcare 37(24): 24–8, June 11, 2007.
Ford, Eric W., and Jeremy C. Short. “The Impact of
Web Sites
Health System Membership on Patient Safety
Initiatives,” Health Care Management Review 33(1): American Hospital Association (AHA): http://www.aha.org
13–20, January–March 2008. Center for Studying Health System Change (HSC):
Li, Pengxiang, James A. Bahensky, Mirou Jaana, et al. http://www.hschange.com
“Role of Multihospital System Membership in Federation of American Hospitals:
Electronic Medical Record Adoption,” Health Care http://www.americanhospitals.com
Management Review 33(2): 169–77, April–June 2008. Healthcare Financial Management Association (HFMA):
Longman, Phillip. Best Care Anywhere: Why VA Health http://www.hfma.org
Care Is Better Than Yours. Sausalito, CA: U.S. Department of Veterans Affairs (VA):
PoliPointPress, 2007. http://www.va.gov
N
Education for families is delivered through the
National Alliance for Family-to-Family program, which provides educa-
the Mentally Ill (NAMI) tion for family members of those with mental ill-
ness and a multimedia presentation, Hearts and
Founded in 1979 by family members of seriously Minds, which aims to decrease heart disease among
compromised mental health consumers in mental health consumers.
Wisconsin, the National Alliance for the Mentally Trained consumers prepare and present pro-
Ill (NAMI) is one of the nation’s largest grassroots grams for the general public to community groups
health organizations. With a national office in through an educational speakers’ bureau that dem-
Arlington, Virginia, and state-based organizations onstrates recovery and provides accurate education
in all 50 states, NAMI is well connected to com- about mental illness. The general efforts include the
munities across the country. NAMI organizations multimedia presentation In Our Own Voice. Parents
and their supporters strive not only to improve the and Teachers as Allies is a program specific to edu-
quality of life of those who suffer from mental cators that is provided by teachers who are trained
illness but also to eliminate mental illness all mental health consumers and family members.
together. Although NAMI started out with the Education for providers includes the NAMI
purpose of supporting consumers of mental health- Provider Education course, taught by consumers,
care, it now also supports family members of consumers’ family members, and mental health
those who have mental illness. NAMI supporters professionals, which offers 10 weeks of training
include a variety of community leaders, educators, for mental health providers.
healthcare providers, researchers, advocates, and
families. The organization is open to all who are Advocacy Functions
interested in membership. NAMI’s initial purpose was to protect the most
disabled mentally ill individuals who could not
advocate for themselves. Rather than focus solely
Education and Training
on the patient, NAMI encourages a partnership
Education and training opportunities through between healthcare teams, consumers, and their
NAMI are targeted to four major audiences: con- families. Today, NAMI is advised by the Consumer
sumers, families and caregivers, the general pub- Council and provides numerous avenues for con-
lic, and providers. Consumer education includes sumer support.
multimedia presentations, a NAMI support group, The NAMI on Campus initiative provides
and the Peer-to-Peer program, which offers indi- student-led support to fellow students who either
vidualized information. have mental illness or are affected by it in another
791
792 National Alliance for the Mentally Ill (NAMI)
way. Services include education for students, Initiatives

faculty, and college administrations; advocacy for
Many public awareness initiatives are spearheaded
students with mental illnesses; and promotion of
by NAMI. Mental Illness Awareness Week, held
early detection and treatment. Efforts to counter
during the 1st week of October, is intended to
the effects of stigma against mental illness are of
raise public awareness about the myths of mental
equal importance.
illness and the benefits of treatment. NAMI
NAMI’s Multicultural Action Center (MAC)
Campaign for the Mind of America is a political
was created in response to reports by the Surgeon
initiative designed to create relationships at the
General and the national Institute of Medicine
local, state, and federal levels of government.
(IOM) regarding the extreme toll that lack of
These relationships are meant to promote policies
quality treatment for mental health has taken on
that advance mental health through economic and
our country. The center seeks to secure culturally
scientific systems.
sensitive access to mental health services for all
NAMI Action Centers focus on the specific
persons and their families, especially people of
needs of unique groups such as children and ado-
color, who are disproportionately represented
lescents, multicultural populations, and clients of
among consumers who receive low-quality men-
the criminal justice system. These action centers
tal health services or none at all. Current priori-
work to develop and promote education, advo-
ties regarding policy changes for the center
cacy, and research among these particular groups.
include health disparities; culturally competent
services, including proper language fit between
providers and consumers; research, particularly Policy Research
in the area of genetics, children and adolescents
with mental illness, and depression; and the Mental healthcare policy is a priority for NAMI
overrepresentation of mental illness in correc- and is highlighted through specific areas of inter-
tional systems. In connection with the group’s est, including integration of consumers and family
Support Technical Assistance Resource (STAR) members in development of mental health services
Center, MAC produces a newsletter called in all settings, equitable access to the most current
Recovery for All. and complete mental healthcare interventions,
NAMI also conducts educational courses for and insurance coverage for mental health services.
consumers and families, including the Peer-to- The research activities and awareness initiatives
Peer course for consumers, the NAMI-CARE supported by NAMI focus on positive policy
(Consumers Advocating Recovery Through change.
Empowerment) Mutual Support Program, and the
Hearts and Minds multimedia program. It offers Publications
resources such as the NAMI Information Help
Line and online communities for discussion of NAMI produces several publications for its mem-
common interests. The Child and Adolescent bers, including the quarterly The Advocate. It also
Action Center provides discussion groups for teen provides many specialty publications that address
consumers as well as for parents and caregivers of the multifaceted needs of its members. The NAMI
children and adolescents. Child and Adolescent Action Center publishes
NAMI Beginnings. And Recovery for All is pub-
lished in connection with the STAR Center and
Internet Resources MAC.
Other services provided over the Internet include
the following: legal support and guidance for con-
Events
sumers; resources for providers; mental health
news and pertinent research updates; legislative NAMI hosts a series of annual NAMIWalks held
alerts and updates; and FaithNet, a Web site rep- at multiple sites with the purpose of raising funds
resenting the partnership between the faith com- and awareness of treatment needs of mental health
munity and NAMI. consumers; in 2007, more than 69 walks were
National Association of Health Data Organizations (NAHDO) 793
held throughout the country. Another large fund-

raiser is the annual Washington, D.C., black tie National Association of
affair, Unmasking Mental Illness Science and Health Data Organizations
Research Gala, which helps to raise money for
research efforts focused on identifying the etiology
(NAHDO)
and treatment of mental illness.
The National Association of Health Data
Organizations (NAHDO) is a national, nonprofit
Future Implications membership and educational association estab-
lished to promote the uniformity and public avail-
NAMI remains committed to improving the lives of
ability of health data to inform healthcare cost,
individuals suffering from mental illness as well as
quality, and access decisions. Based in Salt Lake
their families and communities. Through outreach,
City, Utah, the association brings together the
support, education, and research efforts, NAMI
public and private sectors of the health informa-
can help increase understanding of mental health
tion industry to improve and facilitate the collec-
and promote policy changes that affect this area.
tion and use of healthcare data for diverse
Della Derscheid audiences and applications.
See also Access to Healthcare; Community Mental

Health Centers (CMHCs); Diagnostic and Statistical Background
Manual of Mental Disorders (DSM); Medical
The Washington Business Group on Health
Sociology; Mental Health; Mental Health
(WBGH)—now the National Business Group on
Epidemiology; Substance Abuse and Mental Health
Services Administration (SAMHSA)
Health (NBGH)—and the Intergovernmental
Health Policy Project (IHPP) at George Washing
ton University established NAHDO in the spring
of 1986. Representatives from state health
Further Readings
data organizations in Arizona, Colorado, Iowa,
Cook, Linda J. “Striving to Help College Students With Maryland, New Hampshire, New Jersey, and
Mental Health Issues,” Journal of Psychosocial Tennessee met with WBGH and IHPP in
Nursing and Mental Health Services 45(4): 40–44, Washington, D.C., to launch NAHDO. Shortly
April 2007. thereafter, the new association became a private,
Drapalski, Amy, Tina Marshall, Diana Seybolt, et al. not-for-profit, national, educational membership
“Unmet Needs of Families of Adults With Mental organization.
Illness and Preferences Regarding Family Services,” In 1989, NAHDO’s board of directors broad-
Psychiatric Services 59(6): 655–62, June 2008. ened the membership qualifications to include
Mohr, Wanda K., Joan E. Lafuze, and Brian D. Mohr. organizations and individuals from both the pri-
“Opening Caregiver Minds: National Alliance for the vate for-profit and the not-for-profit sectors.
Mentally Ill’s (NAMI) Provider Education Program,” Today, the association’s membership includes
Archives of Psychiatric Nursing 14(5): 235–43, 2000.
state health data organizations, federal agencies,
“NAMI Publishes Report Cards on State Mental Health
peer review organizations, software and hardware
Systems,” Psychiatric Services 57(4): 592, April 2006.
vendors, consulting groups, universities, represen-
tatives from state and regional hospital associa-
tions, managed-care organizations, health services
Web Sites research organizations, and the media.
National Alliance on Mental Illness (NAMI): NAHDO is governed by a board of directors
http://www.nami.org representing states, healthcare organizations, cor-
National Institute of Mental Health (NIMH): porations, and payers. The organization is funded
http://www.nimh.nih.gov through membership dues, meeting revenues, and
Substance Abuse and Mental Health Services grants. NAHDO’s staff, the board of directors, and
Administration (SAMHSA): http://www.samhsa.gov its members work as a community of professionals
794 National Association of Health Data Organizations (NAHDO)
to overcome the political and technical challenges diagnosis and a standard race and ethnicity stan-
to healthcare transparency and performance report- dard for electronic hospital transactions. The
ing. Some segments of the healthcare industry still association and its standards consultant have pro-
resist independent, objective public reporting on duced the Health Data Reporting Guide for the
quality and cost. The association works with its national X12N standards for inpatient hospital
members and other allies to improve the underly- encounters to be used by state agencies.
ing data sources and promote consumers’ use of NAHDO represents state health data system
the data. interests in national forums, including the National
Quality Forum (NQF), to promote measures that
are relevant for state and public health agencies
Functions
and provides testimony and comment to federal
NAHDO monitors the data collection and release agencies and national entities, including the
policies of state and private health data organiza- National Committee on Vital and Health Statistics.
tions. Members and reporting data agencies and The association is a leader in the implementation
their national and local stakeholders use this of Web-based data query systems, and it provides
information for planning purposes. The associa- technical assistance to states implementing Web-
tion also uses this information to advocate sus- based reporting and promotes data dissemination
tainable funding for statewide health data systems policies that support interactive, dynamic Web-
and to advise states about best practices in data based data release. It also works with its mem-
collection and dissemination. The group provides bers, state data system stewards, to make
technical assistance and guidance to states to healthcare data available for public health pro-
establish statewide health data hospital inpatient grams and surveillance.
and emergency department reporting systems,
facility-based ambulatory-surgery reporting sys-
Activities and Meetings
tems, health maintenance organizations, and
health plan performance measurement systems, NADHO has convened annual meetings of its
and recently, the group began to facilitate the members for more than 20 years, and it conducts
establishment of all-payer, all-claims reporting special regional and topical workshops as well as
systems for commercial and public health plans. online conferences called webinars. These meet-
The association also provides technical assistance ings and webinars facilitate state-to-state informa-
to health data agencies to produce data products tion sharing and transfer of knowledge. The
and comparative reports, including consumer association’s technical expertise also includes dis-
quality reports and Web sites. cussion forums, Listservs, and newsletters. Like
most membership-based associations, NAHDO’s
success is directly linked to its members’ involve-
Partnerships
ment, expertise, and commitment to its mission.
NAHDO is a leader in promoting and implement-
ing national standards that support public health Denise Love
and quality reporting purposes. NAHDO’s See also Benchmarking; Data Privacy; Data Security;
National Standards Consultant is a voting mem- Data Sources in Conducting Health Services Research;
ber of the National Uniform Billing Committee Healthcare Cost and Utilization Project (HCUP);
(NUBC), which maintains hospital content stan- Health Informatics; Health Insurance Portability and
dards under the Health Insurance Portability and Accountability Act of 1996 (HIPAA); Quality of
Accountability Act of 1996 (HIPAA), and a vot- Healthcare
ing member of the American National Standards
Institute X12N and Health Level 7 (HL7), both
data standards maintenance organizations. NAHDO Further Readings
actively worked to add standard data fields to the Love, Denise, and Gulzar H. Shah. “Reflections on
core uniform billing standard (Uniform Bill 04), Organizational Issues in Developing, Implementing,
such as a “present-on-admission indicator” for each and Maintaining State Web-Based Data Query
National Association of State Medicaid Directors (NASMD) 795
Systems,” Journal of Public Health Management and Organizational Structure

Practice 12(2): 184–88, March–April 2006.
Love, Denise, Luis M. C. Paita, and William S. Custer. The structure of the NASMD includes a 12-mem-
“Data Sharing and Dissemination Strategies for ber Executive Committee. In addition to a chair,
Fostering Competition in Health Care,” Health vice chair, cochair, and immediate past chair, rep-
Services Research 36(1 pt. 2): 277–90, April 2001. resentatives from four geographic regions and the
Rudolph, Barbara A., Gulzar H. Shah, and Denise Love. U.S. territories serve on this committee. Two
“Small Numbers, Disclosure Risk, Security, and members from each region—the Midwest, West,
Reliability Issues in Web-Based Data Query,” Journal Northeast, and South—sit on the committee;
of Public Health Management and Practice 12(2): whereas the U.S. territories have a single member.
176–83, March–April 2006. This group oversees administrative matters for the
association, represents the NASMD in meetings
with the Centers for Medicare and Medicaid
Web Sites Services (CMS), offers testimony before the U.S.
National Association of Health Data Organizations Congress when appropriate, and provides overall
(NAHDO): http://nahdo.org policy guidance for the association.
National Association for Public Health Statistics and
Information Systems (NAPHSIS): Technical Advisory Groups
http://www.naphsis.org The association also has several Technical Advisory
National Committee on Vital and Health Statistics
Groups (TAGs). These work groups are a joint
(NCVHS): http://www.ncvhs.hhs.gov
effort of state programs and the CMS. They get
together to discuss issues that may arise from
Medicaid programs and operations. TAGs do not
National Association of State set policy; rather, they serve as a sounding board to
develop strategies surrounding technical or opera-
Medicaid Directors (NASMD) tional concerns. If the TAG determines that the
issue being dealt with might have significant policy
The National Association of State Medicaid implications, group members will defer to the
Directors (NASMD) is a professional and biparti- Executive Committee or the full NASMD for con-
san nonprofit organization composed of officials sideration. TAG members communicate strategies
from Medicaid programs in the 50 states, the and solutions to the states in their region, helping
District of Columbia, and the U.S. territories. It is provide the necessary information and resources.
one of the nine affiliate organizations under the The NASMD currently has 10 TAGs, which
American Public Human Services Association cover issues such as welfare reform, long-term
(APHSA). Its focus is on improving the health and care, managed care, and prescription medications.
well-being of adults, children, and families by The Eligibility Policy TAG helps state programs
advocating for effective public human service and the CMS to interpret and implement welfare
policies. The NASMD, whose members include reform laws as they affect eligibility for recipients;
state directors and their senior staff, has operated the Chronic Care TAG, formerly known as the
as a focal point for communication between state Long-Term Care TAG, handles home- and commu-
programs and the federal government since 1979. nity-based services, quality and cost-effectiveness of
It also works to provide an information network these services, and delivery-of-care methods; and
for the states on pertinent Medicaid policy and the Fraud and Abuse Control TAG serves as a
program issues. Its efforts help inform and influ- forum for all control activities, including effective
ence legislative policy, federal and state regula- methods of identifying fraud and excess and imple-
tions, health information technology, and Medicaid menting legislation to strengthen control measures.
reform. The key issues addressed by the NASMD The Managed Care TAG looks at the cost setting,
include the following: citizenship requirements, quality assurance, and state and federal issues
coordination of benefits, long-term care, and pre- that may come to light in the development and
scription drug coverage. implementation of managed-care programs.
796 National Association of State Medicaid Directors (NASMD)
Similarly, the Quality TAG offers ongoing infor- and drug therapy effectiveness. While the center
mation to state programs on the quality of services focuses on mental health services, it handles the
provided by managed-care programs. The Pharmacy dissemination of information and resources in the
TAG assists state programs with issues concerning same way as NASMD and the Center for Workers
prescription drugs, alternative medications, drug with Disabilities.
utilization, cost containment of medication cover-
age, and drug dispute authorizations; and the
Systems TAG helps CMS and state programs to Future Implications
review the quality of their systems and data collec- The NASMD and the APHSA continue to support
tion. The Payment Error Rate Measurement the changing needs of Medicaid administrators and
(PERM) TAG was initiated in 2007 to help address professionals. State regulations and federal legisla-
issues associated with this new program; the tion remain dynamic, shifting to reflect new
Medicaid and Mental Health TAG helps state pro- approaches to human services and public health
grams to address mental health benefits and to policy. In response to policy reform and new laws,
identify challenges that arise in this area; and the NASMD created new TAGs and focused on
finally, the Coordination of Benefits/Third Party specific key regulation issues. In this sense, the asso-
Liability TAG helps to develop better coordination ciation will play an ongoing and vital role in help-
and collection of third-party payments. ing state Medicaid programs and administrators, as
well as federal agencies, politicians, and the general
public, to provide needed support and resources.
Centers
The NASMD also houses the Center for Workers Kathryn Langley
with Disabilities, which helps states administer
Medicaid Infrastructure grants. Specifically, the (CMS); Health Insurance; Medicaid; Nursing Homes;
center assists states in developing Medicaid-Buy-In Public Policy; State-Based Health Insurance Initiatives;
programs for employees with disabilities, and it Vulnerable Populations
provides technical guidance and support to states
to increase the number of disabled individuals in
the workforce. Like the NASMD, the Center for Further Readings
Workers with Disabilities serves as an information
National Association of State Medicaid Directors.
exchange between state programs, offering
Medicaid Reform Initiatives and Their Relationship
resources for program development, policy analy- to Health Centers. Washington, DC: National
sis, and technical assistance. It benefits from the Association of State Medicaid Directors, 2006.
resources of NASMD, especially when partnering National Association of State Medicaid Directors. State
with federal agencies, other state organizations, Perspectives on Emerging Medicaid Long-Term Care
and policymakers. Policies and Practices. Washington, DC: National
The Medicaid and Mental Health Center is also Association of State Medicaid Directors, 2007.
affiliated with the National Association of State National Association of State Medicaid Directors. State
Medicaid Directors. This center collaborates with Perspectives: Medicaid Pharmacy Policies and
the Substance Abuse and Mental Health Services Practices. Washington, DC: National Association of
Administration (SAMHSA), the National Institute State Medical Directors, 2007.
of Mental Health (NIMH), and the National
Association of State Mental Health Program
Directors (NASMHPD) to explore the relationship Web Sites
between Medicaid benefits and mental health American Public Human Services Association (APHSA):
needs. The center also collects information and http://www.aphsa.org
resources on a broad array of services, including Centers for Medicare and Medicaid Services (CMS):
state regulation of residential facilities, mental http://www.cms.hhs.gov
health parity legislation, depression care, service National Association of State Medicaid Directors
utilization, reimbursement and cost-effectiveness, (NASMD): http://www.nasmd.org
National Business Group on Health (NBGH) 797
most of the coalition’s activities; however, it does

National Business Group receive funds from the federal government, private
on Health (NBGH) foundations, and other health-related sources.
The National Business Group on Health (NBGH) Governance, Staffing, and

is a nonprofit healthcare coalition that represents Organizational Structure
large employers’ views on national health policy
issues and provides practical solutions to its mem- The NBGH is governed by a board of directors,
bers’ healthcare concerns. Based in Washington, which consists of approximately 20 individuals
D.C., the NBGH’s members include mainly large from member companies and the president of the
companies, which provide coverage to more than coalition. NBGH’s staff consists of approximately
50 million workers, retirees, and their families 33 individuals, including a president, five vice
throughout the United States. Under the leader- presidents, and 27 managers, analysts, and other
ship of its president, the NBGH strives to attain employees. Staff members work in eight areas:
transparency, increase the use of technology (1) finance and administration; (2) membership
assessment to ensure access to beneficial new tech- and member services; (3) public policy; (4) Institute
nologies, eliminate ineffective technologies, and on the Costs and Health Effects of Obesity;
make evidence-based practices the standard of (5) Institute on Health Care Costs and Solutions; (6)
healthcare. Global Health Benefits Institute; (7) the Center for
Prevention and Health Services; and (8) the Institute
on Health, Productivity and Human Capital.
Background
The NBGH (formerly known as the Washington Activities, Services, and Products
Business Group on Health) was founded in 1974 The NBGH provides many activities, services, and
to serve as a leading voice for large employers products for its members. The coalition holds a
dedicated to finding innovative and progressive number of meetings throughout the year, includ-
solutions to the nation’s most important health- ing leadership meetings, employers’ summits, and
care issues. an annual national conference. It holds weekly
webinars and monthly conference calls. The
NBGH also conducts a number of surveys of its
Mission members and provides the results of its surveys to
The main objective of the NBGH is to provide members so that they can benchmark their perfor-
business solutions, be the national voice of large mance in various areas.
employers, link large employers with Washington, Many of the NBGH’s activities center in a number
drive national policy on healthcare and productiv- of institutes, committees, and councils. Its institutes
ity issues, and encourage hands-on membership and committees include the following: Global Health
involvement. Benefits Institute; Institute on Health Care Costs and
Solutions; Institute on the Costs and Health Effects
of Obesity; National Leadership Committee of
Consumer Directed Health Care; and National
Membership
Committee of Evidence-Based Benefit Design. The
Over 290 companies are members of NBGH. coalition’s councils include the following: Public
Many of the members are Fortune 500 companies. Policy Advisory Group; Council on Employee Health
Current members include such companies as and Productivity; and Pharmaceutical Council.
American Express, the Boeing Company, Cisco The NBGH is engaged in a number of public
Systems, DuPont Company, Ford Motor Company, policy initiatives. It provides its membership with
IBM Corporation, Marriott International, Inc., timely information and analysis on health policy
NIKE, Inc., Time Warner, Wal-Mart Stores, Inc., issues that have a direct impact on employers. The
and Xerox Corporation. Membership dues fund coalition also encourages its members to be actively
798 National Center for Assisted Living (NCAL)
involved in the political process by writing to mem- Meyerhoff, Allen S., and David A. Crozier. “Health Care
bers of the U.S. Congress and signing petitions. Coalitions: The Evolution of a Movement,” Health
Additionally, the NBGH works to assist legislators Affairs 3(1): 120–28, Spring 1984.
and policymakers to understand how certain issues National Business Group on Health. A Toolkit for
affect employer-sponsored healthcare. Action: The Imperative for Health Reform.
The NBGH publishes newsletters, policy briefs, Washington, DC: National Business Group on
and reports. Many of these publications are available Health, 2008.
on the coalition’s Web site. However, some publica-
tions are only available to member companies.
The NBGH presents several annual awards to Web Sites
its members and others, including the Award for Leapfrog Group: http://www.leapfroggroup.org
Excellence and Innovation in Value Purchasing, Midwest Business Group on Health (MBGH):
the Best Employers for Healthy Lifestyles Award, http://www.mbgh.org
and the Behavioral Health Award, to recognize National Business Coalition on Health (NBCH):
individuals, employers, and programs. http://www.nbch.org
National Business Group on Health (NBGH):
http://www.businessgrouphealth.org
Future Implications National Labor Alliance of Health Care Coalitions
The NBGH’s membership continues to grow, as (NLAHCC): http://www.nlahcc.org
large businesses are confronted with increasing
challenges in tackling complex healthcare issues.
With its membership’s pivotal involvement, the
NBGH works to improve the health of tens of mil- National Center for
lions of individuals across the nation. The NBGH
remains a leading voice in advocating for change
Assisted Living (NCAL)
in healthcare, and it will likely continue to play a
key role in shaping the future of the nation’s The National Center for Assisted Living (NCAL)
healthcare system. is the assisted living voice of the American Health
Care Association (AHCA), the nation’s largest
Jared Lane K. Maeda association representing long-term care. The diver-
sification of long-term care has brought rapid
See also Cost of Healthcare; Evidence-Based Medicine; growth to the assisted living profession, and the
Forces Changing Healthcare; Health Insurance; center is an important resource for professionals
Leapfrog Group; Midwest Business Group on Health;
in the field. Specifically, the Center serves the
Quality of Healthcare; Technology Assessment
needs of the assisted living community through
advocacy activities, education, networking, pro-
Further Readings fessional development, and quality initiatives.
Darling, Helen. “Employment-Based Health Benefits and

Public-Sector Coverage: Opportunity for Leadership,” Background
Health Affairs 25(6): 1475–86, November–December
2006. Located in Washington, D.C., the NCAL is an
Darling, Helen. “Evidence-Based Benefit Design. individual membership association. Through its
Interview by Ian Morrison,” Managed Care 16(9 national federation of state affiliates, the Center
Suppl. 9): 21–3, September 2007. supports lobbying efforts at the state level. While
Darling, Helen. “Interview With a Quality Leader: the Center primarily focuses on federal issues, it
Helen Darling on Healthcare Business Coalitions, also provides the support that state affiliates need
Purchasing, and Health Policy. Interview by to affect policy decisions regarding assisted living
Joann-Genovick-Richards and Jill Flateland.” issues.
Journal of Healthcare Quality 27(2): 26–8, 36, The Center’s state affiliates actively represent
March–April 2005. assisted living providers’ interests in state regulatory
National Center for Assisted Living (NCAL) 799
issues. In recent years, assisted living has received designed to keep state association leaders informed
increasing attention at the federal level: the U.S. of state and national news that affects long-term
Congress, the Department of Labor, the General care professionals so that they can incorporate cur-
Accountability Office (GAO), and the Department rent national trends into their decision making at
of Health and Human Services have each examined the state level. AHCA Notes is a monthly newslet-
various aspects of assisted living operations. ter that updates the Center’s members on long-
The NCAL and the AHCA have worked together term care trends as well as state and national
to offer strong federal representation and have regulatory and legislative activity. Additionally,
the largest long-term care federal relations in the Center has an e-newsletter, NCALconnections,
Washington, D.C. Both organizations are recog- which is targeted at the association’s leadership,
nized as important sources of information and state affiliates, and associate business members.
opinion by policymakers and regulators. Whether The Center also created and sponsors the National
serving on a federal agency task force or testifying Assisted Living Week. Held each September, this
before the U.S. Congress, the Center ensures that annual event is designed to raise awareness of the
its members’ voices are heard. assisted living profession and to encourage commu-
nity support. Each year, the Center develops an
original National Assisted Living Week Planning
Activities
Guide as well as a product catalog for its members.
The NCAL represents the assisted living commu- Both are designed to promote high-quality services
nity through various communications and by in assisted living residences nationwide.
working directly with the media. The general pub- The NCAL is committed to high-quality assisted
lic’s perception of assisted living affects all the living services and provides a number of tools and
staff members of assisted living organizations and educational products designed for the assisted liv-
the environment in which providers operate. ing professional. The Center actively supports
Whether delivered through news releases, direct Quality First, a covenant for healthy, affordable,
media mailings, media interviews, or responses to and ethical long-term care, and adherence to its
media queries, the Center’s research findings and principles and goals. The Center also maintains a
position statements find their way into newspa- professional staff of experts who are available to
pers, magazines, and newsletters reaching the answer member questions and who conduct origi-
public and other critical audiences. nal studies, surveys, and other timely research on
The Center publishes books, reports, and news- assisted living.
letters. One of its most widely read publications is Together, the NCAL and AHCA host an annual
A Consumer’s Guide to Assisted Living and convention and offer a number of educational
Residential Care, which is designed to help consum- seminars that are designed to keep assisted living
ers select an assisted living facility that meets their professionals apprised of the latest trends, innova-
needs. The book provides a description of services tions, theories, and legal developments that affect
and includes a checklist and cost calculator. their operations. State affiliate associations also
The Center periodically publishes guidance provide regional educational programs. The NCAL
resources for providers. For example, in 2007 it and the AHCA also collaborate to maintain the
published The Power of Ethical Marketing, compli- Mark A. Jerstad Information Resource Center,
mentary copies of which it distributed to all inter- which contains a wide collection of materials about
ested parties on request. assisted living that can be accessed by members.
The Center publishes a number of monthly The NCAL’s Web site is widely used. Its fea-
newsletters. Its Assisted Living Focus covers the tures include consumer and long-term care infor-
latest business news, trends, regulatory activity, mation, weekly electronic updates of issues and
and legislative developments concerning long-term trends, regulatory issues, previews of and order
care and assisted living. This newsletter also pro- forms for publications, other assisted living prod-
vides examples of some of the best practices in ucts, and “members only” information.
assisted living residences across the nation. The
AHCA/NCAL Gazette is a daily publication Katherine Lehman
800 National Center for Health Statistics (NCHS)
See also Access to Healthcare; American Health Care to unhealthy influences affecting designated popu-
Association (AHCA); Disability; Disease Management; lations. Data are also gathered on the onset and
Long-Term Care; Medicaid; Medicare; Vulnerable diagnosis of illness and disability. For health poli-
Populations cymakers, NCHS investigates the use and financ-
ing of healthcare and rehabilitative services. In
addition to data collection and analysis, NCHS
Further Readings disseminates its data to interested health partners,
Carlson, Eric. Critical Issues in Assisted Living: Who’s conducts studies in statistical and survey research
In, Who’s Out, and Who’s Providing the Care. methodology, and provides technical assistance in
Washington, DC: National Senior Citizens Law access to or use of existing health-related data. It
Center, 2005. also has cooperative working programs with pub-
Golant, Stephen M., and Joan Hyde, eds. The Assisted lic and private agencies and organizations at the
Living Residence: A Vision for the Future. Baltimore: state, national, and international levels.
Johns Hopkins University Press, 2008.
National Center for Assisted Living. Assisted Living
State Regulatory Review. Washington, DC: National History
Center for Assisted Living, 2008. The first NCHS surveys on the nation’s health
Pearce, Benjamin W. Senior Living Communities: were mandated through the federal National
Operations Management and Marketing for Assisted Health Survey Act (PL 84–652) enacted on July 3,
Living, Congregate, and Continuing Care Retirement 1956. The purpose of these surveys was to pro-
Communities. 2d ed. Baltimore: Johns Hopkins
vide continuing study of the nation’s health. These
surveys also provided a means for the study of
methods and techniques for obtaining statistical
health information and disseminating the findings
Web Sites
to those who could benefit from them.
American Health Care Association (AHCA): In 1960, NCHS became an established organi-
http://www.ahcancal.org zation within the U.S. Public Health Service (PHS)
National Center for Assisted Living (NCAL): through the merging of the National Health Survey
http://www.ncal.org and the National Office of Vital Statistics. The
PHS became responsible for vital statistics in 1946
as a result of the transfer of that responsibility
National Center for from the U.S. Bureau of the Census.
NCHS was established in law and its mandate
Health Statistics (NCHS) codified under Section 306 of the Public Health
Services Act through the Health Services Research
Located in Hyattsville, Maryland, the National and Evaluation and Health Statistics Act of 1974
Center for Health Statistics (NCHS) is the primary (PL 93–353). This act required NCHS to perform
health statistics agency of the federal government. a variety of functions related to health in the United
NCHS is part of the Centers for Disease Control States. NCHS was called on to collect a wide range
and Prevention (CDC). Through cooperation with of statistical information on illness and disability
states and other partners, the CDC provides nationwide. Data from birth, death, marriage, and
health surveillance to monitor and prevent out- divorce records were to be obtained annually.
breaks of disease, implement strategies to prevent NCHS also had the role of supporting research,
disease, and maintain national health statistics. demonstrations, and evaluations regarding survey
The primary mission of NCHS is to compile methods. Technical assistance was to be provided
statistical information to guide public health to state and local jurisdictions. Finally, this act
and health policymakers. Mandated by the U.S. established the National Committee on Vital and
Congress, NCHS addresses the entire spectrum of Health Statistics, which provided an expert advi-
human health from birth through death. It investi- sory committee to the Secretary of the Department
gates overall health status, lifestyles, and exposure of Health and Human Services (HHS).
National Center for Health Statistics (NCHS) 801
Authority was established in 1970 and then National Health Care Survey (NHCS) and the
formally instituted through PL 95–623 in 1978 to National Vital Statistics System. Many key surveys
create the Cooperative Health Statistics System. and data sources are detailed below.
The purpose of this program was to coordinate as
well as provide support and evaluation of the state
National Health and Nutrition
and federal health statistics systems.
Examination Survey (NHANES)
In 1989, with the establishment of the Agency
for Health Care Policy and Research by PL The NHANES is a very comprehensive assess-
101–239 for the study of healthcare effectiveness ment that aims to get a picture of the health and
and outcomes, the legislative authority of the nutritional status of the general population. Data
National Center for Health Services Research are obtained on a nationally representative sample
(NCHSR) was eliminated. This law produced a of approximately 5,000 people of all ages each
number of amendments to NCHS’s authority. year. Much focus has been placed on obtaining
As the interest in obtaining more detailed data data on African Americans, Mexican Americans,
on racial and ethnic populations grew, the federal adolescents, pregnant women, and people over
Disadvantaged Minority Health Improvement Act age 60. While some of the data are obtained
of 1990 (PL 101–527) mandated NCHS to obtain through home-based personal interviews, much of
vital statistics, conduct national surveys, and the information is collected through the use of
establish a grants program for learning more about specially designed Mobile Examination Centers
minority populations. that allow for quality control. These mobile
centers travel to 15 sites in the nation each year,
conducting physical medical examinations, stan-
Data Sources and Surveys
dardized dental examinations, physiological mea-
NCHS employs a variety of methodologies and surements, and laboratory tests on blood and
collaborations with public and private health urine. The data collected include the prevalence of
partners to obtain accurate information regard- specific conditions or chronic diseases, blood
ing the health of the population, influences on pressure, serum cholesterol, body measurements,
health, and health outcomes. Data systems and nutritional status and deficiencies, and exposure
surveys are employed, with some conducted to environmental toxins.
annually and others periodically. Systems based NHANES also studies a number of diseases,
on populations collect information through per- medical conditions, and health indicators that
sonal interviews with individuals, physicians, and affect the nation’s population. These conditions
facility administrators in healthcare organiza- include allergies, anemia, diabetes, eye disease,
tions. They also obtain information through hearing loss, kidney disease, nutrition, obesity,
examinations, such as physical and dental exami- oral health, osteoporosis, physical activity and fit-
nations, laboratory tests, and nutritional assess- ness, vision, cardiovascular disease, cognitive func-
ments. Systems based on records look at hospital tioning, environmental exposure, infectious
records, state vital registration and state death diseases, reproductive history, sexually transmitted
certificates for information. Many of NCHS’s diseases, supplements, and medications. These
surveys are conducted via telephone interviews, data are considered the most authoritative source
including the National Immunization Survey for standardized clinical, physical, and psychologi-
(NIS), the National Asthma Survey (NAS), the cal information on the nation’s population.
National Survey of Children’s Health (NSCH), Findings from the survey are used by a joint U.S.
and the Joint Canada/United States Survey of Department of Health and Human Services and
Health (JCUSH). U.S. Department of Agriculture program that
Population-based surveys include the National monitors the diet and nutritional status of
Health Interview Survey (NHIS), the National Americans to create food policies and dietary
Health and Nutrition Examination Survey guidelines. Results are published in Series 11 of the
(NHANES), and the National Survey of Family Vital and Health Statistics series and Advance
Growth (NSFG). Record-based surveys include the Data from Vital and Health Statistics.
National Health Care Survey (NHCS) Survey. In 1960, NCHS began conducting the sur-
vey following the merging of the National Health
The NHCS is a record-based survey designed to
Survey and the National Vital Statistics Division.
collect data that can be used to analyze patient
The NHIS is a population-based survey provid-
outcomes, the relationship between health and use
ing principal information on the status of health,
of health services, and the use of healthcare ser-
illness, and disability of civilian, noninstitutional-
vices at the local level. The NHCS constitutes a
ized populations in the nation. The survey is
family of surveys each of which relates to a specific
conducted annually through interviews of approxi
setting. Currently, there are four surveys that study
mately 50,000 households. Questions are based on
aspects of ambulatory- and hospital-care settings:
current health topics, which may vary from year to
the National Ambulatory Medical Care Survey
year. For example, in 1986, topics focused on
(NAMCS), which samples visits to nonfederally
health insurance, vitamin use, dental care, and
employed physician’s offices that primarily pro-
longest job worked. In 1990, the focus was on
vide service in direct patient care; the National
health promotion and disease prevention, assistive
Hospital Ambulatory Medical Care Survey
devices, podiatric services, and hearing impair-
(NHAMCS), which is conducted in a national
ments. Since 1987, questions on knowledge and
sample of hospital emergency and outpatient
attitudes about HIV/AIDS have been included each
departments in the 50 states and the District of
year. Data from the survey provide information on
Columbia; the National Hospital Discharge Survey
the incidence and prevalence of disease and the
(NHDS), which obtains a representative sample of
relationship between health and demographic and
information on inpatients discharged from short-
socioeconomic characteristics. Results of the sur-
term hospital stays in general and children’s gen-
vey are published in Series 10 of Vital and Health
eral hospitals; and the National Survey of
Statistics series and Advance Data From Vital and
Ambulatory Surgery (NSAS), which provides the
Health Statistics.
only national sample of information regarding
ambulatory-surgery visits.
Two other surveys included in this family of National Immunization Survey (NIS)
surveys are the National Home and Hospice Care
The NIS, sponsored by the National Immuni
Survey (NHHCS) and the National Nursing Home
zation Program (NIP) and conducted jointly by
Survey (NNHS), which address long-term care set-
NIP and NCHS, began in 1994. This survey moni-
tings. The NHHCS collects information about
tors childhood immunization coverage levels
licensed or certified agencies providing home and
among children in the nation. Estimates of vaccina-
hospice care as well as their current patients and
tion coverage are generated for each of 78
discharges. The NNHS provides a national sample
Immunization Action Plans (IAP) which include
of data about licensed or certified nursing homes,
the 50 states, the District of Columbia, and 27
their residents, and their staff.
large metropolitan areas; NIS also provides esti-
mates at the national level. Newly licensed vaccina-
tions recommended for use are included as well.
National Health Interview Survey (NHIS)
The survey uses a random digital dialing telephone
The NHIS is a major data collection project of method, searching for households with children
NCHS. Beginning with the National Health Survey aged 19 to 35 months currently living in the nation.
Act of 1956, continuing surveys and studies were Parents or guardians are interviewed to provide
established to gather current, accurate statistical names and dates of vaccines charted on the child’s
information on illness and disability in the United “shot card” that is kept in the home. Demographic
States. These studies and surveys were specifically and socioeconomic information is also collected.
concerned with measuring the incidence, preva- At the end of the interview, the interviewers ask
lence, and distribution and effects of disease, and permission to follow up by mail with the child’s
the medical services rendered to treat them. The vaccination providers, which may include pediatri-
first survey from this act was initiated in 1957 and cians, family physicians, and other health provid-
is now called the National Health Interview ers, for verification. Quarterly estimates of
National Center for Health Statistics (NCHS) 803
vaccination coverage are calculated, and data are Vital and Health Statistics series and Advance
used to evaluate progress toward national goals, Data From Vital and Health Statistics.
such as the Healthy People 2010 initiative. The
CDC also uses this data to identify states with the
National Vital Statistics System (NVSS)
highest and lowest rates of immunization.
The NVSS is a collaborative intergovernmental
effort to obtain official vital statistics on the regis-
Longitudinal Studies of Aging (LSOAs)
tration of births, deaths, marriages, and divorces
The LSOAs is a collaborative effort between at the state and local levels within the 50 states,
NCHS and the National Institute on Aging (NIA). two cities (Washington, D.C., and New York
Two cohorts of persons aged 70 years or older are City), and five territories (Puerto Rico, the Virgin
studied for changes in health, functional status, Islands, Guam, American Samoa, and the
living arrangements, and the use of health services Commonwealth of the Northern Marina Islands).
as they move through the older ages of life. Four These data provide public health officials with
surveys are included in this project: the 1984 important information for monitoring progress in
Supplement on Aging (SOA); the 1984–1990 achieving health goals. These data can tell public
Longitudinal Study of Aging (LSOA); the Second health officials, for example, the number and loca-
Supplement on Aging (SOA II); and the 1994–2000 tion of teen births in a given year, the risk factors
Second Longitudinal Study of Aging (LSOA II). A for problematic pregnancies, the rate of infant
recent addition is the 1994–2002 LSOA II Linked mortality, the leading causes of death, and the life
Mortality File, which includes all the participants expectancy of a population. One very significant
of the LSOA II aged 70 and older. It provides component of the NVSS is the National Death
follow-up mortality data, including fact, date, and Index (NDI). In collaboration with state offices,
cause of death, from the LSOA II participation NCHS is able to index death records that may be
from 1994–2000 through December 31, 2002. used for epidemiological studies or verifications of
death for individuals being studied. Additional
components of the NVSS include Linked Birth and
National Survey of Family Growth (NSFG)
Infant Death Data Set, the National Survey of
The NSFG, a population-based survey con- Family Growth, the Matched Multiple Birth Data
ducted through household interviews of women of Set, the National Maternal and Infant Health
childbearing age, monitors change in childbearing Survey, and the National Mortality Follow-back
practices and measures reproductive health. More Survey. Data from the NVSS are published in elec-
specifically, these data address family-planning tronic form through the Vital Statistics of the
practices and attitudes, factors influencing fertility, United States, the National Vital Statistics Reports,
fecundity impairments, sexual activity, family for- and additional reports. In addition, electronic
mation, and aspects of maternal and child health. micro-data files containing individual vital records
Cycles I and II of this survey began in 1973 and are accessible for public use.
1976, with interviews conducted with approxi-
mately 10,000 never-married women aged 15 to
Health Topics
44 years. The population sample was expanded
with Cycles III and IV in 1982–1983 and 1988, NCHS also produces data covering a wide range of
respectively, to include a representation of all specific health topics. Summary data sheets are
women aged 15 to 44 years regardless of marital made available on its Web site for important cur-
status. At this time, new topics were also intro- rent health concerns. The site provides portraits of
duced to include beginning of sexual activity, first health status for specific critical age groups, such as
use of contraceptives, first use of family planning infants and toddlers, children, adolescents, and
services, knowledge and experience of sexually older adults. Information on health conditions
transmitted diseases, and adoption. During Cycle such as cancer, injuries, obesity, and teenage preg-
IV in 1990, respondents were reinterviewed by nancy is available. Individual summary data sheets
telephone. Results are published in Series 23 of the also address current health-related issues, including
patient safety, health insurance and access to care, academic scientists. Another area of interest for
and racial and ethnic health disparities. NCHS is determining analytical methods for their
registration systems and sample surveys. Research
is also conducted on the development of auto-
Utilization of Data
mated and graphical technology. Survey design
Numerous audiences make use of NCHS data. research, where a program is developed to evalu-
The U.S. Congress and health policymakers use ate, redesign, and link many of the surveys so as
the data to track initiatives, prioritize prevention to improve efficiency and analytical capability,
and research programs, and evaluate outcomes. remains an important area of focus.
Epidemiologists, biomedical researchers, and
health services researchers look for trends in dis-
Publications and Data Access
eases, uncover the relationship between risk fac-
tors and diseases, and monitor the use of health The NCHS uses multiple means to disseminate
services. Pharmaceutical and food manufacturers, vital and health statistics and the results of its
research firms, consulting firms, and trade asso- research to as broad a range of people as possible.
ciations make use of the data for their businesses. In addition to publications, public use data files,
Public health professionals employ this informa- and unpublished tabulations, efforts are made to
tion to determine preventable illnesses and evalu- reach various specialized groups of data users,
ate intervention programs. Physicians use the data health professionals, and the general public
to evaluate health and risk factors in their patients, through journal articles, presentations, speeches,
such as cholesterol, weight, blood pressure, and conferences, workshops, and consultations.
growth chart records for children. Media and Information services available through the NCHS
advocacy groups rely on the data to help raise also provide reference and referral services, main-
awareness of major health issues such as cancer, tain mailing lists for distribution of new publica-
diabetes, heart disease, Alzheimer’s disease, and tions, coordinate requests for presentations and
health disparities. exhibits, and issue a catalog of publications and
electronic products.
Its Web site makes data on current important
International Activities
health concerns available. Published reports also are
The NCHS works collaboratively with other coun- available both in print and online. Major publica-
tries and other agencies of the PHS to conduct tion series include Health, United States, Vital and
comparative international research. Experts from Health Statistics, Advance Data From Vital and
the United States and other countries are brought Health Statistics, Vital Statistics of the United
together to focus on specific health issues of States, and Monthly Vital Statistics Report. In addi-
mutual interest. Some examples of global research tion, data files for public use are made available to
include the examination of perinatal and infant researchers for analysis. Pretabulated tables of state-
mortality, health and healthcare of the elderly, and level data are prepared on specific interest health
international comparability of health data. issues such as births and deaths. State and national
data on a range of health topics are available
through interactive data warehouses, examples of
Research and Survey Methodology
which include Health Data for All Ages and Trends
The NCHS also maintains an active program in in Health and Aging. At the Research Data Center,
statistical research and survey methods. The detailed data are available through secure access.
National Laboratory for Collaborative Research
in Cognition and Survey Measurement, a major
Future Implications
initiative started in 1985, applies cognitive meth-
ods in questionnaire survey research design. The The NCHS plays a vital role in the collection,
NCHS develops and tests its data collection interpretation, and dissemination of important
instruments in collaboration with other internal health data. Through its many surveys and studies,
programs and through research contracts with as well as its collaborative efforts with state,
National Citizens’ Coalition for Nursing Home Reform (NCCNHR) 805
regional, community, and academic entities, the organization that advocates for the rights, safety,
NCHS captures broad and in-depth information and dignity of America’s long-term care residents.
on individuals, health professionals, and health- Located in Washington, D.C., NCCNHR is a coali-
care institutions. Further advances in technology tion of approximately 200 citizen advocacy organi-
will make this data, recommendations, and research zations with members from 42 states in the United
findings even more accessible. States as well as long-term care ombudsman from
most states. These organizations and NCCNHR’s
Barbara Nail-Chiwetalu approximately 1,000 individual members work to
See also Centers for Disease Control and Prevention
improve the quality of long-term care, largely focus-
(CDC); Data Sources in Conducting Health Services ing on nursing home care and assisted living but
Research; Health Indicators, Leading; Health Surveys; recently expanding to include home and commu-
Morbidity; Mortality; Public Health; Public Policy nity-based care.
Both its mission and structure make NCCNHR
a unique organization. Most citizen advocacy
Further Readings groups in healthcare tend to focus on one disease
or on conditions affecting a single organ system
Adams, Patricia F., Jacqueline W. Lucas, and Patricia M.
(e.g., American Cancer Society), or they focus on a
Barnes. Summary Health Statistics for the U.S.
specific group of citizens (e.g., AARP), attempting
Population: National Health Interview Survey 2006.
to address the entire spectrum of their health
HHS Pub. No. 2008–1564. Hyattsville, MD:
needs. In contrast, NCCNHR advocates for indi-
National Center for Health Statistics, 2008.
Bernstein, Amy B. Health Care in America: Trends in
viduals receiving one type of healthcare—residential
Utilization. HHS Pub. No. 2004–1031. Hyattsville,
long-term care.
MD: National Center for Health Statistics, 2003. This national-level coalition of diverse citizen
Hueston, William J., Mark E. Geesey, and Vanessa Diaz. action groups had its beginning in 1975. Its
“Prenatal Care Initiation Among Pregnant Teens in the founder, Elma L. Holder, was then working with
United States: An Analysis Over 25 Years,” Journal of the National Gray Panthers’ Long-Term Care
Adolescent Health 42(3): 243–8, March 2008. Action Project. She organized a conference in
Lochner, Kimberly, Robert A. Hummer, Stephanie Washington, D.C., that included members of a
Bartee, et al. “The Public-Use National Health dozen citizen advocacy groups who came together
Interview Survey Linked Mortality Files: Methods of to speak with the nursing home industry concern-
Reidentification Risk Avoidance and Comparative ing the need for fundamental change in their
Analysis,” American Journal of Epidemiology 168(3): operations. At the conference, attendees discov-
336–44, August 1, 2008. ered that they shared a variety of common inter-
ests. These interests and goals led them to form
NCCNHR. Holder became NCCNHR’s first exec-
Web Sites utive director, a position she held for two decades,
during which she transformed the organization
http://www.cdc.gov from a small startup advocacy group to its current
National Center for Health Statistics (NCHS): status as the primary voice of nursing home resi-
http://www.cdc.gov/nchs dents in national public policy.
Throughout its years of operation, NCCNHR
has engaged in a wide variety of activities to
improve nursing home care. It has trained mem-
National Citizens’ Coalition bers of the national service program Volunteers in
for Nursing Home Reform Service to America (VISTA), operated a National
Long-Term Care Ombudsman Resource Center,
(NCCNHR) maintained an information clearinghouse on resi-
dential long-term care, issued reports on a range
The National Citizens’ Coalition for Nursing Home of topics, published books to inform consumers
Reform (NCCNHR) is a nonprofit membership and policymakers, and educated members of the
806 National Citizens’ Coalition for Nursing Home Reform (NCCNHR)
U.S. Congress and officials in executive branch policy circles. This approach to thinking about
agencies who play major roles in long-term care quality moves policymakers away from a purely
public policy. It also provides important technical punitive or regulatory approach. Instead, it places
assistance and support to its member organizations much more emphasis on collaborative quality
that work for change at the state and local levels. improvement efforts involving government, con-
One of NCCNHR’s greatest achievements was sumers, and providers. As part of this effort,
its involvement in the development, passage, and NCCNHR has embraced the culture change move-
implementation of the Nursing Home Reform ment in nursing homes, voicing its support for
Act, part of the federal Omnibus Budget such resident-centered approaches to care as the
Reconciliation Act of 1987 (OBRA-87). NCCNHR Pioneers, the Eden Alternative, the Wellspring
was the motivating core of a coalition of con- Initiative, and the Green House Movement.
sumer groups, unions, and provider associations In terms of its organizational structure,
that generated bipartisan support for the OBRA-87 NCCNHR is governed by a 20-person board,
reforms. OBRA-87 contained the seeds of a new which includes a number of nursing home resi-
model of nursing home care that included uni- dents. Board members are elected by NCCNHR’s
form resident assessment, increased attention to member groups and meet quarterly to deal with
resident rights and quality of life, and a revised set policies, financing, and strategic planning. The
of quality standards and enforcement remedies. Executive Director, approximately seven paid
OBRA-87 was a fundamental change in federal staff members, a few consultants, and volunteers
regulation, shifting the focus of regulators from conduct its Washington, D.C., operations. As
paper compliance with regulations to the actual with many groups advocating for vulnerable
care and quality of life experienced by residents. populations, maintaining adequate funding is
Furthermore, with its focus on resident-centered NCCNHR’s major organizational challenge. It
care, it laid the foundation for the current move- has an annual budget of approximately $1.2 mil-
ment for culture change in nursing homes. lion. Over 40% of NCCNHR’s current revenues
As important as its role in the development and come from a grant supporting its operation of the
passage of federal legislation was, NCCNHR also National Long Term Care Ombudsman Resource
deserves considerable credit for its dogged determi- Center. Other grants and donations provide the
nation to ensure that all elements of OBRA-87 were remainder of NCCNHR’s revenues.
implemented in their original form. While the Recently, NCCNHR changed its name. It is
nation’s nursing home industry did not use all of its now the NCCNHR: the National Consumer
considerable political power to oppose OBRA-87’s Voice for Quality Long-Term Care. This new
passage, the industry did commit itself to delaying name reflects its broadened mission. Since its
the implementation of the enforcement remedies inception in 1975 it has, with scarce resources,
and attempting to have these measures watered successfully advocated for millions of frail and
down as they were translated into rules and regula- vulnerable Americans receiving nursing home
tory procedures. During this period of conflict in the care. Its current advocacy efforts include such
mid-1990s, NCCNHR was the unifying force that public policy issues as nursing home staffing stan-
brought together citizen advocates, medical and dards, poor working conditions in nursing homes,
gerontological professionals, and policymakers to residents’ rights and empowerment, the develop-
fight against efforts to repeal segments of OBRA-87 ment of family councils for residents’ families,
or to render it toothless in its implementation. reducing physical and chemical restraint use, the
In recent years, NCCNHR has expanded its high costs of poor quality care, and the adequacy
emphasis from concerns about standards and of quality assurance in assisted living and other
enforcement to include more engagement with the forms of residential care.
nursing home industry and regulatory agencies in
their quality improvement efforts. In part, this Charles D. Phillips and Catherine Hawes
change reflects the nursing home industry’s rela- See also Long-Term Care; Medicaid; Nursing Home
tive success in riding the wave of “healthcare Quality; Nursing Homes; Public Policy; Quality of
excellence,” which is so popular in current public Healthcare; Vulnerable Populations
National Coalition on Health Care (NCHC) 807
Further Readings Overview

Burger, Sarah Greene. Nursing Home Staffing: A Guide The NCHC is headquartered in Washington, D.C.
for Residents, Families, Friends, and Caregivers. The honorary cochairs of the organization include
Washington, DC: National Citizens’ Coalition for former presidents George H. W. Bush and Jimmy
Nursing Home Reform, 2002. Carter. The present cochairs include the former
Burger, Sarah Greene, Virginia Fraser, Sarah Hunt, et al. governor of Iowa, Robert D. Ray and the former
Nursing Homes: Getting Good Care There. 2d ed. member of the U.S. Congress from Florida, Paul
Washington, DC: National Citizens’ Coalition for G. Rogers. In addition, 14 members serve on the
Nursing Home Reform, 2001.
Board of Directors; these individuals are promi-
Harrington, Charlene, Helen Carrillo, and C. LaCava.
nent in the fields of politics, academia, and health
Nursing Facilities, Staffing, Residents, and Facility
and community services and in the business sec-
Deficiencies, 1999 Through 2005. San Francisco:
tor. The NCHC also has a staff comprising the
Department of Social and Behavioral Sciences,
University of California, San Francisco, 2006.
president, executive director, senior vice president
for policy and strategy, senior vice president for
operations, and administrative staff. Additionally,
Web Sites the various members of the coalition include large
National Citizens’ Coalition for Nursing Home Reform
and small businesses; labor, consumer, religious,
(NCCNHR): http://nccnhr.org and primary-care provider groups; distinguished
National Long Term Care Ombudsman Resource Center leaders from academia, business, and government;
(ORC): http://www.itcombudsman.org and distinguished politicians.
Pioneer Network: http://www.pioneernetwork.net
Social Security Online, Omnibus Budget Reconciliation
Act of 1987 (OBRA-87), Public Law 100–203, Purpose and Principles
Subsection C: Nursing Home Reform: The NCHC seeks to focus public attention on the
http://www.ssa.gov/OP_Home/comp2/comp2toc.html current problems and inequities in America’s
healthcare system. It strives to provide people
with factual information, helping them to form
educated opinions and bring about necessary
National Coalition on change. In addition, the NCHC’s health advocacy
Health Care (NCHC) efforts are centered on three main issues: (1) the
state of the quality of healthcare in the nation, (2)
The National Coalition on Health Care (NCHC) the rising costs of healthcare, and (3) the growing
is one of the nation’s largest and most broadly number of uninsured and underinsured Americans.
representative alliances working to improve These issues have been addressed by the coali-
healthcare in America. The nonprofit and nonpar- tion’s national social marketing and education
tisan NCHC was founded in 1990 and comprises strategy campaign, which is focused on establish-
more than 70 organizations, employing or repre- ing a national policy that will ensure access to
senting about 150 million Americans. The coali- quality, appropriate, and affordable healthcare.
tion works to bring large and small employers as To accomplish the goals of improving the qual-
well as consumer, labor, and religious groups, ity of care, lowering costs, and providing health
primary-care providers, and health and pension insurance coverage to all Americans, the NCHC
funds together. The core principles of NCHC has identified five guiding principles that it feels
include the following: bringing healthcare cover- are necessary for effective policy reform.
age to all, managing healthcare costs, improving
healthcare quality and patient safety, increasing
Healthcare Coverage for All
administrative simplification, and ensuring more
equitable financing. The coalition’s slogan states The NCHC advocates for mandatory health
that the nation is capable of achieving better and coverage for all. This goal can be accomplished in
affordable healthcare for everyone. many ways, including efforts that involve the use
808 National Coalition on Health Care (NCHC)
of employer and individual mandates, Medicaid activists, the media, and the general public. The
and State Children’s Health Insurance Program coalition began its work by identifying concerns
(SCHIP) expansion, individual subsidies, and a and gaps in the public’s knowledge. As a result, it
number of related ideas as part of a multifaceted has published a series of reports designed to fur-
approach. nish basic information about the changes and
challenges in the nation’s healthcare system.
One of NCHC’s recent reports, Prevention’s
Cost Management Potential for Slowing the Growth of Medical
The NCHC supports the creation of an indepen- Spending (2007), deals with the preventive aspects
dent board, chartered and overseen by the U.S. of healthcare interventions. Using immunizations
Congress, that would be responsible for establish- as an example, the report highlights the future cost
ing and administering measures for calibrating rates savings of early prevention efforts. Previous reports
and limitations to keep costs and insurance premi- released by the coalition have focused on cost,
ums in alignment with defined annual targets. quality, and access to healthcare.
In addition to publishing reports, the NCHC
furthers its advocacy campaign through involve-
Improvement of Healthcare Quality and Safety ment in public forums, congressional hearings,
The NCHC recommends the establishment of a conferences, social events, and media appearances.
federal board to lead the development and coordi- Much of the coalition’s work is available and
nation of a national effort to improve healthcare accessible online at its Web site.
quality and set common treatment standards. In As a nonpartisan alliance, the NCHC briefs
addition, the proposed board would oversee pro- policymakers and shares its reports with politi-
tocols for patient records, prescription ordering, cians and bureaucrats in the administration. Local
billing standards, and privacy standards. representatives that are coalition members also
reach out to other organizations and opinion lead-
ers at the state level. In the past, the coalition has
Equitable Financing also conducted a national advertising campaign in
The NCHC’s members suggest that health plans popular media outlets, including The New York
should be funded from a wide variety of sources, Times, The Washington Post, USA Today, and
including general revenues, earmarked taxes and Roll Call. Coalition members also place advertise-
fees, employer contributions, individual contribu- ments in their own internal publications and in the
tions, and co-payments. The NCHC also advo- local media.
cates the use of sliding scale assistance for
lower-income citizens. Fact Sheets
The NCHC has developed fact sheets on many
Simplified Administration issues, which are broadly classified into five cate-
gories: health insurance coverage, cost, quality,
The NCHC endorses the establishment and uti-
world healthcare data, and economic sheets.
lization of a core standard healthcare benefits
Several of the coalition’s available economic fact
package to create a consistent set of ground rules
sheets point out the impact of rapidly escalating
for patients, payers, and providers. The creation of
healthcare costs and insurance premiums on
a national information technology structure for
workers and their families, business operations,
healthcare should ultimately lead to decreased
small businesses, pension programs and beneficia-
costs and medical errors.
ries, the federal budget, state governments, and
local communities. Healthcare researchers, health-
care activists, and the general public can use these
Strategies
compiled resources. For example, the fact sheet on
The NCHC uses different approaches to target World Healthcare Data provides information on
and reach healthcare interest groups, community Canada, France, Germany, the United Kingdom,
National Commission for Quality Long-Term Care (NCQLTC) 809
and Japan. These data offer a global view of dif-

ferent healthcare systems, their funding resources, National Commission for
and the costs associated with them. Quality Long-Term Care
(NCQLTC)
Future Implications
The National Commission for Quality Long-Term
The NCHC is a broad-based organization that
Care (NCQLTC) is a nonpartisan and indepen-
advocates for a multitude of changes to the
dent body charged with the responsibility for
nation’s healthcare system. It is important to note,
improving long-term care in the United States.
however, that the coalition’s members also include
The commission, which has been cochaired by
large national insurance companies and pharma-
former U.S. Senator Bob Kerrey and former
ceutical corporations. While these members might
Speaker of the House of Representatives Newt
represent a conflict of interest, the coalition con-
Gingrich, comprises appointed commissioners
tinues its media campaigns and furthers its com-
who reflect a diversity of backgrounds ranging
mitment to improving the quality of healthcare,
from academic, government, quality improve-
decreasing healthcare costs, and increasing access
ment, and long-term care settings. The commis-
to health insurance coverage.
sion was created as an outgrowth of a long-term
Vikrant Vats care industry–driven quality initiative titled
“Quality First: A Covenant for Healthy, Affordable,
See also Access to Healthcare; Cost Containment and Ethical Long-Term Care,” and it is overseen
Strategies; Cost of Healthcare; Health Insurance by The New School.
Coverage; Medical Errors; Patient Safety; Quality of In 2004, three leading long-term care organiza-
Healthcare; Uninsured Individuals tions called for an independent commission to
evaluate the quality of long-term care in the nation,
identify the factors that influence quality improve-
Further Readings ment, and recommend strategies to sustain quality
National Coalition on Health Care. Building a Better
improvement nationally. The commission was
Health Care System: Specifications for Reform. convened in October 2004 and was originally
Washington, DC: National Coalition on Health Care, housed at the National Quality Forum. The three
2004. founding organizations—the Alliance for Quality
Russell, Louis B. Prevention’s Potential for Slowing the Nursing Home Care (AQNHC), the American
Growth of Medical Spending. Washington, DC: Association of Homes and Services for the Aging
National Coalition on Health Care, 2007. (AAHSA), and the American Health Care
Schoeni, Patricia Q., ed. Care in the ICU: Teaming Up Association (AHCA)—provide funding for the
to Improve Quality. Washington, DC: National commission’s work. The commission functions
Coalition on Health Care, 2002. independently, led by its executive director Doug
Simmons, Henry E., and Mark A. Goldberg. Charting Pace, and is currently located at The New School.
the Cost of Inaction. Washington, DC: National
Coalition on Health Care, 2003.
Thorpe, Kenneth E. Impacts of Health Care Reform: Background
Projections of Costs and Savings. Washington, DC:
The growing concern over the quality of long-
National Coalition on Health Care, 2005.
term care prompted the three major long-term
care organizations listed above to pledge to a
5-year voluntary initiative entitled “Quality First:
Web Sites A Covenant for Healthy, Affordable, and Ethical
Institute for Healthcare Improvement (IHI): Long-Term Care” on July 16, 2002. This initiative
http://www.ihi.org was aimed at attaining excellence in the quality of
National Coalition on Health Care (NCHC): care and services for older persons as well as
http://www.nchc.org increasing the public trust in the delivery of care
810 National Commission for Quality Long-Term Care (NCQLTC)
and services. The reasoning behind this initiative Americans obtain credible information to compare
was that, if quality could be reliably measured and their options for long-term care?
the results made publicly available, providers Although the nation’s long-term care system
would be motivated to improve their quality, and faces significant challenges, there is much promise
the public would be able to distinguish between of finding feasible solutions. The commission has
good and poor performers. laid out a road map for long-term care reform with
At about the same time, the U.S. Department of six key areas: culture transformation, empowering
Health and Human Services (HHS) launched its individuals and families, workforce, technology,
Nursing Home Quality Initiative (NHQI) and the regulation, and finance.
Home Health Quality Initiative (HHQI). With the The commission believes that the culture of long-
growing number of initiatives focused on long-term term care can be transformed through organizational
care, there was a need for an independent body to innovations that improve an individual’s quality of
evaluate long-term care quality, identify the factors life and quality of care. Some promising initiatives
that influence improvements in quality of care, and that can facilitate this cultural transformation include
make recommendations about national efforts that resident-centered care and the provision of palliative
could result in sustained quality improvement. and hospice care. Additionally, individuals and fami-
lies can be empowered through a broader array of
high-quality, affordable, and accessible long-term
Long-Term Care Reform
care services that are available in homes and commu-
The nation’s long-term care system is currently nities. Family caregivers must also be given the tools,
straining to meet the demands of a growing older information, and support that will allow them to
population whose magnitude was never antici- continue their role in caring for those with disabilities.
pated. Some of the challenges that the system is The long-term care workforce must be supported to
confronted with include individuals who face a improve their working conditions and wages and be
loss of independence because of disability and provided with greater opportunities for advancement.
who may also be confronted with a loss of home, Technology should be used more effectively to pro-
income, and/or assets. Individuals may also face a mote higher quality of care and greater consumer
loss of their family and choice among long-term independence. Furthermore, long-term care regula-
care options. Often families have little of the tions must be accurate, timely, and consistently imple-
information or training needed to support those mented to improve quality. Last, the commission
with disabilities; direct care workers are generally believes that there should be a long-term care financ-
paid low salaries and receive little respect from the ing system that is fair and equitable and that every
medical community and general public. Provider American should have access to the services they need
organizations may be pressured to deliver high- to live independently for as long as possible.
quality care but face constraints with low reim-
bursements. In addition, regulatory agencies are
unable to enforce regulations that should serve to Future Implications
protect individuals receiving long-term care due to The long-term care system is faced with daunting
staffing shortages; and policymakers are grappling challenges in the way of meeting the needs of a
with pressures to improve long-term care while growing elderly population. On December 3,
balancing the budget. 2007, the commission issued its final report that
Given the challenges of the nation’s long-term called for a national discussion about how the
care system, the commission is committed to find- nation can create a new and better long-term care
ing solutions to the most pressing questions that system. The report features recommendations in
affect the aging population. These questions include the areas of workforce, quality, and technology. In
the following: How can long-term care be financed addition, it also discusses important steps that
consistently with policies that ensure that all must be taken in identifying crucial features of a
Americans have choices? How can long-term care long-term care financing system.
workers be retained? What are the best approaches
for improving and ensuring quality? Where can Jared Lane K. Maeda and Douglas Pace
National Committee for Quality Assurance (NCQA) 811
See also Access to Healthcare; Long-Term Care; Background

Medicaid; Medicare; Nursing Home Quality; Nursing
Homes; Quality Indicators; Quality of Healthcare Located in Washington, D.C., the National
Committee for Quality Assurance (NCQA) was
founded in 1990 as a private, nonprofit organiza-
Further Readings tion. At the time, there were few nationwide
efforts to systematically measure and improve
Bearing Point Management and Technology Consultants. quality. Since then, NCQA has been working vig-
Essential but Not Sufficient: Information Technology orously with employers, providers, health plans,
in Long-Term Care as an Enabler of Consumer
patients, and policymakers to build a consensus
Independence and Quality Improvement.
on healthcare quality. These efforts have focused
Washington, DC: National Commission for Quality
on how to best measure and improve quality.
Long-Term Care, 2007.
NCQA maintains a diverse set of programs to
Institute for the Future of Aging Services. The Long-
Term Care Workforce: Can the Crisis Be Fixed?
accomplish its mission of improving quality in
healthcare. Specifically, it offers five accreditation
Long-Term Care, 2007. programs, four certification programs, and four
Miller, Edward Alan, and Vincent Mor. Out of the physician recognition programs that apply to
Shadows: Envisioning a Brighter Future for Long- health plans, medical groups, and individual physi-
Term Care in America. Washington, DC: National cians, all of which are voluntary. NCQA relies on
Commission for Quality Long-Term Care, 2006. the system of measure, analyze, improve, and
National Commission for Quality Long-Term Care. From repeat to address healthcare quality.
Isolation to Integration: Recommendations to Improve
Quality in Long-Term Care. Washington, DC: National Quality Assessment
Commission for Quality Long-Term Care, 2007.
NCQA employs a variety of approaches to assess
Tumlinson, Anne, Scott Woods, and Avalere Health.
healthcare quality, including on- and off-site sur-
Long-Term Care in America: An Introduction.
veys, audits, satisfaction surveys, and performance
Long-Term Care, 2007.
measures. It uses these methods in its accredita-
tion, certification, recognition, and performance
programs that evaluate organizations, medical
Web Sites groups, and physicians. Through these programs,
NCQA obtains relevant information on healthcare
National Commission for Quality Long-Term Care quality that is made available to consumers,
(NCQLTC): http://qualitylongtermcarecommission.org
employers, health plans, and physicians. The infor-
mation gathered from these programs can be used
by consumers and employers to make informed
National Committee for purchasing decisions regarding their healthcare as
well as drive quality improvement efforts.
Quality Assurance (NCQA) NCQA’s seal is highly recognized as a symbol of
quality. The organizations and individuals who
The National Committee for Quality Assurance participate in NCQA’s programs earn the privilege
(NCQA) is a major driving force in improving the of using the Committee’s seal. Organizations that
quality of the nation’s healthcare system. NCQA seek NCQA accreditation must pass a rigorous and
establishes standards of quality and service that comprehensive review and complete an annual per-
health plans should provide to their members. formance survey. Health plans must meet more
Known for its Healthcare Effectiveness Data and than 60 standards and report on performance in
Information Set (HEDIS) measures, NCQA pro- more than 40 areas to be accredited with additional
vides voluntary accreditation of physicians, medi- criteria that continue to be added each year.
cal groups, and health plans. It strives to transform Although the standards and requirements per
the quality of healthcare through measurement, assessment program vary, the participating organi-
transparency, and accountability. zations and individuals must be able to demonstrate
812 National Committee for Quality Assurance (NCQA)
that quality practice, clinical, and satisfaction health plans to target their areas of improve-
thresholds are met. In 2008, NCQA started evalu- ment. To stay current, the HEDIS measurement
ating preferred provider organizations (PPOs) on set is updated annually. Employers and patients
the same standards, measures, and patient experi- use HEDIS data and accreditation information to
ence ratings that it uses to evaluate health mainte- make their purchasing decisions. Health mainte-
nance organizations (HMOs) and point of service nance organizations (HMOs) submit HEDIS
(POS) plans, to allow consumers and purchasers to data to participate in the Medicare Advantage
reliably compare across different health plans. program.
Many of the nation’s leading employers, federal The early efforts of HEDIS included a narrow set
and state government, and individual consumers of preventive process measures. Since then, HEDIS
rely on NCQA’s accreditation to select among has grown to include a broad array of measures
various health plans. Furthermore, in more than that include the underuse, overuse, value, processes,
30 states, health plans that are NCQA accredited and outcomes of care. In 2008, HEDIS included
are exempted from most or all of the requirements measures that assess how many children under 2
of annual state audits. years of age and enrolled in a Medicaid managed-
NCQA also offers a variety of educational procare program have been tested for lead exposure.
grams and publications for providers and organi- Another new measure examined if patients with
zations to help meet quality goals. These programs aggravated chronic obstructive pulmonary disease
include educational seminars, online continuing (COPD) received prescriptions for bronchodilators
education programs, corporate training, and spe- and systemic corticosteroids at discharge from a
cial events. hospital or emergency department.
As the HEDIS measures continue to evolve,
NCQA ensures that the measures contain the fea-
Performance Measurement
tures of relevance, soundness, and feasibility.
NCQA has played a significant role in refining NCQA also makes certain that the measures are
performance measures. Performance measures valid, address focal areas, and are not onerous to
allow for the direct comparison of health plans. In implement.
the mid-1990s, NCQA developed objective mea- NCQA has published The State of Health Care
sures that resulted in a standardized measurement Quality since 1997, which gives an overall assess-
tool known as the Healthcare Effectiveness Data ment of the U.S. healthcare system. This report is
and Information Set (HEDIS), which is widely released just prior to the open-enrollment season
used by the industry. It has also developed other when individuals choose their health plan for the
measures for various healthcare organizations. following year. Over the past 5 years, the report
HEDIS is a tool used by over 90% of the has shown that health plans have made significant
nation’s health insurance plans to measure areas of improvements across a broad range of quality
patient care and service. This comprehensive tool measures.
surveys a broad area of healthcare that includes 71
measures over 8 domains of care. HEDIS measures
Physician Recognition
cover the effectiveness of care; health plan stability;
cost of care; access of care; use of services; informed NCQA’s physician recognition programs help
choice; health plan information; and satisfaction of patients identify providers who consistently deliver
care. Some areas of HEDIS measurement include evidence-based care. Employers have also begun
breast cancer screenings, beta-blocker treatment to realize the value of the physician recognition
after a heart attack, antidepressant medication program.
management, and comprehensive diabetes care. In collaboration with the American Diabetes
The availability of HEDIS allows for an objec- Association and the American Heart Association/
tive, standardized measurement and reporting American Stroke Association, NCQA has devel-
that permits side-by-side comparison on the per- oped two physician recognition programs. These
formance of health plans and comparison of programs recognize physicians who deliver excel-
performance to benchmarks. HEDIS also enables lent care to patients with diabetes or cardiac-related
National Committee for Quality Assurance (NCQA) 813
illnesses. Physicians who participate in the recogni- Public Policy

tion programs have also rapidly improved the care
NCQA also maintains an active public policy
they deliver. Those who participated in the Diabetes
department. The department works with legisla-
Physician Recognition Program increased their
tors and policymakers to educate them on how to
rates of nephropathy screening, lipid screening, and
support healthcare policies that benefit the public.
blood pressure control by 50% to 100% within 5
In addition, the NCQA works collaboratively
years.
with other organizations to advance policies that
Another program, the Physician Practice
improve the efficiency and quality of the health-
Connection, recognizes physicians who have imple-
care system.
mented practice systems, such as electronic medi-
cal records, that help them consistently deliver
high-quality care. A new program will identify Future Implications
physicians who provide efficient and effective evi-
dence-based care for patients with back pain. The National Committee for Quality Assurance
(NCQA) continues to stimulate significant improve-
ments in healthcare quality through its quality
Public Reporting assessment, performance measurement, and physi-
An educated consumer serves as a powerful driv- cian recognition programs. It is furthering its work
ing force for improving healthcare. Thus, NCQA by developing a broader set of performance mea-
works to facilitate informed consumer choices by sures and expanding the boundaries of quality.
making available, free of charge, most of the NCQA remains a leader for facilitating change in
information it collects on health plans, medical the nation’s healthcare system by providing employ-
groups, and physicians to the media and individu- ers and consumers with the necessary tools and
als via the Internet. To reach as wide an audience information to make informed choices.
as possible, NCQA also maintains a partnership
Jared Lane K. Maeda
with U.S. News & World Report to produce its
annual list of “America’s Best Health Plans.” See also Healthcare Effectiveness Data and Information
NCQA also has a number of tools available to Set (HEDIS); Health Maintenance Organizations
help consumers make informed decisions. The (HMOs); Health Report Cards; Managed Care;
interactive Health Plan Report Card contains a Outcomes Movement; Preferred Provider Organizations
searchable database that allows consumers to (PPO); Quality Indicators; Quality of Healthcare
choose an appropriate health plan. The report
card, which is based on the review of hundreds of
health plans, includes a comprehensive evaluation Further Readings
of member satisfaction, clinical quality, and key
McCormick, Danny, David U. Himmelstein, Steffie
systems and processes as well as accreditation
Woolhandler, et al. “Relationship Between Low
information and performance ratings. NCQA also
Quality-of-Care Scores and HMOs’ Subsequent
makes available an online directory of physicians
Public Disclosure of Quality-of-Care Scores,” Journal
in its recognition programs and a quality dividend of the American Medical Association 288(12):
calculator that can estimate the increased produc- 1484–90, September 25, 2002.
tivity and decrease in sick days that are the result Mihalik, Gary J., Michael R. Scherer, and Robert K.
of selecting a high-quality health plan. Quality Schrecter. “The High Price of Quality: A Cost
Compass is another tool developed for consumers. Analysis of NCQA Accreditation,” Journal of Health
This tool contains comprehensive health plan per- Care Finance 29(3): 38–47, Spring 2003.
formance data, trend data, and health plan-specific National Committee for Quality Assurance. The
HEDIS rates, in addition to regional and national Essential Guide to Health Care Quality. Washington,
averages. With Quality Compass, users can track DC: National Committee for Quality Assurance, 2007
quality improvement, analyze annual plan perfor- National Committee for Quality Assurance. The State of
mance, develop custom reports, and conduct mar- Health Care Quality. Washington, DC: National
ket analyses. Committee for Quality Assurance, 2007.
814 National Guideline Clearinghouse (NGC)
Ohldin, Andrea, and Adrienne Mims. “The Search for Background

Value in Health Care: A Review of the National
Committee for Quality Assurance Efforts,” Journal of The initial construction of the NGC began in 1997.
the National Medical Association 94(5): 344–50, To gain input and support for the proposed clear-
May 2002. inghouse, individuals in the U.S. Department of
O’Kane, Margaret E. “Redefining Value in Health Care: Health and Human Services (HHS) met with repre-
A New Imperative,” Healthcare Financial sentatives from the American Medical Association
Management 60(8): 64–8, August 2006. (AMA), the American Association of Health Plans
Reinke, Tom. “NCQA Shifts Focus on Physician (AAHP), and the U.S. Agency for Health Care
Performance,” Managed Care 16(3): 48, 53, March Policy and Research (now the Agency for Healthcare
2007. Research and Quality, or AHRQ). In December,
1998, the clearinghouse was launched, and it was
officially unveiled in January, 1999.
Web Sites When launched, the clearinghouse included
National Committee for Quality Assurance (NCQA): approximately 200 clinical practice guidelines and
http://ncqa.org other related material. By 2000, the number of
NCQA Health Plan Report Card: guidelines had more than tripled to nearly 700.
http://reportcard.ncqa.org Similarly, the number of visitors to the Web site
increased substantially. By the end of the 1st year
of its operation, there were more than 17 million
hits and 1 million sessions (a “hit” is looking at
National Guideline one page, while a “session” involves multiple con-
Clearinghouse (NGC) current hits).
Usage has continued to increase to approxi-
mately 38,000 visits a week. The average user vis-
The National Guideline Clearinghouse (NGC) is a
its about 10 pages and stays for around 6 minutes.
federally funded Web site devoted to maintaining
Also, the clearinghouse is continuing to grow in
a current database of clinical practice guidelines
size every week—it currently has over 4,000 guide-
for physicians, other health professionals, and
lines available on the Web site.
healthcare providers. Specifically, the mission of
the NGC is to provide objective, detailed informa-
tion on clinical practice guidelines and to further
Clinical Practice Guidelines
their dissemination, implementation, and use. The
clearinghouse accomplishes its mission through a Clinical practice guidelines are commonly defined
number of different components. It provides a by the national Institute of Medicine (IOM) as
searchable database of current clinical practice “systematically developed statements to assist
guidelines, each with an abstract and full-text ver- practitioner and patient decisions about appro-
sion (or link to purchase). It offers guideline priate healthcare for specific clinical circum-
comparisons—either in the form of automatically stances.” The number of clinical practice
generated side-by-side comparisons or novel doc- guidelines has greatly increased during the past
uments written by the clearinghouse—comparing two decades. This has primarily been due to
differences and similarities between guidelines on research studies that showed that physician’s
the same topic. Guidelines and guideline compari- practices and treatments vary greatly and to the
sons can be downloaded to personal digital assis- increase in managed care. The belief is that using
tants (PDAs) for easy, mobile viewing. The Web clinical practice guidelines can lead to more stan-
site contains an annotated bibliography section dardized practice and thus increased quality and
that offers a database of clinical-practice-guideline- cost-effectiveness.
related resources from peer-reviewed journals and Health Partners, a health insurance company
other sources. Finally, it provides a Listserv for based in Minnesota, found that among its physi-
discussion of clinical-practice-guideline-related cians, more than 80 different treatments were
issues and questions. being used for bladder infections. To address this
National Guideline Clearinghouse (NGC) 815
type of substantial variation in treatments, clinical Users of Guidelines

practice guidelines have been developed—in theory
Information on who uses clinical practice guide-
care can now be standardized to effective treat-
lines varies based on a number of factors. Among
ment plans. However, the situation is not that
family practitioners, about 60% were at least
simple—in the NGC, there are 13 different guide-
somewhat familiar with three relevant guidelines;
lines relating to urinary tract infections (including
14% reported not being familiar with any of the
bladder). Physicians must sift through these guide-
three presented guidelines. The use of the guide-
lines to see which one is applicable to their par-
lines varied based on the guideline, ranging from
ticular patients—since some guidelines may be age
44% to 64%. Additionally, staff-model health
or gender specific or may be related to a specific
maintenance organization (HMO) physicians were
subtype of the condition (chronic urinary tract
very likely (100%) to use guidelines, especially as
infection, for example).
compared with those in private practice (23%).
A different study looked at the cost-effectiveness
As for those who use the NGC, it is difficult to
of clinical practice guidelines. It found that, among
know exactly, but most likely nurses and physi-
coronary-care intensive-care unit patients, dis-
cians are its greatest users. The majority of hits
charging patients according to the established
come during normal business hours, suggesting
guideline decreased the amount of time spent in
that healthcare providers may be using it at work
the hospital without changing mortality rates or
or during their practice. It is also believed that
health status at follow-up. This saved an average
younger physicians are using the clearinghouse
of $1,000 per patient.
more than older physicians, because younger phy-
sicians are more likely to be trained in information
Development of Guidelines systems and feel more comfortable using the
Internet in general.
Historically, one of the major problems with
clinical practice guidelines has been the lack of a
consistent set of rules used in their development Issues and Problems
and implementation. To address this problem, the
NGC has implemented a number of requirements While clinical practice guidelines seem like a good
for inclusion into its database. idea in theory, there are often issues and problems
Guidelines submitted for inclusion must be cur- in their implementation. These problems include
rent (within the past 5 years). They must include keeping the guidelines up to date with current
systematically developed statements that help knowledge, methodological problems with their
physicians and others make decisions for their development, the usefulness of the guidelines to
patients. They must be developed under the aus- patients with multiple comorbidities, and the
pices of medical specialty associations; by relevant problem of physician resistance to using the guide-
professional societies, public or private organiza- lines in their practices.
tions, government agencies at the federal, state, or
local level; or by healthcare organizations or
Keeping Guidelines Current
plans. Finally, they must be available in English
for free or for a fee. Among guidelines submitted With constantly changing research and technol-
to the clearinghouse for inclusion, only about ogy, clinical practice guidelines are also changing.
10% are rejected for not meeting the inclusion This means that a physician or other healthcare
criteria. provider may access a guideline, use its recommen-
Additional recommendations for guideline dations, and later find out that it is already out of
development have been discussed in various jour- date or inaccurate. In addition, depending on the
nal articles. The articles suggest making a formal nature of the guidelines, different review criteria
cost analysis a part of guidelines, defining evidence might be required. For example, the treatment for
and how it was selected, making data available for ingrown toenails is less dynamic than cancer thera-
review, and the use of randomized controlled trials pies; therefore, clinical practice guidelines relating
as part of the evidence. to cancer treatment should be reviewed more
816 National Guideline Clearinghouse (NGC)
frequently than those relating to more established monetary, temporal (needing refills and trips to the
treatments. pharmacy), and bodily (it requires periodic white
One review of 279 clinical practice guidelines blood cell counts). The assumption that the authors
found that a large majority (89%) of them failed point out is frequently held by researchers is that
to include a statement about when they should be the patient would rather take the cheaper over-
reviewed or when they should expire. This becomes the-counter aspirin than the more expensive, more
problematic because, as previously discussed, with- effective ticlopidine. While this may be true for
out a set date of review; these guidelines might most patients, it may not be true in every case.
continue to be reviewed long after they have been Therefore, clinical practice guidelines should make
made current. explicit any implicit value judgments made in the
Additionally, the time at which a study is pub- development of the guidelines.
lished can be a year or more after the data was
initially taken. A guideline is partially based on
Comorbidities
studies, so it may take another year or two before
a guideline is published. By the time the guideline Guidelines are often written with one medical
is found in the NGC, it may be based on data that condition in mind. However, many patients have
are 3 to 4 years old. Thus, when reviewing guide- comorbid conditions or multiple diseases. For
lines (especially ones without a set expiration example, 48% of Medicare beneficiaries have
date), physicians and other healthcare providers three or more chronic disease conditions. One
should note the dates of the supporting studies and study examined this problem explicitly by looking
any other dates provided in the guideline. at relevant clinical practice guidelines for a hypo-
The NGC works to minimize this problem by thetical 78-year-old woman with five comorbid
requiring all guidelines to have been made current conditions: osteoporosis, osteoarthritis, Type 2
within the past 5 years. It automatically eliminates diabetes, hypertension, and chronic obstructive
those that are older from its database, unless there is pulmonary disease (COPD). It found that strictly
evidence that it has been or will soon be updated. following all the guidelines would produce drug-
disease and drug-drug and drug-food interactions.
In addition, the patient would be taking 12 medi-
Guideline Methodology
cations (19 doses) per day at five different times.
Another problem is the consistency in method- The estimated cost of the drugs would be about
ology of the guideline development. In a study of $400 per month.
279 clinical practice guidelines, not one of the Strictly following clinical practice guidelines
guidelines met all the criteria set forth by the that only focus on one disease can be difficult. It is
authors. Most frequently, the guidelines lacked important to be aware of the limitations of the
methodological standards such as not disclosing guidelines in treating patients with comorbidities.
information about how data was obtained, In addition, it may be beneficial for future guide-
extracted, selected for inclusion, and graded. lines to address and prioritize comorbidities.
One additional problem is implicit value judg-
ments used in the guidelines. Frequently, the authors
Physician Resistance
of guidelines have to make a decision about what
the patient is most likely to want. While these deci- Not all physicians are interested in using clinical
sions may seem relatively obvious, not all patients practice guidelines or the NGC. Some physicians
may share the same values as the researchers. For are reluctant because they feel that using guidelines
example, one article cited an example of this prob- is “cookbook medicine,” which takes away their
lem with the use of aspirin instead of ticlopidine in medical skills. Others are reluctant to use them in
the treatment of patients with transient ischemic everyday practice because they feel comfortable
attack (or mini stroke). Aspirin is cheap and avail- with medical conditions they see on a regular
able over the counter; however, ticlopidine pro- basis; however, they might consult relevant guide-
duces a 15% lower risk of another attack. This lines for preparing presentations, treating complex
lower risk, however, comes at a price—including cases, or in other special situations.
National Healthcare Disparities Report (NHDR) 817
Specialists are most likely to consult clinical Cassey, Margaret Z. “Incorporating the National
practice guidelines in their respective journals. So Guideline Clearinghouse into Evidence-Based Nursing
the NGC may not be as popular as it might, Practice,” Nursing Economics 25(5): 302–303,
because physicians are already accessing guidelines September–October 2007.
from different sources. If they hold their own jour- Fenton, Susan H., and Robert G. Badgett. “A
nal in the utmost regard, then they may have no Comparison of Primary Care Information in
interest in or need for searching for other guide- UpToDate and the National Guideline
lines from other sources. Clearinghouse,” Journal of the American Medical
Library Association 95(3): 255–59, July 2007.
Rao, Goutham. Rational Medical Decision Making: A
Future Implications Case-Based Approach. New York: McGraw-Hill
Medical, 2007.
Clinical practice guidelines can be beneficial if
Skolnik, Neil S., Doron Schneider, Richard Neill, et al.,
regularly used and properly developed. With the eds. Essential Practice Guidelines in Primary Care.
advent of new technology, it has become possible Totowa, NJ: Humana Press, 2007.
to centralize information—in this case, in the form
of the NGC. The clearinghouse has grown dra-
matically over the past several years, and it will Web Sites
undoubtedly continue to grow. Additionally, as it
grows, so will the number of people who will use Agency for Healthcare Research and Quality (AHRQ):
http://www.ahrq.gov
it. Currently, there are thousands of visits per
American Medical Association (AMA):
week, and this number will grow as knowledge of
this database grows.
National Guideline Clearinghouse (NGC):
Clinical practice guidelines were originally
http://www.guidelines.gov
developed to standardize practices to more evi-
dence-based interventions and in an attempt to
lower costs. It has been shown that these guide-
lines can accomplish both of these goals given the
right conditions. For large change to be realized,
National Healthcare
guidelines must be appropriately developed (includ- Disparities Report (NHDR)
ing cost analysis and statements of implicit judg-
ment) and more widely used in practice. The National Healthcare Disparities Report
Ultimately, the NGC is a valuable resource for (NHDR) is a comprehensive overview of the racial,
physicians and other healthcare providers. It con- ethnic, and socioeconomic disparities in the access
tinues to provide a central access point for current to and quality of healthcare in the nation’s general
clinical practice guidelines. population; among priority populations including
women, children, the elderly, racial and ethnic
John Schrom minority groups, low-income groups, and residents
of rural areas; and for individuals with special
healthcare needs, including the disabled, people in
(AHRQ); Clinical Decision Support; Clinical Practice
need of long-term care, and people requiring end-
Guidelines; Evidence-Based Medicine (EBM);
Outcomes Movement; Quality of Healthcare; United of-life care. The federal Healthcare Research and
Kingdom’s National Institute for Health and Clinical Quality Act of 1999 directed the Agency for
Excellence (NICE) Healthcare Research and Quality (AHRQ) to
develop an annual NHDR to provide a summary
of the state of healthcare disparities in the United
Further Readings States. The first NHDR was released in 2003. The
Bowker, Richard, Monica Lakhanpaul, Maria Atkinson, 2004 report built on the first report by providing
et al., eds. How to Write a Guideline From Start to an updated national overview of disparities and
Finish: A Handbook for Healthcare Professionals. added another critical goal: tracking the nation’s
New York: Churchill Livingston Elsevier, 2008. progress toward eliminating healthcare disparities.
818 National Healthcare Disparities Report (NHDR)
The 2005 report focused mainly on tracking prog- Healthcare disparities were also found to be
ress toward eliminating disparities, while the 2006 costly for individuals and for society as a whole.
and 2007 reports focused on healthcare access and Disparities in quality of care can lead to missed
quality improvements for different populations diagnoses and poorly managed care, resulting in
across the nation. avoidable and expensive complications. For indi-
viduals, disparities in healthcare can cause disabil-
ity, lost productivity, and morbidity. For society,
Overview treating conditions that have worsened as the
The NHDR is a vital step in the effort to improve result of poor care and/or poor management
healthcare in the United States. By tracking racial, results in considerable financial costs, notably for
ethnic, and socioeconomic disparities in health- taxpayers, who fund public healthcare programs.
care access and quality over time, this can increase Barriers to access to healthcare can also lead to
the general awareness about disparities and inspire adverse health outcomes. For example, individuals
action to reduce and/or eliminate them. The without health insurance coverage or a usual
NHDR also offers data and analyses that can help source of care are generally less likely to obtain
researchers, policymakers, clinicians, administra- preventive healthcare services and are more likely
tors, and community leaders to monitor the to delay seeking needed care. As a result, these
trends, determine areas of greatest need, identify individuals are more likely to seek medical care
best practices for addressing those needs, and with their illness at later and less treatable stages.
develop new and improved interventions to elimi- Disparities among population groups were also
nate healthcare disparities. Additionally, commu- found to exist in the use of evidence-based preven-
nities and providers can use the NHDR methods tive services. For example, many racial and ethnic
and measures to determine the most serious dis- minorities and individuals of lower socioeconomic
parities, create targeted interventions, and track status were less likely to receive screening and
progress against national standards. treatment for cardiac risk factors and recom-
mended immunizations.
Findings from the report suggested that targeted
Key Findings of the Reports efforts could reduce healthcare disparities. For
example, community-based cervical cancer screen-
The 2003 Report
ing and outreach programs may be the reason why
The 2003 NHDR presented seven key findings: Black women have higher screening rates for cervi-
(1) inequality in quality persists, (2) disparities cal cancer and no evidence of later-stage cervical
come at a personal and societal price, (3) differen- cancer presentation despite the fact that in general
tial access to healthcare may lead to disparities in Blacks and the poor are more likely to seek care
quality, (4) opportunities to provide preventive with later-stage cancers and to have higher death
care are frequently missed, (5) knowledge of why rates.
disparities exist is limited, (6) improvement is pos-
sible, and (7) data limitations hinder targeted
improvement efforts. The 2004 Report
Specifically, the report confirmed that there The 2004 NHDR presented three key findings:
were significant inequalities in healthcare qual- (1) disparities are pervasive; (2) improvement
ity in the nation along racial, ethnic, and socio- is possible; and (3) gaps in information exist,
economic lines. For example, the report showed particularly for specific medical conditions and
that compared with Whites, minorities were populations.
more likely to be diagnosed with late-stage Specifically, the report found that disparities
breast and colorectal cancer and patients of were pervasive in the nation’s healthcare system.
lower socioeconomic status were less likely to Disparities affected healthcare across all dimen-
receive recommended diabetic services and were sions of access and quality; across many medical
more likely to be hospitalized for diabetes and conditions, levels and types of care, and healthcare
its complications. settings; and within many subpopulations.
National Healthcare Disparities Report (NHDR) 819
The report found that in both 2000 and 2001, deficient areas and also indicated the need for bet-
Asians, when compared with Whites, received ter data and measures.
poorer quality of care for approximately 10% of
the quality measures and had poorer access to care
for approximately one third of the access mea- The 2007 Report
sures. Also, Blacks, when compared with Whites, The 2007 NHDR presented three key findings:
received poorer quality of care for approximately (1) disparities in healthcare quality and access are
two thirds of the quality measures and had poorer not decreasing, although progress continues to be
access to care for approximately 40% of the access made; (2) the largest gaps in quality and access are
measures. not being reduced; and (3) lack of health insurance
Several gaps identified in the 2003 NHDR were coverage continues to be a major barrier to reduc-
filled in the 2004 report. These included increased ing disparities.
information on hospital care received by American Specifically, the report found that although
Indians and Alaska Natives; healthcare delivered overall progress continues to be made to improve
in community health centers; children with special healthcare quality, some of the largest gaps in
healthcare needs; and a broader analysis that quality persist. For example, the proportion of
allowed for the separation of disparities related to Blacks who receive hemodialysis has improved
race, ethnicity, and socioeconomic status. since 2001, and their current rate of treatment is
not statistically different from Whites. However,
despite the improvement, gaps in health still
The 2005 Report
remain. Blacks were found to have a 10 times
The 2005 NHDR presented four key findings: higher rate of new AIDS cases than Whites. The
(1) disparities still exist, (2) some disparities are report also highlighted that the growing number of
diminishing, (3) opportunities for improvement uninsured individuals significantly contributes to
still remain, (4) and information about disparities the problem of poor healthcare quality.
is improving.
Specifically, the report found that disparities
still existed in nearly all aspects of healthcare. Future Implications
Minorities and the poor continued to receive Moving forward, the improvement in available
lower-quality healthcare than comparison groups data and the recording of trends in access and the
and also had worse access to care. The report quality of healthcare will enable future NHDRs to
found that for racial minorities, more disparities in identify and lead to decreases in inequities in
quality of care were improving than were worsen- health. By tracking outcomes and looking at the
ing. The persistence of disparities indicated that most vulnerable populations, these reports will
opportunities for improvement remained. continue to serve as important tools in eliminating
health disparities.
The 2006 Report Elizabeth A. Calhoun and Anna M. S. Duloy
The 2006 NHDR presented four key findings:
See also Access to Healthcare; Agency for Healthcare
(1) disparities still remain; (2) some disparities are
Research and Quality (AHRQ); Cultural Competency;
decreasing, while others continue to increase; (3) Ethnic and Racial Barriers to Healthcare; Health
there remain opportunities to reduce disparities; Disparities; Healthy People 2010; Vulnerable
and (4) information on disparities is getting better, Populations
but there are still gaps.
Specifically, the report found that minorities
and the poor continued to receive poor-quality Further Readings
care and had poor access to care. The report also Agency for Healthcare Research and Quality. National
highlighted that for the poor, most disparities were Healthcare Disparities Report. Rockville, MD:
getting worse. These gaps indicated that ample Agency for Healthcare Research and Quality,
opportunity existed to continue to improve these 2003–2007.
820 National Healthcare Quality Report (NHQR)
Brady, Jeffrey, Karen Ho, and Carolyn M. Clancy, “The reform called for accountability and transparency
Quality and Disparities Reports: Why Is Progress So as important catalysts to fostering system changes.
Slow?” American Journal of Medical Quality 23(5): During the 1990s, a Clinton Presidential Advisory
396–8, September–October 2008. Commission on Consumer Protection and Quality
Kelley, Edward, Ernest Moy, Daniel Stryer, et al. “The in the Health Care Industry issued a report in
National Healthcare Quality and Disparities Reports: 1998 calling for a national commitment from the
An Overview,” Medical Care 43(3 Suppl.): 13–18, public and private sectors to improve healthcare
March 2005. quality and reporting. By the end of the decade,
Moy, Ernest, Elizabeth Dayton, and Carolyn M. Clancy,
the U.S. Congress enacted the Healthcare Research
“Compiling the Evidence: The National Disparities
and Quality Act of 1999 directing the AHRQ to
Reports,” Health Affairs 24(2): 376–87, March–April
publish annual reports that addressed the quality
2005.
information gap. Around the same period, the
National Academy of Sciences, Institute of
Web Sites Medicine (IOM), released two seminal reports on
healthcare quality (To Err Is Human and Crossing
Agency for Healthcare Research and Quality (AHRQ): the Quality Chasm) that would shape the overall
http://www.ahrq.gov framework of the NHQR.
Families USA: http://www.familiesusa.org
http://www.kff.org Framework
The NHQR is anchored on a framework that sets
forth the concept of healthcare quality resulting
National Healthcare from the dynamic interplay between the organiza-
tional delivery system domains and consumer
Quality Report (NHQR) domains of care. The organizational domains cor-
respond to the traits of quality that exemplify
The National Healthcare Quality Report (NHQR) effectiveness (giving care based on current scien-
is a comprehensive source of information on tific knowledge, avoiding overuse or underuse),
trends in the quality of healthcare provided to the safety (avoiding harm), timeliness (giving care
American people. It is published annually by the when needed), and patient-centeredness (giving
U.S. Agency for Healthcare Research and Quality care that respects patient preferences and values).
(AHRQ). A key objective of the report is to inform The consumer domains correspond to the traits of
the U.S. Congress and national healthcare policy- quality that result from obtaining care, which
makers on quality of care issues as well as to include staying healthy, getting better, managing
monitor the impact of federal and state changes in chronic illness or disability, and coping with end-
healthcare. The report is relevant to health ser- of-life issues. Thus, quality is indicated by a
vices researchers because they investigate the link matrix of the four dimensions of organizational
between healthcare quality, access, and costs, as quality and four dimensions of consumer care to
well as how the translation of evidence into clini- exemplify the interdependence between healthcare
cal practice and organizational actions affects structures and how outcomes of consumer care
outcomes of care. influence system performance.
Background Content Focus

The idea behind reporting the quality of health- The U.S. Congress stipulates that the NHQR pro-
care to the general public originated towards the vide information on the relationship between qual-
end of the 20th century at a time when national ity, outcomes, access, utilization, and changes over
discourse on health reform and strategies to time on frequently occurring clinical conditions,
improve performance in quality and safety of care including the impact of federal and state policy
had gained momentum. A strategic imperative of changes. In this capacity, the NHQR differs from
National Healthcare Quality Report (NHQR) 821
other national comparative quality reports because acute-, ambulatory-, preventive-, nursing-, home
it provides a broad perspective on quality, by health, and managed-care settings.
assessing progress and defining actions to improve
performance across a wide range of provider set-
tings, clinical conditions, and populations. Although Future Direction
the report was commissioned to inform Congress, While the NHQR is the broadest analysis of lon-
it also seeks to enhance awareness among policy gitudinal data on national trends in the quality of
leaders, purchasers, providers, health profession- healthcare, it remains a work in progress. The
als, researchers, and the lay public using a chart- analysis of measures has gradually expanded since
book format that highlights key findings and it was first published in 2003. A major challenge
themes to facilitate and encourage the use of data to maintaining its viability as a trustworthy source
among this audience. Findings of quality outcomes of information on trends in quality of care hinges
are presented in chapters organized by the four on advancements in the field of quality measure-
domains of organizational quality, plus appendixes ment itself. National initiatives to expand mea-
with data tables and measurement specifications surement across the entire spectrum of medical
for researchers and analysts. The report under- conditions, populations, and provider settings are
scores four basic themes that point to what areas of likely to remain public policy imperatives for
quality are improving, where variability remains, reducing variation in the quality of healthcare for
where progress is strong, and where opportunities all Americans.
for improvement remain, using examples across
states and regions by clinical conditions and patient Iris Garcia-Caban
characteristics. It also highlights progress on mea-
sures used in national quality initiatives such as See also Agency for Healthcare Research and Quality
Medicare’s Quality Improvement Organizations (AHRQ); Medical Errors; National Healthcare
Disparities Report (NHDR); Outcomes Movement;
(QIOs) and disease management programs. The
Patient Safety; Quality Improvement Organizations
NHQR is also published with a companion report, (QIOs); Quality Indicators; Quality of Healthcare
the National Healthcare Disparities Report
(NHDR), which emphasizes trends in the quality
of healthcare for racial and ethnic minority groups Further Readings
and other vulnerable populations.
Agency for Healthcare Research and Quality. 2006
National Healthcare Quality Report. Rockville, MD:
Quality Measures U.S. Department of Health and Human Services, 2006.
The NHRQ draws on a broad set of quality mea- Hurtado, Margarita P., Elaine K. Swift, and Janet M.
sures selected based on their importance (e.g., Corrigan, eds. Envisioning the National Health Care
health effects on morbidity and mortality, finan- Quality Report. Washington, DC: National
Academies Press, 2001.
cial impact), scientific soundness, and feasibility
Kohn, Linda T., Janet Corrigan, and Molla S.
for collection. Quality measures are constructed
Donaldson, eds. To Err Is Human: Building a Safer
using various public- and private-sector data
Health System. Washington, DC: National Academies
sources collected from national and federal data
Press, 2000.
systems, sample data from healthcare facilities
Institute of Medicine, Committee on Quality of Health
and individual providers, population survey data, Care in America. Crossing the Quality Chasm: A
surveillance and vital statistics data, and health New Health System for the 21st Century.
plan data from the Health Employer Data Washington, DC: National Academies Press, 2001.
Information System (HEDIS). Each year, the
report analyzes 200 to 300 measures, balanced
across dimensions of organizational and consumer
Web Sites
care, to present information on quality for fre-
quently occurring medical conditions across dif- Agency for Healthcare Research and Quality (AHRQ):
ferent populations seeking care and treatment in http://www.ahrq.gov
822 National Health Insurance
Joint Commission: http://www.jointcommission.org drugs, dental and vision services, and certain forms
National Healthcare Quality Report (NHRQ): http:// of institutional care. Overall, public sources cover
nhqrnet.ahrq.gov/nhqr/jsp/nhqr.jsp the vast majority of healthcare that may be needed
President’s Advisory Commission on Consumer by an individual. In Canada, for example, the
Protection and Quality in the Health Care Industry: national health insurance system represents about
http://www.hcqualitycommission.gov 70% of total healthcare spending.
The major features of a national health insur-
ance system include the following: It is universal,
covering all citizens; it is comprehensive, covering
National Health Insurance all conventional medical care including inpatient
and outpatient services; it is accessible, with no
National health insurance provides healthcare restrictions on services that are covered or extra
coverage for all of a country’s population against charges to patients; it is portable within a country;
the costs associated with illness and required and it is publicly administered and under the
healthcare. The term also refers to government- control of government or a nonprofit agency or
financed, guaranteed, and/or mandated health organization.
insurance for all citizens. The system, as a rule, is In many national health insurance systems, pri-
publicly funded from general tax revenues and vate practitioners provide healthcare services and
does not include direct charges to patients such as are paid on a fee-for-service basis. A fee schedule
deductibles or copayments. The various types of for all services is set each year through negotia-
national health insurance systems may differ in tions between the government, insurers, and pro-
terms of how they are structured and financed. viders. Annual fee increases are determined by the
Some form of national health insurance currently previous year’s rate plus an allowance for inflation
exists in Australia, in Canada, in China, in virtu- and increases due to advances in technology and
ally all of Europe, in New Zealand, and in much innovation. There are similar negotiated fee sched-
of Africa and Asia. ules for diagnostic tests and referrals to specialists.
Most physicians are self-employed in either solo or
small-group practices, as are other practitioners
Overview
such as dentists and pharmacists. In some national
National health insurance systems begin with the health insurance systems, physicians receive an
basic assumption that healthcare is an entitlement annual salary as employees of the government.
and a right of citizens and even, in many cases, of For inpatient services, hospitals are not-for-
residents. It aims to insure all citizens for a com- profit and are overseen by boards of trustees or by
prehensive range of medical and hospital services, a government regulatory agency. They receive an
generally covering inpatient and outpatient ser- annual global budget, and these funds are expected
vices, physician services, prescription drugs, and to cover all care for all the patients in a given year.
many forms of rehabilitation. A national health Institutional care outside the hospital is provided
insurance system places virtually all responsibility by facilities such as nursing homes and rehabilita-
for both regulation and financing of healthcare tion centers, which are reimbursed on a per diem
with government. The government sets standards basis.
for a core set of benefits that must be included in In a national health insurance system, all citi-
the healthcare or medical programs, and it pro- zens have the same public insurance coverage for
vides funding for these services. In a national physician and hospital care, which covers all medi-
health insurance system, some private insurance, cally necessary services. Patients have free choice of
which is relatively expensive, may be available to any provider in the system (which is virtually all
individuals who wish to use it as a supplement or, physicians). While other industrialized countries,
in some cases, as a substitute for the national pro- including the United States, rely on patient cost-
gram. As a supplement, this private insurance may sharing arrangements such as deductibles and
cover those services that are not included in the copayments, most national health insurance sys-
basic health insurance scheme, such as prescription tems have elected not to use these methods for cost
National Health Insurance 823
containment. As a result, there are not direct costs National Health Insurance in Context
to seeking care for those covered by a national
National health insurance can best be understood
health insurance system. Under this type of system,
by examining the different methods for financing
primary care is the foundation of healthcare, and
and organizing healthcare systems. There are
patients are encouraged, though not required, to
three basic sets of institutional relationships in dif-
visit their primary-care physician rather than seek-
ferent healthcare systems: reimbursement, con-
ing a specialist directly. Eighty-five percent of
tractual, and integrated. The reimbursement
Canadians, for example, have a primary-care phy-
system, which is usually combined with fee-for-
sician whom they see on a regular basis. Specialists
service payments, is common in countries with a
receive a larger fee for their services when a pri-
mix of public and private insurers and providers,
mary-care physician refers their patients to them.
including Canada, Germany, Japan, and the
This practice encourages providers to direct patients
United States. The contract system is found in
to use their generalist appropriately.
social insurance systems, as in the Netherlands,
In a healthcare system organized around national
which has predominantly private, nonprofit pro-
health insurance, every individual who is covered
viders. It involves an agreement between providers
is issued an insurance or medical card. Consumers
and third-party payers to impose limits on the
present this card when they visit the physician or
total amount and distribution of spending.
the hospital; the provider, in turn, submits charges
Contract agreements typically include global pro-
to the government or agency administering the
spective budgets for hospitals and rules for reim-
system for reimbursement. For the basic set of
bursement, including per diem or capitation
medical services covered by public insurance, no
payments. Integrated systems combine into one
further paperwork is required by either the patient
agency the funding for as well as the provision of
or the physician. For care received in a hospital,
health services. Health professionals are usually
the hospital is responsible for managing the
salaried employees, and agency budgets serve to
resources allocated for each case to keep within its
control spending. Public integrated health systems
annual global budget. Additional paperwork may
are found in the United Kingdom and the
be required for supplemental services that are
Scandinavian countries.
insured privately.
In general, countries combine these relation-
This basic public insurance for physician and
ships in the healthcare system through social insur-
hospital services includes only limited coverage for
ance or public health services. Social insurance
a variety of supplemental health benefits, and the
countries finance healthcare from general taxation
majority of these supplemental services are paid for
or from compulsory payroll and employer contri-
through private insurance or out-of-pocket pay-
butions. Employment-based taxes often provide
ment by patients. Those services that are not fully
the financing for nonprofit “sickness funds” that
covered by the public insurance scheme include
then reimburse providers for services. There are
prescription drugs, dental care, vision care, medi-
two broad types of integrated public systems:
cal equipment and appliances, independent living
those that are nationally integrated, such as the
arrangements for the disabled and the services of
United Kingdom’s National Health Service (NHS);
allied health professionals. While some public cov-
and those that are organized at the local level
erage for these services is available in limited cases,
through the counties, as in Scandinavia.
the rates of coverage vary on a case-by-case basis.
In some countries, for example, the coverage and
rates vary by geographic region or area. Because of
Similarities and Differences
this, supplemental health benefits are often funded
With the U.S. System
through private health insurance or through addi-
tional allocations by regional or local governments. The United States does not have a comprehensive
In many cases, these costs for additional or supple- healthcare system that provides a core set of ser-
mental services have been rising, as they are not vices to all citizens. Instead, some form of national
subject to the same price bargaining structures as health insurance is provided to the elderly through
physicians’ fees and hospital costs. the nation’s Medicare program, to low-income and
disabled persons through the state-administered systems. Between 90% and 95% of citizens in
Medicaid program, to veterans through the these systems are insured by public health insur-
Veterans Health Administration (VHA), and to ance, and in most cases the government will pay
low-income children through the State Children’s for care provided to patients regardless of whether
Health Insurance Program (SCHIP). These they have an insurance card. As a result, physicians
American programs are remarkably similar to do not incur financial risk by caring for uninsured
national health insurance programs in countries patients, as is the case in the United States.
such as Australia, Canada, England, and New
Zealand, in terms of their organization and
Administrative Costs and Cost Controls
financing. Some of the administrative or organiza-
tional relationships, such as the federal/state part- Estimates of administrative costs in national
nerships, are similar to those in Canada. health insurance systems range from less than 1%
In Canada, as in the United States, most physi- to rates similar to those of U.S. private insurers,
cians operate in private practice. Unlike the U.S. which is roughly 20%. These studies attempt to
model, however, all Canadian physicians are part take into account additional sources of overhead
of the same insurance program. The benefit of this not included in the lower estimates, such as the
model for the Canadian system is two-fold: a single hidden costs of tax-based financing and patient-
fee schedule can be negotiated for all providers in time costs. Notwithstanding such attempts to
each province; and the risks and benefits of par- uncover real but hidden costs of national health
ticipation are spread among all physicians. insurance systems, administrative costs of these
Some, though not all, of the cost-control mech- healthcare systems are significantly lower than
anisms used in many national health insurance those in the United States.
systems are also common in U.S. public and pri- Two components at play in these systems appear
vate insurance programs. The most notable excep- to be key to achieving administrative efficiency.
tion to this is the fact that the Canadian system First, a macromanagement approach to cost con-
does not use point-of-care patient cost-sharing trol sets and enforces overall budgetary limits on
mechanisms such as deductibles and copayments, hospitals and clinics. Being a single-payer system
as do most U.S. private insurers and, increasingly, saves time and cost for both the coverage party,
Medicaid and Medicare plans. The global budget- either the government or a not-for-profit agency,
ing scheme used for payment to hospitals in and the provider, by having a single billing system.
Canada is different from the U.S. Medicare’s Second, by setting global budgets, rather than
Diagnosis Related Groups (DRGs) mechanism itemizing charges and then billing for each encoun-
used to control the costs of an episode of hospital ter with each individual patient, the system reduces
care. The global budget arrangement in Canada is the amount of time and personnel needed for
perhaps somewhat more labor-intensive for the administration.
hospital because it requires overall planning for all
patient encounters in a year rather than the imme-
Waiting Lists
diate resource management for each individual
episode of care required by DRGs. Waiting lists, or queues, are a concern for consum-
U.S. managed-care organizations typically pay ers in national health insurance systems and for
providers through a capitation arrangement, where American policymakers looking at these systems.
payments are made on a per-patient basis. Rather Waiting times for certain procedures are longer in
than capitation, however, physicians in many many of the national health insurance countries
national health insurance systems are paid on a than they are in the United States. This issue is a
fee-for-service basis for each patient encounter; source of anxiety for Canadian patients, for exam-
these fees are negotiated in advance, however, and ple, as well as a difficult planning concern for its
are much lower than in the United States, even policymakers. In response, the Canadian province
under capitation schemes. of Ontario operates a waiting list management
The most striking difference is the breadth of program, which uses guidelines that include indi-
coverage offered by most national health insurance cators of severity and urgency to place patients in
National Health Insurance 825
appropriate rank order. Studies suggest that those Waiting lists for elective procedures are often
with more severe or urgent conditions do experi- considered a source of cost control in Canada
ence shorter waiting times. because they can reduce use and therefore spend-
It is difficult to get accurate data on the average ing, but they do not appear to be a large source of
waiting times for nonemergency procedures in the overall spending differential with the United
Canada because there are separate waiting lists for States. The procedures for which the waiting lists
each category of procedure, and there have been in Canada are the longest account for a very small
no organized efforts to collect data on waiting proportion, approximately 3%, of overall spend-
times until recently. These recent efforts include a ing in both the United States and Canada.
survey of people in Canada and four other coun-
tries that shows that the average waiting time for
Costs and Benefits
elective surgery was more than 1 month, with 27%
of people surveyed indicating that they had waited Overall, it is very difficult to assess the costs and
more than 4 months. benefits of a national health insurance system as
Some analyses also suggest that mortality rates compared with a system that is a mix of public
for people waiting for coronary artery bypass graft and private insurance or with one dominated by
are actually lower than expected mortality rates private health insurance. Some of the benefits of
for cardiac patients generally, which indicates that national health insurance include universal or
the waiting list management system has been suc- near-universal coverage, predictable overall costs
cessful at identifying and rapidly treating those for the healthcare system, affordability for con-
patients whose cardiac disease requires immediate sumers, equity across user groups, efficiency in the
attention. allocation and use of resources, and provision of
Studies have found waiting times to be longer in comprehensive care in inpatient and outpatient
Canada than in the United States for a variety of settings. The costs of this system include rationing
elective surgeries. For example, in a study of knee of care, waiting lists, relatively high taxes for citi-
replacement comparing a large sample of American zens, and restrictions on the types of care that will
Medicare patients to Canadian patients, research- be covered. These costs and benefits will be
ers found that the average waiting time was twice assessed and balanced in different ways depending
as long in Canada. The waiting period for the ini- on the objectives government, consumers, and
tial orthopedic consultation was 4 weeks, as com- providers want to achieve.
pared with 2 weeks in the United States; the From another perspective, it is almost impossi-
waiting period for the knee replacement surgery ble politically in most national health insurance
was 8 weeks, as compared with 3 weeks in the systems to cut benefits, even with the cost pres-
United States. The study found no differences in sures facing most systems. It would violate the
overall satisfaction with the surgery between the principles of universality and solidarity that are
two groups. associated with these systems. On the other hand,
The type of rationing embodied by waiting lists the national insurance model makes it possible to
also applies to other types of high-technology eliminate, or nearly eliminate, the administrative
healthcare services, such as the use of magnetic costs that are associated with multiple payers. The
resonance imaging (MRI) machines. National national health insurance model has considerable
health insurance systems usually set limits on the leverage in bargaining with providers.
number of MRI machines that will be available, As a result of affordable access to healthcare
and it plans where they will be available geograph- services for all citizens, Canadians enjoy very good
ically. In 2004 there were 4 times more MRI health relative to people in other industrialized
machines per million in the United States than in nations, including the United States. In a study
Canada (19.5 vs. 4.6). In this case, too, there does comparing 13 of the world’s major industrial coun-
appear to be a rational process based on medical tries using a total of 16 health indicators, Canada
need and urgency that determines the patient’s ranked 3rd on average, while the United States
placement in the queue and ultimate receipt of ranked 12th. The 13 countries included Australia,
services. Belgium, Canada, Denmark, Finland, France,
Germany, Japan, the Netherlands, Spain, Sweden, waiting times. But it has done so through govern-
the United Kingdom, and the United States. In mental power and control. American consumers
other words, national health insurance systems also want their healthcare system to be relatively
appear to produce very positive health outcomes. free of government regulation. To this extent,
What many Americans find appealing about national health insurance may be beyond the scope
national health insurance systems such as those of possible reform options.
found in Australia, Canada, and the United Kingdom However, if Americans see that they could actu-
is that they eliminate insecurity about the availabil- ally spend less on healthcare, this attitude may begin
ity of health insurance and the potential for finan- to change. For example, the United States now
cial ruin caused by illness. The systems also contain spends approximately the same percentage of its
costs, with a smaller proportion of total economic gross domestic product (GDP) on public health
activity devoted to healthcare, as compared with insurance programs as other industrialized countries,
the current system in the United States. about 7%. The United States uses that percentage to
cover a small portion of people, while the other
countries are able to cover all their citizens with the
Lessons to Be Learned
same amount. The U.S. spends another 7%, or $800
What can we learn from a national healthcare billion, for private insurance, and the number of
system, such as the Canadian system, whose fun- uninsured American has grown to 47.5 million.
damental philosophical and organizational prin- Other dimensions of quality and patients’ expe-
ciples are so different from our own? Perhaps riences help assess how desirable national health
more than one might at first glance think. As insurance may or may not be in the United States.
already noted, the United States already has vari- Waiting times for U.S. patients with insurance are
ous healthcare insurance programs that are uni- less than those for most Canadians who do not
versal in nature; these programs focus on specific have life-threatening conditions. The longest waits
groups of people and not the population as a and greatest anxiety are experienced by American
whole, though. patients who do not have health insurance cover-
The United States should evaluate what can be age, although one solution to this well-documented
learned from national health insurance systems disparity would be a system that afforded more
and the policy challenges they face in the context complete coverage to all Americans.
of a crisis of expectations. Americans want access Universal health insurance means providing
to high-quality healthcare that offers choice among insurance to all, not necessarily requiring that
providers at relatively low costs without any type everyone share the same system. What is essential
of rationing in the form of queues or waiting times. in this type of system is that health insurance pro-
In other words, they want high-quality healthcare vide coverage to all people in comparable terms.
on demand and they want to be empowered to Since 1985, tension between consumers, providers,
make their own selection of providers and treat- and third-party payers, including government, has
ments based on the best medical information avail- been growing over which goals or objectives to
able. Existing national health insurance systems maximize. The tensions are reflected in the vexing
provide some good examples and some promise task of balancing cost containment, quality assur-
that such expectations can be met under a national ance, and freedom of choice for consumers and
system. These systems, as a whole, have managed providers. Systems of national health insurance
to insure all citizens for a comprehensive range of offer some important lessons for the United States
medical and hospital services, while also contain- on each of these critical dimensions.
ing medical costs. However, there are fundamental
philosophical barriers to adopting such a system in Robert F. Rich
the United States, and this is where the crisis of See also Access to Healthcare; Healthcare Reform;
expectations becomes most apparent. Canada, for Health Services Research in Canada; International
example, has been successful in creating a rela- Health Systems; Public Policy; Rationing Healthcare;
tively low-cost, easy-access healthcare system that Single-Payer System; United Kingdom’s National
includes a great deal of choice and only moderate Health Service (NHS)
National Health Policy Forum (NHPF) 827
Further Readings congressional staff and administrators of execu-

Boychuk, Gerard W. National Health Insurance in the tive agencies in Washington, D.C.
United States and Canada: Race, Territory, and the Health policy issues often contain many layers
Roots of Difference. Washington, DC: Georgetown and require complex decisions for policymakers.
University Press, 2008. The NHPF offers a nonpartisan exchange of infor-
Canadian Institute for Health Information. CIHI report mation, thus providing policymakers with an
shows increase in MRI and CT scanners, up more than opportunity to sort through the complex layers to
75% in the last decade. Retrieved from http://secure.cihi make accurate and informed decisions. The forum
.ca/cihiweb/dispPage.jsp?cw_page=media_13jan2005_e itself does not take positions on specific health
Century Foundation. The Basics: National Health issues, but rather, provides objective information
Insurance: Lessons from Abroad. New York: Century based on research and data to policymakers. It
Foundation Press, 2008. works to promote understanding of complex health
Funigiello, Philip J. Chronic Politics: Health Care issues and foster decision making. The NHPF is
Security from FDR to George W. Bush. Lawrence: affiliated with George Washington University.
University Press of Kansas, 2005.
Goodman, John C., Gerald L. Musgrave, and Devon M.
Herrick. Lives at Risk: Single-Payer National Health Organizational Structure
Insurance Around the World. Lanham, MD: Rowman The NHPF consists of a staff of 19 people who
and Littlefield, 2004. produce resources for policymakers and the gen-
Gordon, Colon. Dead on Arrival: The Politics of Health eral public. The forum’s employees have strong
Care in Twentieth-Century America. Princeton, NJ: backgrounds in federal government, which pro-
Princeton University Press, 2003.
vides an understanding of not only the govern-
Hall, George M. A Tide in the Affairs of Medicine:
mental process, but also the exact types of issues
National Health Insurance as the Augury of
and decisions faced by policymakers.
Medicine. St. Louis, MO: Warren H. Green, 2004.
The forum’s director is responsible for overseeing
Quadagno, Jill S. One Nation, Uninsured: Why the U.S.
has no National Health Insurance. New York:
the activities of the staff. The director serves as a
Oxford University Press, 2005.
resource not only to the staff, but to policymakers
and funding bodies as well. The director is respon-
sible for the direction of the educational activities
Web Sites provided to federal policymakers. The forum’s dep-
AARP: http://www.aarp.org
uty director coordinates grant writing and reporting
Physicians for a National Health Program (PNHP): activities, daily operations, and programming.
http://www.pnhp.org In addition, the NHPF has a publications director,
Universal Health Care Action Network (UHCAN): who serves as editor for all publications produced by
http://www.uhcan.org the forum and guides production of print materials,
World Health Organization (WHO): http://www.who.int visuals, and the forum’s Web site. Research associ-
ates are assigned to conduct research and analysis of
specific health issues. The health issues addressed by
National Health research associates range from healthcare provider
issues, aging services, and long-term care to health-
Policy Forum (NHPF) care safety net and public health issues. Research
associates conduct research, analyze the results, and
The National Health Policy Forum (NHPF), cre- write reports about their assigned health issues.
ated in 1971, is a think tank that provides current
research and information to senior staff in the
Activities and Services
U.S. Congress and executive agencies in an objec-
tive format and that offers an opportunity to dis- The NHPF produces several types of resources
cuss complex health issues in a private setting. It including issue briefs, background papers, and
was founded based on a recognized need to pro- short briefs about programs and practices called
vide accurate, unbiased information to senior “the Basics.” Materials categorized under this sec-
828 National Health Service Corps (NHSC)
tion aim to provide a basic introduction to a health Funding

topic. Issue briefs are short reports analyzing a
The NHPF is supported by grants and financial
variety of health-related topics and issues, whereas
contributions from several foundations and cor-
background papers provide a more in-depth exam-
porations. While 98% of its funding comes from
ination of a major health issue, looking at the his-
a number of private foundations such as the W. K.
tory, theory, and the various positions of a topic.
Kellogg Foundation and the Robert Wood Johnson
The NHPF also conducts meetings and work-
Foundation, approximately 2% of its revenue
shops on a regular basis for researchers, policymak-
comes from corporate contributions from health
ers, leaders in the healthcare industry, and consumers.
insurance companies, pharmaceutical companies,
Participants attend these events on an invitation-
and other private corporations.
only basis. Forum meetings provide an opportunity
for leaders and decision makers in health policy to Kristin Hartsaw
come together to discuss health issues in an off-the-
See also Child Care; Long-Term Care; Medicaid;
record setting. A specific health topic is designated
Medicare; Pharmaceutical Industry; Public Health;
for each forum session. An expert speaker or panel
Public Policy; Technology Assessment
presents current information relevant to the desig-
nated topic. In addition to regularly scheduled Further Readings
forum sessions, senior congressional staff may
request briefings on specific health issues. These Merlis, Mark. Medicare Advantage Payment Policy.
briefings offer more in-depth analysis and discussion Washington, DC: National Health Policy Forum, 2007.
of a topic. The forum makes materials and handouts O’Shaughnessy, Carol V. The Aging Services Network:
from these sessions available on its Web site. Accomplishments and Challenges in Serving a
The forum’s Web site provides users with access Growing Elderly Population. Washington, DC:
National Health Policy Forum, 2008.
to the same health policy information that is pro-
Ryan, Jennifer. Completing the Recipe for Children’s
vided to policymakers. Information and materials
Health: New Variations on Key Ingredients.
including issue briefs, background papers, site visit
Washington, DC: National Health Policy Forum, 2008.
reports, and meeting archives are grouped by con-
Tucker, Leslie. Pharmacogenomics: A Primer for
tent area. The Web site includes information about Policymakers. Washington, DC: National Health
aging and long-term care, behavioral health, chil- Policy Forum, 2008.
dren’s health, coverage and access, federalism,
Medicaid, Medicare, pharmaceuticals, private
markets, public health and preparedness, quality, Web Site
research and technology, and welfare. National Health Policy Forum (NHPF):
The NHPF also provides access to papers pro- http://www.nhpf.org
duced by the Health Insurance Reform Project
(HIRP) on its Web site. The HIRP, another non-
profit, nonpartisan organization working as an
independent voice in the health policy arena,
strives to improve the health insurance and health-
National Health Service Corps
care industries by monitoring trends and policy. (NHSC)
While it is also affiliated with George Washington
University, HIRP is separate from the forum. The National Health Service Corps (NHSC) is a
The forum also coordinates site visits for federal federal program that recruits primary healthcare
policymakers. Site visits are held throughout the professionals to serve in designated Health
country to showcase innovative programs and to Professional Shortage Areas (HPSAs). The Corps
demonstrate how local health communities deal enlists primary-care physicians and other health-
with specific issues. Recent site visits addressed care practitioners with scholarships and education
topics relating to senior citizen health and housing, loan repayment plans that require work in under-
rural health systems, health records, access to care, served areas of the nation. In FY2007, the pro-
and quality of care. gram’s budget was $125 million.
National Health Service Corps (NHSC) 829
Background recipients may enter private practice wherever they

wish, but the hope is that they will stay in the
The U.S. Congress created the NHSC in 1970
underserved area. The scholarships are available to
with the passage of the Emergency Health
U.S. citizens studying to be allopathic or osteo-
Personnel Act (PL 91–623) in response to the
pathic physicians, dentists, nurse practitioners,
increasing geographic imbalance in access to pri-
physician assistants, nurse midwives, and other
mary care. By the end of the 1960s, rural areas
specific healthcare professionals.
suffered shortages of physicians as existing physi-
The NHSC Loan Repayment Program, added in
cians retired and new ones preferred practicing in
1987, allows healthcare professionals to join the
less remote areas. Innercity urban areas also were
Corps and practice in an underserved area in
experiencing the loss of physicians and other
exchange for repayment of a portion of their edu-
healthcare professionals.
cational loans. Both newly graduated as well as
To identify areas of need, the federal govern-
seasoned professionals are eligible. The loan repay-
ment broadly defines and specifically identifies
ment program contracts require a minimum 2-year
HPSAs. These areas have a shortage of primary-
commitment to the placement site, and recipients
medical-care, dental, or mental health providers
may be able to extend the assignment to gain fur-
and may be geographic (a county or service area),
ther loan repayment. Newly graduated or seasoned
demographic (low-income population), or institu-
professionals are eligible, but must be U.S. citizens
tional (comprehensive health center, federally
and be licensed and/or certified (depending on the
qualified healthcare center, or other public facil-
profession). Specifically, eligible professionals
ity). Specific shortage areas are designated by the
include allopathic and osteopathic physicians, pri-
Secretary of the Department of Health and Human
mary-care certified nurse practitioners, certified
Services (HHS). Currently, there are over 5,000
nurse-midwives, primary-care physician assistants,
designated shortage areas in the nation. These
general-practice dentists, registered clinical dental
shortage areas encompass about 50 million
hygienists, health service psychologists, licensed
Americans, or 20% of the U.S. population.
clinical social workers, psychiatric nurse special-
ists, marriage and family therapists, and licensed
professional counselors.
The NHSC program is managed by the U.S. Other Programs
Department of Health and Human Services,
Health Resources and Services Administration’s The NHSC also recruits professionals to serve on
Bureau of Health Professions (BHPr). The pro- a basis other than to repay obligations of a schol-
gram has a national advisory council, which com- arship or for loan repayment. One such recruiting
prises 15 clinicians and healthcare administrators. effort is the Rapid Response Program. Rapid
The council identifies priorities, suggests and ana- responders, all primary-care professionals, serve
lyzes policy changes, and generally advises possi- as U.S. Public Health Service (USPHS) commis-
ble improvements in access to primary care sioned officers for 3 years in a medically under-
through the program to the Secretary of the HHS served area and receive training to be part of a
and the Administrator of the Health Resources mobile team available in case of a large scale or
and Services Administration (HRSA). national emergency.
Additionally, the NHSC also runs the
Ambassador Program, which is composed of vol-
unteers on college and university campuses or in
Scholarship and Loan Programs communities. The Ambassador Program is com-
Under the NHSC Scholarship Program, student posed of about 650 members. College Ambassadors
recruits agree to serve 1 year as a salaried profes- help promote careers in primary care and inform,
sional in an approved underserved area after gradu- recruit, and support interested students. Community
ation for each year that they received the full tuition Ambassadors also help recruit clinicians and pro-
scholarship. After their commitment, scholarship vide mentorship and support for Corps members.
830 National Information Center on Health Services Research and Health Care Technology (NICHSR)
Program Success National Health Service Corps (NHSC): http://nhsc.bhpr

.hrsa.gov
Since its inception, the NHSC has supported over U.S. Public Health Service (USPHS): http://www.usphs.gov
27,000 health professional recruits in every state,
territory, and possession of the United States. In
2007, the program had 4,600 health profession-
als working in underserved urban and rural areas,
with 50% serving in community health centers. National Information Center
They serve 5 million people. As part of its mis- on Health Services Research
sion, the Corps hopes that its members will con-
tinue to practice in underserved communities and Health Care Technology
once they have fulfilled their obligatory service. (NICHSR)
Records show that many Corps members do not
stay at their original placement site, leaving the The National Information Center on Health
impression that access in underserved areas is not Services Research and Health Care Technology
dramatically improved in the long term. However, (NICHSR) was established by the federal National
further studies reveal that, although these profes- Institute of Health Revitalization Act of 1993 (PL
sionals do not necessarily stay in their original 103–43). A unit of the National Library of
placement site, many do go to other underserved Medicine (NLM), the NICHSR has the broad mis-
areas to practice. Over 75% of those who repay sion of improving the collection, storage, analysis,
their loans continue to work in underserved retrieval, and dissemination of information on
areas, while just over 60% of scholarship recipi- health services research, clinical practice guide-
ents remain. lines, and healthcare technology, including the
Ruth Ann Althaus assessment of such technology. The NICHSR has
a professional staff of six, including librarians and
See also Access to Healthcare; Health Professional a health data standards specialist. It reports to the
Shortage Areas (HPSAs); Health Resources and director of the NLM.
Services Administration (HRSA); Primary Care; Public
Health; Rural Health; Vulnerable Populations
Goals
The overall goals of the NICHSR are as follows:
Further Readings (a) to make the results of health services research,
Mullan, Fitzhugh. “The National Health Service Corps including clinical practice guidelines and technol-
and Inner-City Hospitals,” New England Journal of ogy assessments, readily available to health
Medicine 336(22): 1601–1604, May 29, 1997. practitioners, healthcare administrators, health
Mullan, Fitzhugh. “The Muscular Samaritan: The policymakers, payers, and the information profes-
National Health Service Corps in the New Century,” sionals who serve these groups; (b) to improve
Health Affairs 18(2): 168–75, March–April 1999. access to data and information needed by the cre-
Probst, Janice C., Michael E. Samuels, Terry V. Shaw, ators of health services research; and (c) to con-
et al. “The National Health Service Corps and tribute to the information infrastructure needed to
Medicaid Inpatient Care: Experience in a Southern foster patient record systems that can produce
State,” Southern Medical Journal 96(8): 775–83, useful health services research data as a by-prod-
August 2003. uct of providing healthcare.
Health services research is a multidisciplinary
field; its research domains include individuals,
Web Sites families, organizations, institutions, and communi-
Association of American Medical Colleges (AAMC): ties. As a result, evidence from health services
http://www.aamc.org research is spread through a variety of sources,
National Association of Community Health Centers often making it difficult for health professionals,
(NACHC): http://www.nachc.com healthcare administrators, and health policymakers
National Information Center on Health Services Research and Health Care Technology (NICHSR) 831
to find the information needed to guide their deci- database developed by the staff of AcademyHealth
sion making. It is the role of the NICHSR to meet and the Cecil G. Sheps Center for Health Services
this need by coordinating the development and Research at the University of North Carolina at
management of information resources and services Chapel Hill. Finally, the NLM’s Directory of
at the NLM in the fields of health services research Information Resources On-line, known as
and public health. DIRLINE, has a special subfile covering health ser-
vices research organizations, including those
involved in technology assessment and develop-
Databases
ment of clinical practice guidelines.
An important aspect of this role is the selection of
health services literature for the NLM’s collection,
Recent Activities
including both published research and grey litera-
ture (e.g., material that is not found through con- In 2005, the NICHSR launched the HSR
ventional channels such as recent technical reports Information Central, a Web portal designed to
and working papers from research groups or com- centralize access to health services research infor-
mittees). This function is coordinated jointly mation. The HSR Information Central was devel-
through the NICHSR, the Literature Selection oped with input from the Agency for Healthcare
Technical Review Committee (LSTRC), and the Research and Quality (AHRQ), the National
NLM’s Technical Services Division. This biblio- Cancer Institute (NCI), the Health Services
graphic information used to reside in a separate Research and Development Service (HSR&D) at
database known as HealthSTAR, but in 2000, it the Veterans Administration, and other organiza-
was integrated with other NLM resources. It is tions. A librarian evaluates each link on the HSR
now available in the following ways: (a) journal Information Central before it is added to the site,
citations are added weekly to the NLM’s PubMed; and users of the site are encouraged to submit
(b) books, book chapters, technical reports, and additional Web links via the “Suggest-a-Link”
conference papers are added regularly to the form available at the site.
NLM’s online catalog, LocatorPlus; and (c) meet- In addition to its online databases, the NICHSR
ing abstracts from AcademyHealth (formerly the and other NLM staff develop guides, fact sheets,
Academy for Health Services Research and Health bibliographies, and other products targeted to
Policy and the Association for Health Services health services researchers. The NICHSR has
Research) and Health Technology Assessment developed classes and other training materials
International (HTAi) (formerly known as the designed to assist health sciences librarians in pro-
International Society of Technology Assessment in viding health services research to their patrons.
Health Care) are accessible through the NLM Core library recommendations have been devel-
Gateway. oped for the areas of health services research meth-
In addition to these resources, the NICHSR odology, health outcomes, health economics, and
coordinates the development and maintenance of health policy. These lists include books, journals,
databases related to health services research. Available and Web sites and are intended to guide individu-
databases include the following: (a) HSTAT, a free, als unfamiliar with the subject area. The NICHSR
Web-based resource of full-text documents that has also created online self-study courses, such as
provide health information and support healthcare “Finding and Using Health Statistics,” “Introduction
decision making; (b) HSRProj, a database of cita- to Health Care Technology Assessment,” and
tions to research-in-progress funded by federal and “Health Economics Information Resources.”
state agencies and foundation grants and contracts; The NICHSR collaborates with NLM units and
and (c) Health Services and Sciences Research with members of the National Network of Libraries
Resources (HSRR), a free searchable catalog of of Medicine to exhibit NLM products and services
research databases, survey instruments, and soft- and to present training classes at national meetings
ware relevant to health services research, behav- of health services research–related organizations.
ioral and social sciences, and public health. The The NICHSR, along with other NLM staff, is an
HSRProj became available in 1995. It builds on a active participant in Partners in Information Access
832 National Institutes of Health (NIH)
for the Public Health Workforce. This initiative National Information Center on Health Services
works to improve information for public health Research and Health Care Technology. Introduction
working professionals. Other partners include the to Health Services Research: A Self-Study Course.
Agency for Healthcare Research and Quality Bethesda, MD: National Information Center on
(AHRQ), the American Public Health Association Health Services Research and Health Care
(APHA), the Association of Schools of Public Technology, 2007.
Health (ASPH), the Association of State and National Information Center on Health Services
Territorial Health Officials (ASTHO), the Centers Research and Health Care Technology. Finding and
Using Health Statistics. Bethesda, MD: National
for Disease Control and Prevention (CDC), the
Information Center on Health Services Research and
Health Resources and Services Administration
Health Care Technology, 2008.
(HRSA), the Medical Library Association (MLA),
Wilczynski, Nancy L., R. Brian Haynes, John N. Lavis,
the National Association of County and City
et al. “Optimal Search Strategies for Detecting Health
Health Officials (NACCHO), the National Services Research Studies in MEDLINE,” Canada
Network of Libraries of Medicine (NN/LM), the Medical Association Journal 171(10): 1179–85,
Public Health Foundation (PHF), and the Society November 9, 2004.
for Public Health Education (SOPHE). The
NICHSR also works closely with the AHRQ and
other organizations to improve the dissemination Web Sites
of the results of health services research.
Future Implications http://www.nlm.nih.gov/nichsr
National Library of Medicine (NLM):
The passage of the federal Health Insurance http://www.nlm.nih.gov
Portability and Accountability Act of 1996 (HIPAA) Partners in Information Access for the Public Health
created new challenges for health services research, Workforce: http://phpartners.org
focusing on computer-based patient records, secu-
rity, and privacy standards. Recent research and
development efforts at the NICHSR have focused
on the expansion of the Unified Medical Language National Institutes of
Systems’ Metathesaurus to improve its utility in
creating and retrieving computer-based patient Health (NIH)
records, as well as the funding of extramural
research and evaluation involving the creation and The National Institutes of Health (NIH) is the
use of computer-based patient records. principal federal agency responsible for overseeing
and financially supporting health-related and bio-
Susan Jacobson and Catherine Selden medical research. It funds and oversees research
conducted within the United States as well as
research conducted internationally. The primary
(AHRQ); Health Communication; Healthcare Web
Sites; Health Informatics; Health Services Research,
goal of the NIH is to promote health and prevent
Origins; Health Services Research Journals; National disease through health-related research that pro-
Institutes of Health (NIH); Technology Assessment vides significant insights and solutions to these
problems. The NIH is regarded as one of the
world’s leading biomedical research centers and it
Further Readings is the hub of medical research activity in the
National Information Center on Health Services nation. Researchers at the NIH are at the fore-
Research and Health Care Technology and front of finding ways to prevent, treat, and cure
AcademyHealth. Health Outcomes Core Library diseases as well as find the causes of rare and com-
Recommendations. Bethesda, MD: National mon diseases. The NIH works to improve the
Information Center on Health Services Research and health of people in the United States and save the
Health Care Technology, 2004. lives of millions.
National Institutes of Health (NIH) 833
The NIH consists of 20 institutes and 7 centers, studies and designated the newly established
each with its own specific areas of research and National Cancer Institute (NCI) as an Institute of
resources of health information. The NIH is 1 of the NIH. Accordingly, the NIH gradually began to
11 U.S. Public Health Service Agencies of the U.S. enlarge its facilities and research funding mecha-
Department of Health and Human Services (HHS). nisms. The NCI was already authorized by the U.S.
The NIH’s headquarters and main campus are Congress in 1937 through the National Cancer
located in Bethesda, Maryland, with satellite sites Institute Act (PL 75–244) to provide research
across the nation. In 2007, NIH had a staff of funds to nonfederal workers and to sponsor
more than 18,000 employees and a budget of research training fellowships outside of the organi-
nearly $28 billion. Additionally, more than 83% zation. As the other institutes were established,
of the NIH’s funds were awarded through com- between 1948 and 2000, the thriving NCI grants
petitive grants and contracts to over 325,000 and research training programs continued to
researchers located at universities, medical schools, expand. Funding for the NIH grew tremendously
and research institutions throughout the nation during this time period, from $2.5 million in 1944
and the world. to more than $1 billion in 1966. And NIH funding
has continued to expand.
History
Overview
The political and historical context has contrib-
uted to the multifaceted organization of the NIH’s Over the decades, the significant work of the NIH
institutes, centers, and offices and their myriad has resulted in numerous important discoveries
roles and responsibilities. The NIH began in 1887 and medical treatments that have saved the lives
with one research scientist, Joseph J. Kinyoun, of many, increased the life expectancy of the
working in a one-room laboratory within the nation’s population, and improved the quality of
Marine Hospital Service (MHS). As a physician he life of individuals. The NIH has been able to
was authorized to create the Hygienic Laboratory translate research findings into interventions that
located at Staten Island, New York. The Hygienic have benefited the general public, patients, and
Laboratory was primarily used to conduct bacte- their families. Furthermore, the outcomes of the
riological research focusing on screening for infec- NIH’s research have resulted in decreased death
tious diseases such as cholera among merchant rates from heart disease, stroke, HIV/AIDS, and
seamen and officers of the U.S. Navy. As a result, sudden infant death syndrome (SIDS); the increased
research activities were limited to biological inves- survival rate of childhood cancer patients; and
tigations, and they did not address other factors prevention of the spread of infectious diseases
affecting the public’s health. through vaccinations.
During the early 20th century, the general pub- In addition to conducting cutting-edge research
lic increasingly believed in the usefulness of science that has transformed medical science, the NIH also
to advance the health of Americans, which pro- provides funding and training opportunities. All its
vided numerous opportunities to expand the roles institutes support research, funding, and training
and responsibilities of the Hygienic Laboratory. A opportunities for research scientists in a variety of
series of legislative events prompted the transfor- settings such as hospitals, universities, and labora-
mation of the Hygienic Laboratory into a federal tories. The NIH centers also provide and coordi-
agency responsible for the nation’s health. nate resources that facilitate intensive research
In 1930, the Hygienic Laboratory was officially training and development of a strong national
renamed the National Institute of Health, and it research infrastructure. Under the guidance of the
was authorized to provide research training fel- Office of the Director, the 27 institutes and centers
lowships through the passage of the Ransdell Act aim to meet the four stated overarching goals of the
(PL 71–251). The U.S. Congress passed the Public NIH: (1) to foster fundamental creative discoveries,
Health Service Act (PL 78–410) in 1944, which innovative research strategies, and their applica-
gave the U.S. Surgeon General of the Public Health tions as a basis to advance the nation’s capacity to
Service (PHS) increasing authority to fund research protect and improve health significantly; (2) to
develop, maintain, and renew scientific human and Institutes

physical resources that will ensure the nation’s
The NIH comprises 20 different institutes that
capability to prevent disease; (3) to expand the
work to accomplish its overarching goals. Each
knowledge base in medical and associated sciences
institute is briefly discussed below.
in order to enhance the nation’s economic well-
being and ensure a continued high return on the
public investment in research; and (4) to exemplify National Cancer Institute
and promote the highest level of scientific integrity, The National Cancer Institute (NCI) was estab-
public accountability, and social responsibility in lished in 1937 to conduct and support research
the conduct of science. The establishment of these concerning the cause, diagnosis, prevention, and
institutes reflects the direction of present scientific treatment of cancer and to regularly provide fed-
discoveries and societal needs. Specifically, the NIH eral cancer statistics. Of all the institutes at the
concentrates its research agenda and educational NIH, the NCI has the largest budget, at nearly
efforts on input from expert researchers and clini- $4.7 billion. The NCI publishes a large number of
cians, patient advocacy and grassroots organiza- articles, books, and other material on various
tions, and representatives from the U.S. Congress. types of cancer, treatment options, clinical trials,
With federal funds, the NIH supports intramu- coping with cancer, testing for cancer, nutrition,
ral and extramural research studies in which both and cancer risk factors.
types of studies undergo a careful process of scien-
tific review before investigation, and they follow
strict guidelines throughout the research process. National Eye Institute
Intramural research activities are conducted in The National Eye Institute (NEI) was estab-
NIH laboratories and at the NIH Clinical Center lished in 1968 to conduct and support vision
at its main campus in Bethesda. Seven major NIH research to prevent and treat visual impairment
Inter-Institute Scientific Interest Groups are orga- and blindness. The NEI conducts public educa-
nized by the NIH Office of Intramural Research tional programs through its National Eye Health
and offer training opportunities and expert guid- Education Program. The NEI publications include
ance for junior researchers. The NIH Office of information about eye diseases and disorders and
Extramural Research (OER) develops and imple- eye care resources.
ments NIH grants, policies, and guidelines primar-
ily for university investigators. The NIH awards
funds to external organizations to help accomplish National Heart, Lung, and Blood Institute
its program goals through research grants, coop- The National Heart, Lung, and Blood Institute
erative agreements, and contracts. (NHLBI), established in 1948, fosters and furthers
In FY2006, approximately 50,000 research research on cardiovascular diseases as well as sleep
grants were awarded through the OER. Grant disorders. The NHLBI publications include health
applications and cooperative agreements are sub- assessment and educational resources for patients,
ject to a system of two separate peer reviews. One clinicians, and researchers.
is a scientific assessment, and the second is an
evaluation of the first assessment as well as
National Human Genome Research Institute
resource funding allocations.
Contracts are reviewed under a separate process The National Human Genome Research Institute
including a request for proposals (RFP) based on (NHGRI) was established in 1989 to represent the
the needs of the specific institute. RFPs are reviewed work of the NIH on the International Human
by peer reviewers and NIH staff reviewers. The Genome Project (IHGP). After the successful com-
offers that are deemed the most beneficial to the pletion of the IHGP in 2003, the NHGRI contin-
public are awarded contracts. The peer review sys- ues to conduct and support human genome
tem constructs a foundation of decision making research. The NHGRI educational resources
based on scientific integrity and responsibility include a Human Genome Project CD and genetics
regarding the federal stewardship of funds. and genomics education resources for the public.
National Institute on Aging National Institute of Biomedical

Imaging and Bioengineering
The National Institute on Aging (NIA), created
in 1974, is focused on better understanding the The National Institute of Biomedical Imaging
aging process through scientific research. and Bioengineering (NIBIB) is the most recently
Currently, the NIA funds external research studies established institute. Since 2000, it has worked to
on the biology of aging, behavioral research, neu- foster the study of biomedical technology and
roscience, and geriatrics and gerontology. The engineering. Currently, the NIBIB supports exter-
NIA’s publications include information related to nal research studies on biomaterials, biomedical
healthy aging, medications, safety, Alzheimer’s informatics, biomedical and medical imaging,
disease, health conditions related to aging, and nanotechnology, nuclear medicine, tissue engineer-
care giving. ing, and ultrasound.
National Institute on Alcohol National Institute of Child

Abuse and Alcoholism Health and Human Development
The National Institute on Alcohol Abuse and The National Institute of Child Health and
Alcoholism (NIAAA) was established in 1970 to Human Development (NICHD) was established in
conduct and support research on the causal fac- 1962 to conduct and support the study of infants,
tors, diagnosis, prevention, and treatment of alco- children, and their families and human develop-
hol-related conditions. The NIAAA’s publications ment across the lifespan. The NICHD currently
include the journal Alcohol Research and Health, supports external research studies on developmen-
professional education materials for researchers tal biology and perinatal medicine, reproductive
and clinicians, and pamphlets and brochures on health, child development, and pediatric and
alcohol-related topics for the public. maternal HIV/AIDS. It also sponsors health cam-
paigns to target problems such as autism, obesity,
and sudden infant death syndrome (SIDS).
National Institute of Allergy
and Infectious Diseases
National Institute on Deafness
National Institute of Allergy and Infectious
and Other Communication Disorders
Diseases (NIAID), which focuses on research on
infectious, immunologic, and allergic diseases, was Since its inception in 1988, the National Institute
established in 1948. The NIAID strategic plan for on Deafness and Other Communication Disorders
the 21st century includes further investigation of (NIDCD) has focused on the study of communica-
allergic diseases and asthma, autoimmune diseases tion disorders. Currently, the NIDCD is conduct-
(e.g., Type 1 diabetes, rheumatoid arthritis, and ing research studies on human communication and
multiple sclerosis), HIV/AIDS, tuberculosis, genetics, sensory and signal transduction mecha-
malaria, influenza, hepatitis, and bioterrorism. nisms, and physiological and developmental stud-
ies of the inner ear.
National Institute of Arthritis and
Musculoskeletal and Skin Diseases National Institute of Dental
and Craniofacial Research
The National Institute of Arthritis and
Musculoskeletal and Skin Diseases (NIAMS), cre- The National Institute of Dental and Craniofacial
ated in 1986, examines and supports research on Research (NIDCR) was established in 1948 to
the causal factors, diagnosis, prevention, and treat- conduct and support research on the causal fac-
ment of arthritis and musculoskeletal and skin tors, diagnosis, prevention, and treatment of cran-
diseases. The NIAMS’ Information Clearinghouse iofacial-oral-dental diseases and disorders. The
provides health information for professionals and NIDCR is currently conducting research studies on
the general public. genomics and proteomics, as well as the repair and
regeneration of tissues related to craniofacial- technology; genetics and developmental biology;

oral-dental diseases and disorders. and pharmacology, physiology, and biological
chemistry.
National Institute of Diabetes
and Digestive and Kidney Diseases National Institute of Mental Health
The National Institute of Diabetes and Digestive The National Institute of Mental Health (NIMH)
and Kidney Diseases (NIDDK), established in is charged with advancing research on the causal
1948, supports and conducts research on the study factors, diagnosis, prevention, and treatment of
of diabetes as well as endocrine, metabolic, diges- mental illness. It was established in 1949. Currently,
tive, kidney, urologic, and hematologic diseases. the NIMH funds external research studies on basic
The NIDDK clearinghouse provides publications neuroscience and behavioral science, adult and
for patients and researchers on diabetes and diges- pediatric mental disorders, biobehavioral processes
tive, kidney, and urologic diseases. related to HIV/AIDS transmission and infection,
and mental health interventions.
National Institute on Drug Abuse
National Institute of Neurological
Established in 1973, the National Institute on
Disorders and Stroke
Drug Abuse (NIDA) works to advance research
on the causal factors, diagnosis, prevention, and The National Institute of Neurological Disorders
treatment of drug abuse and addiction. The NIDA and Stroke (NINDS), created in 1950, conducts
provides a vast array of prevention and treatment and fosters research on the causal factors, diagno-
resources to healthcare providers, researchers, sis, prevention, and treatment of neurological dis-
parents, and teachers, as well as to students and ease and stroke. The NINDS areas of neuroscience
young adults. Currently, the NIDA supports research include, but are not limited to, the struc-
external research studies on treatment for drug ture and functioning of the nervous system through
disorders, drug abuse aspects of HIV/AIDS, genet- examining neural circuits, neural environment,
ics and genomics of drug addiction, and prescrip- neurodegeneration, and neurogenetics.
tion drug abuse.
National Institute of Nursing Research
National Institute of Environmental Since 1986, the National Institute of Nursing
Health Sciences Research (NINR) has focused its efforts on nursing
The National Institute of Environmental Health research among individuals, families, communi-
Sciences (NIEHS) was created in 1969 to conduct ties, and populations. Currently, the NINR areas
and support the study of environmental factors and of research emphasis include improving health
causes related to health and illness. The NIEHS promotion and quality of life, eliminating health
2006–2011 Strategic Plan includes goals to increase disparities, and advancing end-of-life research.
the understanding of environmental influences related
to human biology and to expand clinical research National Library of Medicine
programs on environmental exposures.
The National Library of Medicine (NLM),
established in 1956, strives to advance the study of
National Institute of General Medical Sciences biomedical informatics and communications. The
The National Institute of General Medical NLM is located at the NIH headquarters in
Sciences (NIGMS), active since 1962, focuses on Bethesda, Maryland, and serves as the world’s
the study of biomedical sciences for understanding largest medical library. The NLM’s online data-
the pathways of disease diagnosis, prevention, and bases, such as PubMed/Medline, include biomedi-
treatment. The NIGMS funds studies on bioinfor- cal publications from thousands of journals;
matics and computational biology; cell biology and MedlinePlus serves as a resource for health infor-
biophysics; structural genomics and proteomics mation for professionals and the general public.
Centers CAM products, energy medicine, traditional/

indigenous practices, and ethical and social issues
In addition to its 20 institutes, the NIH houses 7
related to the use of CAM.
research centers. Each center is briefly discussed
below.
National Center on Minority
Health and Health Disparities
Center for Information Technology
The National Center on Minority Health and
The Center for Information Technology (CIT) Health Disparities (NCMHD), established in 1993,
has been working to develop computer systems, conducts and supports research to improve minor-
provide computer facilities, and conduct computa- ity health and eliminate health disparities.
tional research since its creation in 1964. The Currently, the NCMHD provides loan repayment
CIT supports NIH’s institutes with information funds for researchers working in minority health
technology, computing, and telecommunications and health disparities research, as well as for those
services. For example, the CIT’s Division of who are developing external research training pro-
Computational Bioscience applies technologies to grams and centers.
biomedical applications such as biomedical infor-
matics and medical imaging.
National Center for Research Resources
Center for Scientific Review The National Center for Research Resources
(NCRR), created in 1962, provides researchers with
The Center for Scientific Review (CSR), which biomedical resources as well as technological sup-
was established in 1946, recruits and organizes port to develop successful clinical research environ-
expert peer reviewers into study sections to evalu- ments. Currently, the NCRR focuses on providing
ate the research grant applications sent to the NIH. support in biomedical technology, clinical research,
These external experts are recruited nationally and comparative medicine, and research infrastructure.
represent the areas of expertise needed to effec-
tively decide on funding of the most promising
research activities. NIH Clinical Center
Originally established as a research hospital
facility in 1953, the NIH Clinical Center (CC) sup-
John E. Fogarty International Center ports clinical research conducted by all the NIH
The John E. Fogarty International Center (FIC) institutes and centers. Admission to the CC is
was established in 1968 to promote and support selective and based on NIH study objectives. The
research on global health. Currently, the FIC funds CC also provides numerous training opportunities
research studies in the developing world on brain to researchers through lectures and computer-
disorders, maternal and child health, and infectious based training as well as fellowship programs.
diseases, such as HIV/AIDS and tuberculosis. It
also supports international research partnerships.
Future Implications
For more than a century, the NIH has been
National Center for Complementary
responsible for improving the nation’s health
and Alternative Medicine
through biomedical and behavioral research. The
In 1999, the NIH created the National Center NIH continues its important work of discovering
for Complementary and Alternative Medicine new knowledge to improve the nation’s health
(NCCAM) to focus on complementary and alter- through its ambitious research agenda. Additionally,
native medical (CAM) practices and training through its institutes and centers, the NIH strives
efforts. Currently, the NCCAM areas of research to provide resources and expertise in the broad
emphasis include mind-body medicine practices, spectrum of clinical medicine and public health.
pharmaceutical and pharmacokinetic properties of The NIH furthers its goals by sponsoring research,
838 National Medical Association (NMA)
fellowships, training, and infrastructure develop-

ment. Through the translation of biomedical National Medical
research discoveries into means of disease preven- Association (NMA)
tion and improvements in clinical outcomes,
reduction in the individual and societal burden of The National Medical Association (NMA) pro-
disease is being achieved. motes the collective interests of physicians and
Michelle Choi Wu patients of African descent and other minority
and underserved populations in the United States.
See also Acute and Chronic Diseases; Centers for Disease The association carries out this mission by serving
Control and Prevention (CDC); Cohort Studies; as the collective voice of Black physicians. It is a
Community-Based Participatory Research (CBPR); leading force for parity in medicine, the elimina-
Health Disparities; Mortality, Major Causes in the tion of health disparities, and the promotion of
United States; National Information Center on Health optimal health.
Services Research and Health Care Technology
(NICHSR); Randomized Controlled Trials (RCT)
History
The National Medical Association was founded
Further Readings in the fall of 1895 at the Cotton States and
Hannaway, Caroline, ed. Biomedicine in the Twentieth
International Exposition in Atlanta, Georgia, after
Century: Practices, Policies, and Politics. Washington,
a group of Black physicians were denied admis-
DC: IOS Press, 2008. sion into the American Medical Association
Robinson, Judith. Noble Conspirator: Florence S. (AMA). In a climate of segregation, the National
Mahoney and the Rise of the National Institutes of Medical Association was founded to provide an
Health. Washington, DC: Francis Press, 2001. organization for Black physicians and health pro-
Varmus, Harold. The Art and Politics of Science. New fessionals. Robert F. Boyd of Nashville, Tennessee,
York: W. W. Norton, 2009. served as the association’s first president.
Zerhouni, Elias A. “The NIH Roadmap,” Science The main priority for the first National Medical
302(5642): 63–72, October 3, 2003. Association’s agenda was how to improve the
Zerhouni, Elias A. “Translational and Clinical Science: health of the nation’s Black population, which
Time for a New Vision,” New England Journal of exceeded 10 million in 1912, and increase the
Medicine 353(15): 1621–23, October 13, 2005. number of Black physicians to adequately serve the
Zerhouni, Elias A., “NIH in the Post-Doubling Era: health of that population. The association’s mem-
Realities and Strategies,” Science 314(5802): bers worked on these priorities by opening hospi-
1088–1090, November 17, 2006. tals with an emphasis on physician training and by
Zerhouni, Elias A., and Barbara Alving. “Clinical and studying the major diseases contracted by Blacks,
Translational Science Awards: A Framework for a such as tuberculosis, hookworm, and pellagra.
National Research Agenda,” Translational Research In 1909, the first issue of the Journal of the
148(1): 4–5, July 2006. National Medical Association was published. Charles
V. Roman served as the journal’s first editor. From
its beginning, the journal focused on scholarly
Web Sites research and findings regarding the treatment, man-
National Institutes of Health (NIH): http://www.nih.gov agement, and prevention of illness and disease.
National Institutes of Health, Clinical Trials: In the 1940s, the National Medical Association
http://clinicaltrials.gov continued its efforts to eliminate discrimination in
National Institutes of Health, Institutes, Centers, & the nation’s hospitals and medical schools. In
Offices: http://www.nih.gov/icd 1951, the association was responsible for several
National Institutes of Health, Office of Extramural segregated medical schools located in the South
Research: http://grants.nih.gov/grants/oer.htm and nearby states beginning to admit Black stu-
National Institutes of Health, Research and Training dents. Within a 10-year period, the number of
Opportunities: http://www.training.nih.gov Black students attending these medical schools
National Medical Association (NMA) 839
doubled. By the 1960s, 14 of the 26 southern The National Medical Association sponsors a
medical schools admitted Black students. wide range of externally funded programs. These
In 1957, the first Imhotep National Conference include the Smoking Cessation Program, the
on Hospital Integration was held. This annual National Diabetes Education Program (cospon-
meeting was sponsored by the National Medical sored with the U.S. Department of Health and
Association, the National Association for the Human Services’ National Diabetes Education
Advancement of Colored People (NAACP), the Program [NDEP]), the Clinical Trials Project
National Urban League, and the Medico- Impact program to increase minority physicians
Chirurgical Society of the District of Columbia (an and consumer awareness and participation in
affiliate of the National Medical Association). This clinical trials, and the Black Bag Mentoring pro-
conference was successfully used as a platform to gram to facilitate African American residents’ and
disseminate strategies to foster the elimination of students’ access to practicing physicians.
segregation in healthcare. In 2004, the association formed The W. Montague
During the turbulent 1960s, the National Cobb/National Medical Association Health Institute.
Medical Association was a viable force in the The focus of the institute is to identify, develop, and
nation’s civil rights movement. The association implement solutions that will reduce racial and eth-
advocated for civil rights by coordinating sit- nic health disparities and improve the health of all
ins, marches, and picket lines and by lobbying Americans. The institute has four centers: (1) the
to pass a federal civil rights act. It supported Multicultural Health Center; (2) the Research,
Martin Luther King Jr.’s efforts to register vot- Surveillance and Professional Education Center; (3)
ers in Selma, Alabama, which ultimately led to the Community/Public Media Information Center;
the passage of the Civil Rights Act of 1965. The (4) and the Mobilization and Advocacy Center.
passage of this act was instrumental in giving The association holds an annual National
Blacks hope of improving their health status by Colloquium on African American Health to foster
outlawing discrimination in government-funded its advocacy mission by offering programs to train
health programs. In particular, the act assured healthcare leaders to address and eliminate health
them access to healthcare through Medicare disparities of Blacks, other minorities, the poor,
and Medicaid programs, and the professional and the medically underserved.
staffs and patient populations at hospitals were The National Medical Association’s advocacy
desegregated. efforts are continued through its International
Affairs Committee, which serves as a resource to
assist and enhance association members’ participa-
Activities
tion in medical missions around the world. In
Currently, the National Medical Association rep- addition, association members’ spouses formed the
resents more than 30,000 Black physicians and Auxiliary to the National Medical Association.
their patients. The association continues to publish The auxiliary’s current efforts consist of develop-
the Journal of the National Medical Association ing and promoting a National Auxiliary Program
monthly, the quarterly Healthy Living newsletter, on Health, Education, and Legislation.
targeted to physicians and patients, and the e-news- The association also supports the Student
letter NMA News. It also publishes the Convention National Medical Association (SNMA). Started in
Daily News, which is available at the association’s 1964 by medical students from Howard University
Annual Convention and Scientific Assembly, where College of Medicine and Meharry Medical College,
about 1,000 scientific sessions are held. the Student Medical Association currently has over
The association offers many continuing medical 5,000 members, including medical students, pre-
education (CME) courses at its national assembly medical students, residents, and physicians. Its
as well as at regional, state, and local society meet- primary focus is the needs and concerns of medical
ings offered in its 33 state and 98 local affiliated students of color, although its efforts include
medical societies. All its courses are accredited by encouraging elementary, high school, and college
the Accreditation Council for Continuing Medical students to consider and prepare for medical and
Education. scientific careers. The National Medical Association
840 National Patient Safety Goals (NPSG)
also provides a Career Center to assist in the

employment and recruitment of minorities into National Patient Safety
medical professions. Goals (NPSG)
Ophelia T. Morey
The Joint Commission’s National Patient Safety
See also Diversity in Healthcare Management; Ethnic and Goals (NPSG) address problematic areas in
Racial Barriers to Healthcare; Health Disparities; healthcare by using evidence- and expert-based
Health Workforce; National Healthcare Disparities solutions. The NPSG are composed of implementa
Report (NHDR); Physicians; Vulnerable Populations tion expectations and requirements for Joint
Commission–accredited organizations. Where
Further Readings possible, the goals focus on systemwide improve-
Braithwaite, Ronald L., and Sandra E Taylor. Health
ments. The goals are program specific and apply
Issues in the Black Community. 2d ed. San Francisco:
variously to ambulatory care, office-based sur-
Jossey-Bass, 2001. gery, behavioral healthcare, critical-access hospi-
Committee on Institutional and Policy-Level Strategies tals, disease-specific care, home care, hospitals,
for Increasing the Diversity of the U.S. Healthcare laboratories, long-term care, integrated delivery
Workforce, Institute of Medicine. In the Nation’s systems, managed-care organizations, and pre-
Compelling Interest: Ensuring Diversity in the Health ferred provider organizations (PPOs). All Joint
Care Workforce. Washington, DC: National Commission–accredited healthcare organizations
Academies Press, 2004. are expected to implement the goals or approved
Hansen, Axel C. “African Americans in Medicine,” alternatives to the services the organization pro-
Journal of the National Medical Association 94(4): vides in order to obtain or maintain their accredi-
266–71, April 2002. tation. The first goals were approved in 2002 and
LaVeist, Thomas A. Minority Populations and Health: have been updated annually since then.
An Introduction to Health Disparities in the United
States. San Francisco: Jossey-Bass, 2005.
Liebschutz, Jane M., Godwin O. Darko, Erin P. Finley, Development of the Goals
et al. “In the Minority: Black Physicians in Residency
and their Experiences,” Journal of the National Formed in February 2002, the Sentinel Event
Medical Association 98(9): 1441–8, September 2006. Advisory Group (SEAG), a panel of patient safety
Satcher, David, Rubens J. Pamies, and Nancy N., Woelfl, experts including nurses, physicians, pharmacists,
eds. Multicultural Medicine and Health Disparities. risk managers, and other professionals, oversees
New York: McGraw-Hill, 2006. the development and improvement of the NPSG
Schlueter, Eric M. “The Bridge to Diversity: The Role of and implementation requirements. Each year, the
the National Medical Association and the African- SEAG works with the Joint Commission staff to
American Physician,” Journal of the National Medical identify potential new goals and requirements
Association 98(9): 1515–17, 2006. through a systematic review of the relevant litera-
Wilson, Donald E., and Jeanette M. Kaczmarek. “The ture and information from available patient safety
History of African-American Physicians and Medicine incident databases, such as the Joint Commission’s
in the United States,” Journal of the Association for Sentinel Event Database and the U.S. Pharmacopeia’s
Academic Minority Physicians 4(3): 93–98, February Medmarx Database. Once potential goals are
1993. identified, input is sought from practitioners, pro-
vider organizations, purchasers, consumers, and
Web Sites patient advocacy groups. The SEAG then deter-
Auxiliary to the National Medical Association (ANMA): mines the highest-priority goals and requirements
http://www.anmanet.org and makes its recommendations to the Joint
National Medical Association (NMA): Commission. To maintain the focus of accredited
http://www.nmanet.org organizations on the most salient patient safety
Student National Medical Association (SNMA): issues, the SEAG may recommend the retirement
http://www.snma.org of selected goals or requirements. Retired goals or
National Patient Safety Goals (NPSG) 841
requirements will usually continue as accredita- already overstretched system. For example, Goal
tion requirements under the relevant accreditation 8, the “medication reconciliation” goal, calls for
standards. The gaps in goal numbering indicate healthcare organizations to obtain an accurate list
that a goal has been retired. of medications from patients and to define a pro-
Specifically, the 2008 NPSG goals for hospitals cess to ensure that information is accurately com-
were as follows: municated from provider to provider. The intent of
the goal is to prevent patient safety incidents
Goal 1: Improve the accuracy of patient involving adverse drug events by ensuring that
identification. healthcare providers have accurate patient medica-
Goal 2: Improve the effectiveness of tion information so that the provider can effec-
communication among caregivers. tively care for the patient. However, inordinate
attention has been paid to documentation or
Goal 3: Improve the safety of using medications.
“obtaining the list,” and therefore, the intent of the
Goal 7: Reduce the risk of healthcare-associated goal is sometimes lost. Organizations that have
infections. successfully implemented medication reconcilia-
Goal 8: Accurately and completely reconcile tion programs are those that have integrated the
medications across the continuum of care. practice of medication reconciliation into existing
processes and then worked to refine those pro-
Goal 9: Reduce the risk of patient harm resulting
cesses to eliminate duplication and redundancy.
from falls.
Organizations that struggle with implementing
Goal 10: Reduce the risk of influenza and medication reconciliation are those that tend to
pneumococcal disease in institutionalized add these processes on to existing systems without
older adults. considering the potential implications of doing so.
Goal 11: Reduce the risk of surgical fires.
Goal 12: Implement the applicable NPSG and Future Implications
associated requirements by components and
practitioner sites. The NPSG focus attention on problematic areas in
healthcare. Successful implementation of the goals
Goal 13: Encourage patients’ active involvement in
is challenging for healthcare organizations, given
their own care as a patient safety strategy.
the complexity of organizational systems, resources,
Goal 14: Prevent healthcare-associated pressure personnel, and cultures. There are no one-size-fits-
ulcers (decubitus ulcers). all solutions, and there is only emerging research
Goal 15: Identify safety risks inherent in its patient that supports the effectiveness of some of the
population. goals. Because the goals are intended to prevent
Goal 16: Improve recognition and response to patient harm and improve safety, the Joint
changes in a patient’s condition. Commission will continue in these efforts despite
the difficulties in implementation.
Last, the organization fulfills the expectations Gerard M. Castro
set forth in the Universal Protocol for preventing
wrong-site, wrong-procedure, and wrong-person See also Adverse Drug Events; Hospitals; Institute for
surgery, and associated implementation guidelines. Healthcare Improvement (IHI); International
Classification for Patient Safety (ICPS); Joint
Commission; Medical Errors; Patient Safety; Quality
Challenges in Meeting the Goals of Healthcare
Depending on the goal, healthcare organizations

may face various system, resource, personnel,
Further Readings
behavioral, and/or cultural barriers to goal imple-
mentation. Some goals have been consistently “2006 National Patient Safety Goals Matrix,” Joint
criticized for the added burden they place on an Commission Perspectives 25(8): 9–10, August 2005.
842 National Practitioner Data Bank (NPDB)
“Approved: Revisions to 2007 National Patient Safety medical and dental boards, (3) professional review
Goals and Universal Protocol,” Joint Commission actions taken by hospitals and other healthcare
Perspectives 27(3): 5–6, March 2007. entities exercising significant peer review activities,
“JCAHO to Establish Annual Patient Safety Goals,” (4) professional society membership actions, (5)
Joint Commission Perspectives 22(5): 1–2, May 2002. actions taken by the U.S. Drug Enforcement
“The Joint Commission Announces the 2008 National Administration (DEA), and (6) Medicare and
Patient Safety Goals and Requirements,” Joint Medicaid exclusions. Medical-malpractice pay-
Commission Perspectives 27(7): 1, 9–22, July 2007. ments are the most common type of report received
“The Joint Commission Announces the 2009 National
by the NPDB. Since its inception, the NPDB has
Patient Safety Goals and Requirements,” Joint
received about 320,000 medical malpractice
Commission Perspectives 28(7): 11–15, July 2008.
reports, which represent about 75% of all reports.
State licensure actions are the next most common
type of report, at 14%, followed by Medicare and
Web Sites
Medicaid exclusion at 8.0% and clinical privileg-
Joint Commission’s National Patient Safety Goals ing actions at about 4%. Professional society
(NPSG): http://www.jointcommission.org/ membership and DEA actions make up less than
PatientSafety/NationalPatientSafetyGoals 0.5% of all reports in the data bank.
Joint Commission’s Sentinel Event Advisory Group
(SEAG): http://www.jointcommission.org/
SentinelEvents/AdvisoryGroup Types of Providers Covered
While the NPDB covers a wide variety of medical
practitioners, physicians are those most often
National Practitioner reported to the data bank. Physicians make up
approximately 70% of all practitioners reported
Data Bank (NPDB) to the data bank. Dentists make up the next larg-
est group, at 13%, followed by nurses and nurs-
Administered by the Health Resources and Services ing-related practitioners, who account for 9%,
Administration (HRSA), the National Practitioner and chiropractors, who represent about 3% of
Data Bank (NPDB) is a federal information clear- those practitioners reported.
inghouse responsible for receiving, storing, and
disseminating information about medical mal-
Types of Entities Reporting
practice payments and adverse actions taken
against healthcare practitioners. Established under Just as there are a variety of types of reports in the
the Health Care Quality Improvement Act of NPDB, there are also a variety of entities provid-
1986, the NPDB began collecting data on ing those reports. Any entity that makes a medical
September 1, 1990. The purpose of the data bank malpractice payment on behalf of a practitioner
is to improve medical-care quality and safety by for full or partial settlement of a claim or judg-
restricting the ability of incompetent physicians, ment must submit a report to the NPDB. In gen-
dentists, and other practitioners to move from eral, medical malpractice reports are made by
state to state without the disclosure of previous insurers or carriers; however, these reports may
medical malpractice payments and adverse actions. also be filed by other types of organizations that
The NPDB is intended to be an alert system that make such payments. Self-insured hospitals, phy-
facilitates a comprehensive review of a healthcare sician groups, and managed-care organizations
practitioner’s professional credentials. can also file reports. State medical and dental
boards are required to report state licensure disci-
plinary actions related to professional competence
Types of Reports
or conduct. Other professional boards are not
The NPDB receives six types of reports: (1) medi- required to report to the data bank. Any hospital
cal malpractice payments made on behalf of a or other healthcare entity that takes a professional
practitioner, (2) licensure actions taken by state review action that restricts or suspends the clinical
National Practitioner Data Bank (NPDB) 843
privileges of a physician or dentist for more then Healthcare practitioners may self-query the
30 days must report that action to the NPDB. data bank about themselves at any time. A practi-
Physicians and dentists may voluntarily surrender tioner may dispute the accuracy of a report in the
or restrict their clinical privileges while being data bank or the fact that the report should have
investigated for possible professional incompe- been filed. If the dispute between the practitioner
tence or improper professional conduct in return and the report is not resolved, the practitioner may
for suspension of the investigation. In these cases, ultimately request a review of the report by the
the healthcare entity must also file a report. This Secretary of the HHS.
situation is considered a reportable clinical privi-
leging action. Clinical privilege actions for other
Research and Impact
practitioners may also be reported, but these
reports are not required. Professional societies are A great deal of research on the NPDB has focused
required to report membership actions taken for on using the longitudinal, national data set to pro-
reasons related to professional competence. The vide information on trends in medical malpractice
DEA provides up-to-date information on revoca- claims. For example, one study compared 2001–
tions and voluntary surrenders of its registration 2004 median anesthesia malpractice payments
numbers. Finally, Medicare and Medicaid exclu- with those for a similar period a decade earlier
sions are publicly available through the Federal and documented a 28% decrease in the number of
Register and do not require a specific reporting anesthesia-related payments per 100,000 popula-
entity. tion but a substantial increase in the median pay-
Federal agencies are not subject to the provi- ment amount from $69,330 to $205,222.
sions of the Health Care Quality Improvement Act While studies focusing on medical malpractice
of 1986. The Secretary of the U.S. Department of payments are most common, a few studies of
Health and Human Services (HHS) signed separate trends in adverse actions have also been published.
memoranda of understanding with various federal These studies tend to focus on the lack of reporting
departments to ensure their participation in the in this area. For example, one research study docu-
NPDB program. The Secretary signed memoranda mented that between 1991 and 1995 only 34% of
of understanding with the U.S. Department of hospitals reported one or more clinical privileging
Defense (DOD) in 1987, the DEA in 1988, and the actions against a physician. In addition, the annual
U.S. Department of Veterans Affairs (VA) in 1990. rate of reporting to the data bank for these types
Other memoranda of understanding include ones of actions actually fell over the period, from 12%
with the U.S. Public Health Service (PHS), signed in 1991 to 10% in 1995. Subsequent studies by the
in 1989 and 1990, and with the U.S. Coast Guard Office of the Inspector General (OIG) of the HHS
and the U.S. Department of Justice, Bureau of found that 60% of hospitals and 84% of health
Prisons, signed in 1994. Under those memoranda maintenance organizations (HMOs) had not
of understanding, 257 medical malpractice cases reported a single adverse action to the data bank
were reported to the NPDB through 2005. in almost 10 years of data collection.
A number of studies have focused on the quality
and usefulness of the data housed in the data bank.
Access to Information
The studies determined that, in general, querying
The only entities that are required to access entities found the reports in the data bank useful
information from the NPDB are hospitals. because they confirmed information received from
According to the authorizing legislation, all hos- other sources, although they did not often change
pitals are required to query the data bank when the credentialing decision of the entity. However,
a physician initially applies for employment or the studies also found a low level of completeness
membership on their medical staff, and at least of data in the data bank.
every 2 years thereafter. Other entities that exer- Another important area of research has been
cise significant peer review, such as managed- the potential impact of the NPDB on medical mal-
care organizations and physician groups, may practice claim settlements and adverse actions.
also query the data bank. A number of researchers and policymakers have
844 National Quality Forum (NQF)
hypothesized that in the face of the reporting flow of information in the presence of those defi-
requirements of the NPDB, individuals and organi- ciencies will continue to play an important role in
zations may take steps to avoid settlements or safeguarding the interests of both patients and
reportable adverse actions. This assumption is providers.
because a report to a federal data bank is consid-
ered onerous, notwithstanding that hospitals Teresa M. Waters and Peter P. Budetti
require physicians to submit the same information See also American Medical Association (AMA);
and the NPDB essentially serves as a check on phy- Credentialing; Health Resources and Services
sician honesty. Because of this perceived burden, Administration (HRSA); Malpractice; Medical Errors;
some have suggested that 29-day clinical privilege Physicians; Quality of Healthcare
suspensions, which are not reportable, are one
major explanation for the limited reporting of
adverse clinical privileging actions. Further Readings
In the arena of medical malpractice payments,
Sandstrom, Robert. “Malpractice by Physical Therapists:
the practice of corporate shielding has become an
Descriptive Analysis of Reports in the National
issue of major concern to policymakers. Because
Practitioners Data Bank Public Use Data File, 1991–
medical malpractice payments on behalf of institu-
2004,” Journal of Allied Health 36(4): 201–208,
tions are not reportable to the NPDB, some have
Winter 2007.
suggested that attorneys may be working out Waters, Teresa M., Peter P. Budetti, Gary Claxton, et al.
arrangements to name institutions, such as hospi- “Impact of State Tort Reforms on Physician
tals and corporate physician groups, rather than Malpractice Payments,” Health Affairs 26(2): 500–
individual physicians, in final settlements in order 509, March–April 2007.
to avoid reportable physician payments. This prac- West, Rebecca W., and Charles Y. Sipe. “National
tice may be responsible for the unexpectedly lower Practitioners Data Bank: Information on Physicians,”
number of medical malpractice reports to the Journal of the American College of Radiology 1(10):
NPDB. However, a study of physician medical 777–79, October 2004.
malpractice claim settlements before and after
implementation of the NPDB found that physi-
cians and insurers were significantly less likely to Web Sites
settle claims since the introduction of the NPDB, National Practitioner Data Bank (NPDB):
especially those less than $50,000. http://www.npdb-hipdb.hrsa.gov
Future Implications
Given the current view that quality and safety in
healthcare are the responsibility of the healthcare
National Quality
system rather than any single individual, the Forum (NQF)
approach of the NPDB may be antiquated because
it focuses on incompetent practitioners. However, The National Quality Forum (NQF) is charged
at this point in time, a number of factors suggest with planning, developing, establishing, and coor-
that the NPDB plays an important ongoing role in dinating voluntary consensus standards for health-
quality assurance. While hospitals are required to care quality, measurement, and reporting through
query the NPDB when credentialing physicians, a formal, structured consensus development pro-
many hospitals routinely use the data bank, ask- cess. Located in Washington, D.C., the NQF is a
ing questions that are not required, as part of their private, nonprofit organization with open mem-
credentialing process. It is also important to note bership that represents a unique consortium of
that the ideal healthcare system is not yet attain- over 350 public and private healthcare-related
able. Fragmentation and poor communication are organizations including federal agencies, health-
and will remain a reality for many years to come, care providers, consumers/patients, purchasers,
and information clearinghouses that facilitate the industry, and other stakeholders. In this capacity
National Quality Forum (NQF) 845
the NQF has significant influence over healthcare Functions

policy decisions made at the federal level.
The NQF’s primary activities fall into three
categories: (1) consensus development process;
(2) national healthcare priority setting and other
Background convening functions; and (3) leadership, educa-
In 1996, President Clinton created the U.S. tion, and award activities. Each of the categories
Advisory Commission on Consumer Protection is discussed below.
and Quality in the Health Care Industry. The
commission was given the broad charge of inves-
tigating the changes occurring in the nation’s Consensus Development Process
healthcare system and recommending measures to The consensus development process is the for-
promote and ensure healthcare quality and value mal process the NQF uses to develop and endorse
and protect consumers and workers in the health- voluntary national consensus standards. Projects
care system. In 1998, the commission’s final that undergo the consensus development process
report recommended the creation of a public- may be suggested by the NQF’s members, member
private forum for healthcare quality measurement councils, staff, and board of directors or by exter-
and reporting to focus incentives for quality nal entities. These projects must be consistent with
improvement on national priorities while ensur- NQF priorities.
ing the public availability of information needed Specifically, the consensus development process
to support the marketplace and oversight efforts. consists of five steps: (1) consensus standard
By May 1999, the Quality Forum Planning development; (2) widespread review; (3) member
Committee had put in place the structure needed voting; (4) consensus standards approval commit-
to establish the National Forum for Health Care tee action and the board of directors’ endorse-
Quality Measurement and Reporting, now known ment; (5) and evaluation. At the initiation of the
as the NQF, as a voluntary consensus standard- consensus development process, a steering com-
setting body. The NQF, empowered by the fed- mittee is formed to oversee, advise, and ensure
eral National Technology Transfer and that input is obtained from relevant parties.
Advancement Act of 1995 and the Office of Steering committees reflect the diversity of the
Management and Budget (OMB) Circular A-119, NQF membership and may also include technical
sets standards for the U.S. Department of Health advisors as needed. The measure developer (or
and Human Services (HHS), the Centers for steward) assumes responsibility for submission of
Medicare and Medicaid Services (CMS), and the candidate standards and updates to endorsed
Agency for Healthcare Research and Quality standards and provides input as requested to the
(AHRQ). deliberations of the steering committee. An NQF
project officer guides this process and acts as the
liaison between the committee and the NQF.
Organizational Structure The consensus standard development proce-
The NQF is governed by a board of directors dure results in draft recommendations that are
composed of individuals from its diverse member- based on those of the steering committee. They are
ship. The NQF members are organized into vari- reviewed, edited, and approved by the steering
ous member councils including the following: committee. And the steering committee must
consumer council; health plan council; health pro- reach a consensus before the draft recommenda-
fessional council; provider organization council; tions can proceed for further review, with all dis-
public/community health agency council; purchase senting views documented. Explicit description of
council; quality measurement, research, and the scientific base for the draft recommendations
improvement council; and supplier/industry coun- is required. Widespread review begins with NQF
cil. These councils contribute expertise to the member and public prevoting review of the draft
development of standards and vote on the endorse- recommendations. Members, member councils,
ment of national consensus standards. and the public have the opportunity to comment
846 National Quality Forum (NQF)
prior to initiation of voting. Based on the com- Leadership, Education, and Award Activities
ments of members and the general public, the
The NQF recognizes individuals and healthcare
NQF staff may revise the draft recommendations
organizations that have significantly contributed
and circulate such revisions to the steering com-
to the improvement of quality and the safety of
mittee for additional review prior to preparing the
care. The NQF and Modern Healthcare acknowl-
recommendations for voting. All comments are
edge the exemplary performances that have effec-
made available to members when voting on the
tively used performance measurements to drive
draft recommendations. All members are given the
change across various settings and times, fostered
opportunity to vote on the draft recommenda-
a transparent and accountable culture aimed at
tions. Members may approve the recommenda-
rebuilding the social contract between healthcare
tions, propose modifications and/or conditions, or
and the community, and increased the expected
vote not to approve the recommendations. All
level of a health system’s performance in the areas
results are then forwarded to the consensus stan-
of quality and safety with the National Quality
dard approval committee for consideration. That
Healthcare Award. In collaboration with the Joint
committee may approve the standard or recom-
Commission, the NQF presents the John M.
mend a second round of voting. The board of
Eisenberg Patient Safety and Quality Award annu-
directors will affirm or overturn the actions of
ally to individuals and healthcare organizations
the consensus standard approval committee.
that have made significant contributions to enhanc-
Recommendations endorsed by the board of direc-
ing patient safety through performing research and
tors are designated as NQF-endorsed consensus
providing service reflective of patients’ needs and
standards. Members and the public have the
perspectives. Honorees are acknowledged for indi-
opportunity to appeal an endorsement, and an
vidual achievement, research, advocacy, and sys-
appeal will be given due process review by the
tem innovation at the organizational, local,
appropriate committees. The board of directors
regional, and national levels.
will then act on the appeal by responding with a
rationale for maintaining or repealing the endorse-
ment. Since its inception, the NQF has endorsed Future Implications
over 200 consensus standards, ranging from adult
diabetes to safe practices for better healthcare. The NQF, recognized as one of the principal
organizations for quality and safety improve-
ment in the nation, endorses consensus-driven
National Healthcare Priority Setting healthcare standards, and develops national
and Other Convening Functions strategies for healthcare improvement. Through
The NQF is involved in numerous priority- these major areas, the NQF will likely continue
setting activities designed to improve the quality to influence the nation’s future healthcare policy
of healthcare in the nation. One example, estab- and promote system improvement and consumer/
lishing safe healthcare practices, includes efforts patient understanding.
in therapeutic drug management, cancer care, Gerard M. Castro
substance abuse, and healthcare-associated infec-
tions. The NQF is also involved in setting priori- See also Clinical Practice Guidelines; Hospitals; Joint
ties for public reporting improvement, payment Commission; Medical Errors; Patient Safety; Public
strategies, information technology, and health- Policy; Quality Indicators; Quality of Healthcare
care system performance. These efforts include
examination of patient safety incidence classifica-
tion, pay-for-performance, electronic medical Further Readings
records, and healthcare equity, effectiveness, and Ferrell, Betty, Steven R. Connor, Anne Cordes, et al.
efficiency. To obtain key stakeholder and mem- “The National Agenda for Quality Palliative Care:
ber input as well as to inform the public, the The National Consensus Project and the National
NQF convenes high-level meetings and confer- Quality Forum,” Journal of Pain and Symptom
ences regularly. Management 33(6): 737–44, June 2007.
Naylor, C. David 847
National Quality Forum. Safe Practices for Better at the Sunnybrook Health Science Centre in Toronto
Healthcare 2006 Update: A Consensus Report. and was responsible for developing the Institute for
Washington, DC: National Quality Forum, 2007. Clinical Evaluative Sciences, where he was the
National Quality Forum. “National Quality Forum inaugural chief executive officer. In addition, he
Issues Brief: Strengthening Pediatric Quality was one of the founding architects of Ontario’s
Measurement and Reporting,” Journal of Healthcare Cardiac Care Network.
Quality 30(3): 51–5, May–June 2008. Naylor has authored or coauthored over 300
U.S. Advisory Commission on Consumer Protection and publications in diverse fields such as social history,
Quality in the Health Care Industry. Quality First:
public policy, epidemiology, biostatistics, and
Better Health Care for All Americans: Final Report to
health economics, as well as clinical and health
the President of the United States. Washington, DC:
services research in most fields of medicine. He has
Government Printing Office, 1998.
been the driving force behind developing a capac-
Wakefield, Douglas S., Marcia W. Ward, Bonnie J.
Wakefield, et al. “A 10-Rights Framework for Patient
ity for multidisciplinary health research in Canada
Care Quality and Safety,” American Journal of
and was on the national task force that established
Medical Quality 22(2): 103–111, March–April 2007. the framework for the Canadian Institutes of
Health Research (CIHR). In 2003, Naylor chaired
the National Advisory Committee on SARS and
Web Sites Public Health. This Committee’s report led to the
creation of the Public Health Agency of Canada, to
National Quality Forum (NQF): increased commitments to public health at the
http://www.qualityforum.org national level, and to the appointment of Canada’s
U.S. Advisory Commission on Consumer Protection and first chief public health officer.
Quality in the Health Care Industry: In addition to publishing frequently cited papers,
http://www.hcqualitycommission.gov
Naylor has served on several editorial boards,
including the Journal of the American Medical
Association, the British Medical Journal, and the
Canadian Medical Association Journal.
Naylor, C. David Naylor’s service has been recognized through
major national and international awards for
C. David Naylor is the president of the University research and leadership in medicine, including the
of Toronto. He is an internationally recognized John Dinham Cottrell medal by the Royal
leader in the fields of health services research, Australasian College of Physicians, the Malcolm
evidence-based medicine, and health policy. Brown award by the Royal College of Physicians
Naylor received a medical degree from the and Surgeons, the Michael Smith award by the
University of Toronto in 1978 with scholarships in Medical Research Council, and the Research
medicine, surgery, and pediatrics. As a Rhodes Achievement award by the Canadian Cardiovascular
Scholar at Oxford University in the Faculty of Society. Most recently, he was appointed a fellow
Social and Administrative Studies, he earned a of the Royal Society of Canada.
doctoral degree in 1983. Subsequently, he trained
in general internal medicine at the University of Gregory S. Finlayson
Western Ontario and then for a year in Toronto as
See also Academic Medical Centers; Epidemiology;
a Medical Research Council of Canada (MRC) fel-
Evidence-Based Medicine (EBM); Health Services
low in clinical epidemiology.
Research in Canada; Infectious Diseases; Public
Prior to becoming the president of the University Health; Public Policy
of Toronto, Naylor was the dean of medicine and
Vice Provost of Relations With Health Care
Institutions at the University of Toronto. Previously,
he was a senior scientist of the Medical Research Further Readings
Council of Canada (MRC). Naylor also developed Naylor, C. David. Private Practice, Public Payment:
and led a research program in clinical epidemiology Canadian Medicine and the Politics of Health
848 Newhouse, Joseph P.
Insurance, 1911–1966. Kingston, Ontario, Canada: diverse areas as health insurance incentives, health-
McGill-Queen’s University Press, 1986. care payment systems, healthcare costs, health
Naylor, C. David, ed. Canadian Health Care and the technology, risk adjustment, medical malpractice,
State: A Century of Evolution. Kingston, Ontario, and the impact of poor health habits. While at the
Canada: McGill-Queen’s University Press, 1992. RAND Corporation (1968–1988), he markedly
Naylor, C. David. “Grey Zones of Clinical Practice: expanded its health research and health policy
Some Limits to Evidence-Based Medicine,” Lancet expertise. Most notable was the RAND Health
345(8953): 840–42, April 1, 1995. Insurance Experiment (HIE), one of the largest
Naylor, C. David. “Meta-Analysis and the Meta-
social science experiments in U.S. history. In lead-
Epidemiology of Clinical Research,” British Medical
ing the HIE, Newhouse oversaw an unprecedented
Journal 315: 617–19, 1997.
research effort for more than 15 years. HIE papers,
Naylor, C. David. “Leadership in Academic Medicine:
reports, and the definitive HIE summary Free for
Reflections From Administrative Exile,” Clinical
Medicine (London) 6(5): 488–92, September–October
All? form the canonical basis for understanding
2006.
healthcare demand and the response to insurance
Naylor, C. David, Cyril Chantler, and Sian Griffiths. incentives, healthcare quality, and health outcomes
“Learning From SARS in Hong Kong and Toronto,” in America.
Journal of the American Medical Association 291(20): Newhouse left the RAND Corporation and
2483–87, May 26, 2004. became a faculty member at Harvard University in
1988. As of 2007, he holds the ranks of John D.
MacArthur Professor of Health Policy and
Web Sites Management (jointly in the Faculty of Arts and
Sciences, Harvard Medical School, Harvard School
Canadian Institutes of Health Research (CIHR): of Public Health, and Kennedy School of
http://www.cihr.ca Government); Director, Division of Health Policy
Institute for Clinical Evaluative Sciences (ICES):
Research and Education; and Director, Interfaculty
http://www.ices.on.ca
Initiative on Health Policy. He created a doctoral
Public Health Agency of Canada (PHAC):
program in health policy that exemplifies produc-
http://www.phac-aspc.gc.ca/new_e.html
tive, collegial collaboration across the major
University of Toronto: http://www.utoronto.ca
schools at Harvard and that has trained more than
100 doctoral graduates now serving on university
faculties, in public health agencies, and major
health foundations.
Newhouse, Joseph P. Since 1966, Newhouse has authored or coau-
thored 350 publications (books, reports, and peer-
Joseph P. Newhouse is a preeminent health econo- reviewed journal articles). In 1981, Newhouse
mist. He has published extensively in the fields of founded the Journal of Health Economics, an
health economics, health policy, and health ser- important economics journal. He continues to lead
vices research. He also has trained many health the editorial board, having edited more than 1,000
economists. papers in the intervening years.
Born in 1942 in Waterloo, Iowa, Newhouse Newhouse has an extensive public service
earned a bachelor’s degree and doctoral degree in record. He has served as chair of the Prospective
economics from Harvard University. In 1963–1964, Payment Assessment Commission (ProPAC), com-
he was a Fulbright Scholar at the Johann Wolfgang missioner of the Physician Payment Review
von Goethe University at Frankfurt am Main in Commission (PPRC), and vice chair of the Medicare
the Federal Republic of Germany. Payment Advisory Commission (MedPAC). In
Since the early 1970s, Newhouse has been a 1977, he was elected to the national Institute of
leading researcher, public servant, and scholar in Medicine (IOM) and served two terms on the IOM
health economics and health policy. He conceived governing council.
and carried out significant, and in some cases Newhouse has been the recipient of numerous
unique, research projects; his research spans such awards, including the first David N. Kershaw
Nightingale, Florence 849
Award honoring persons under 40 years of age for Manning, Willard G., Emmett B. Keeler, Joseph P.
distinguished contributions to public policy analy- Newhouse, et al. “The Taxes of Sin: Do Smokers and
sis and management (1983), the Baxter Health Drinkers Pay Their Way?” Journal of the American
Services Research Prize and the Administrator’s Medical Association 261(11): 1604–1609, March 17,
Citation from the U.S. Health Care Financing 1989.
Administration (HCFA) (both in 1988), and the McClellan, Mark B., Barbara J. McNeil, and Joseph P.
Distinguished Investigator Award from the profes- Newhouse. “Does More Intensive Treatment of Acute
sional association AcademyHealth (1992). He is a Myocardial Infarction Reduce Mortality?” Journal of
the American Medical Association 272(11): 859–66,
past president of the Association for Health
September 21, 1994.
Services Research (now AcademyHealth) and the
Newhouse, Joseph P. Pricing the Priceless: A Health Care
International Health Economics Association, and
Conundrum. Cambridge: MIT Press, 2002.
he was the inaugural president of the American
Newhouse, Joseph P., and the Insurance Experiment
Society of Health Economics. He was elected fel- Group. Free for All? Lessons from the RAND Health
low of the American Academy of Arts and Sciences Insurance Experiment. Cambridge, MA: Harvard
(1995) and fellow of the American Association for University Press, 1993.
the Advancement of Science (2002). Newhouse, Joseph P., Willard G. Manning, Carl N.
Morris, et al. “Some Interim Results From a
Kathleen N. Lohr
Controlled Trial of Cost Sharing in Health
See also Health Economics; RAND Corporation; RAND Insurance,” New England Journal of Medicine
Health Insurance Experiment (HIE) 305(25): 1501–1507, December 17, 1981.
Further Readings Web Sites
Brennan, Troyen A., Lucian L. Leape, Nan M. Laird, Harvard Medical School, Department of Health Care
et al. “Incidence of Adverse Events and Negligence in Policy: http://www.hcp.med.harvard.edu
Hospitalized Patients: Findings from the Harvard Harvard School of Public Health, Department of Health
Medical Practice Study 1,” New England Journal of Policy and Management: www.hsph.harvard.edu/
Medicine 324(6): 370–76, February 7, 1991. departments/health-policy-and-management
Brook, Robert H., John E. Ware, William H. Rogers, Harvard University, John F. Kennedy School of
et al. “Does Free Care Improve Adults’ Health? Government: http://www.ksg.harvard.edu
Results from a Randomized Control Trial,” New
England Journal of Medicine 309(23): 1426–34,
December 8, 1983.
Cutler, David M., Mark B. McClellan, and Joseph P. Nightingale, Florence
Newhouse. “How Does Managed Care Do It?”
RAND Journal of Economics 31(3): 526–48, Autumn
Florence Nightingale (1820–1910) was responsi-
2000.
ble for professionalizing nursing. She also was a
Cutler, David M., Mark B. McClellan, Joseph P.
sanitarian, a hospital administrator, and an early
Newhouse, et al. “Are Medical Prices Declining?”
Quarterly Journal of Economics 113(4): 991–1024,
biostatistician. Born in Florence, Italy, in 1820, to
1998. a wealthy British couple, Nightingale grew up in
Hsu, John T., Maggie Price, Jie Huang, et al. England. She became well educated for a woman
“Unintended Consequences of Medicare Drug Benefit of those times. As a young woman, Nightingale
Caps,” New England Journal of Medicine 354(22): had a calling from God asking her to do His work,
2349–59, June 1, 2006. though she did not discover His plan until years
Leape, Lucian L., Troyen A. Brennan, Nan M. Laird, later. As a result of her interest in then current
et al. “The Nature of Adverse Events in Hospitalized social issues, she began to visit the homes of the
Patients: Findings From the Harvard Medical Practice sick in villages near her home. While a woman of
Study II,” New England Journal of Medicine 324(6): means would never become a nurse, on a tour in
377–84, February 7, 1991. Europe, she visited a Prussian hospital and school
850 Nonprofit Healthcare Organizations
for deaconesses in 1846. She later returned to She campaigned to improve health standards, writ-
train as a nurse, subsequently becoming, in 1853, ing extensively on the subject. Queen Victoria
the unpaid superintendent of a London establish- awarded her the Royal Red Cross in 1883.
ment for sick gentlewomen. Nightingale became the first woman to receive the
The Crimean War broke out in 1854; reports Order of Merit in 1907. She died at the age of 90
criticizing the British medical facilities for the in 1910.
wounded resulted in her appointment to officially
introduce female nurses into the military hospitals Rosemary Walker
in Turkey. Although the physicians did not initially See also Epidemiology; Farr, William; Health Services
welcome her and her nurses, the women’s skills Research, Origins; Hospitals; Nurse Practitioners
were quickly appreciated. Nightingale’s actions (NPs) Nurses; Public Health; Quality of Healthcare
improved both the sanitary and emotional status of
the wounded soldiers. Under her administration,
the mortality rate of patients in the hospital Further Readings
decreased significantly. Her rule that she should be
the only nurse in the wards at night earned her the Dossey, Barbara Montgomery. Florence Nightingale:
title of the “Lady With the Lamp.” Nightingale Mystic, Visionary, Healer. Philadelphia: Lippincott
Williams and Wilkins, 2000.
performed statistical analyses of disease and mor-
Kudzma, Elizabeth Connelly. “Florence Nightingale and
tality. She ultimately became the general superin-
Healthcare Reform,” Nursing Science Quarterly
tendent of the Female Nursing Establishment of
19(1): 61–64, January 2006.
the Military Hospitals of the Army.
McDonald, Lynn, ed. Florence Nightingale: An
Nightingale returned from the Crimean War in Introduction to Her Life and Family. Waterloo,
August 1856, soon participating in the creation of Ontario, Canada: Wilfred Laurier University Press,
the Royal Commission on the Health of the Army. 2002.
She contributed information in the form of her Miracle, Vickie A. “The Life and Impact of Florence
Notes on Matters Affecting the Health, Efficiency, Nightingale,” Dimensions of Critical Care Nursing
and Hospital Administration of the British Army, 27(1): 21–23, January–February 2008.
Founded Chiefly on the Experience of the Late Nightingale, Florence. Notes on Nursing: What It Is and
War. Presented by Request to the Secretary of What It Is Not. Philadelphia: Lippincott Williams and
State for War. Wilkins, 1992.
Nightingale was committed to the use of statis-
tics, which she employed to support her ideas on
healthcare and public health. She worked with the Web Sites
British statistician William Farr. As a result of her
Florence Nightingale International Foundation (FNIF):
statistical accomplishments, she became the first
http://www.fnif.org/nightingale.htm
woman to be elected as a fellow of the Royal
Florence Nightingale Museum:
Statistical Society, in 1858. http://www.florence-nightingale.co.uk
Perhaps Nightingale’s greatest achievement is
her elevation of the status of nursing: It became a
respectable profession for women. In 1860, she
established a nursing school at London’s St.
Thomas’ Hospital. Nurses, trained in her program,
Nonprofit Healthcare
worked in staff hospitals throughout Britain and Organizations
abroad, establishing nursing training schools using
her model. A nonprofit healthcare organization is legally
Nightingale was an advocate of the pavilion structured as a not-for-profit corporation and is
style of hospitals: completely detached pavilions, prohibited from distributing profits to its owners,
separating medical pathologies, to prevent the members, or other individuals with oversight for
spread of diseases. Her Notes on Nursing was first the organization. Nonprofits have a charitable
published in 1860; its latest printing was in 1992. mission related to the provision of healthcare
Nonprofit Healthcare Organizations 851
services, teaching, research, and/or community Tax-Exempt Status

service, and they are legally required to work
As tax-exempt entities, nonprofit healthcare
towards the mission. These organizations are
organizations are expected to provide community
owned by their “community,” which may be a
benefits, commonly achieved through charity care,
religiously affiliated or unaffiliated community or
education and training, research, and/or commu-
other nongovernmental association. Nonprofit
nity service. Tax-exempt status means that the
hospitals are the dominant type of hospital owner-
organization is exempt from paying federal, state,
ship in the United States. Other types of healthcare
and local taxes, including income, sales, and prop-
organizations may also be organized as nonprof-
erty taxes. In addition to being exempt from taxes,
its, including long-term care facilities and health
a nonprofit organization may use tax-exempt
plans. Only a small percentage of the nation’s
bond financing, which lowers its cost of capital
nursing homes are nonprofit, with the majority
investments. Nonprofit organizations have the
being proprietary or for-profit organizations.
advantage of being exempt from paying income
taxes on interest income generated from tax-ex-
empt bonds. Nonprofits may accept charitable
Characteristics donations, and donors may deduct these charitable
Several characteristics conceptually differentiate contributions. From the federal perspective, a
nonprofit from other types of ownership, particu- healthcare organization qualifies under Section
larly for-profit healthcare organizations, including 501(c)(3) of the Internal Revenue Service (IRS) tax
the primary stakeholders of these entities, the ben- code in the United States. Nonprofit organizations
efits of tax-exempt status, their sources of capital, must also meet state requirements for nonprofit
and the provision of community benefits. entities to receive a state income tax exemption as
well as local requirements for local sales and prop-
erty tax exemptions. These requirements vary by
Ownership state and are often more stringent than federal
requirements.
A nonprofit healthcare organization is owned
by its community, meaning that it is owned by a
community or other nongovernmental association, Sources of Capital
such as a church or fraternal organization, and is
governed by a voluntary, self-perpetuating board. Nonprofit healthcare organizations rely on sev-
Nonprofits may or may not be religiously affili- eral primary sources for capital. These include
ated. This is distinct from a for-profit healthcare charitable contributions, which are tax deductible
organization, which is owned by its shareholders by the donor, debt, retained earnings, and govern-
and governed by an elected board, and from a ment grants. Having a tax-exempt status provides
public hospital, which is owned by the federal, nonprofits with the opportunity to use tax-exempt
state, or local government and, in the case of fed- debt as one mechanism to finance capital invest-
eral and state-owned hospitals, principally serves ments. For-profit organizations use retained earn-
selected populations (e.g., military) or, as in the ings and debt to fund capital investments, but they
case of local, government-owned hospitals, often also use equity capital from investors and return-
serves the indigent. While for-profit organizations on-equity payments from third-party payers.
distribute their profits back to their shareholders,
nonprofit organizations are prohibited from dis-
Community Benefit
tributing profits to those who control the organi-
zation, although incentive-based compensation for Although the provision of community benefit is
organization leaders is common. Profits are implic- the linchpin of qualifying as a nonprofit healthcare
itly reinvested into the organization’s community— organization, there is no unambiguous definition
through enhanced services, new plant and of what community benefit entails, how it should
equipment, or other initiatives that provide a com- be measured, or what qualifies as a sufficient
munity benefit. amount in terms of measuring whether a nonprofit
852 Nonprofit Healthcare Organizations
organization meets its community benefit obliga- benefit, cross-institution comparisons would be
tions. Community benefit is generally considered questionable—reports of community benefit may,
to include services that are unprofitable but pro- for example, value charity care based on the
vide an important contribution to the community. charges for care provided to these patients, even
Uncompensated care, Medicaid-covered services, though charges reflect neither the organization’s
and certain unprofitable service lines are consid- costs nor expected payments. Organizations may
ered to be community benefit. Uncompensated or may not include bad debt and losses from ser-
care is composed of charity care and bad debt. vices provided to Medicare and Medicaid patients.
Charity care includes services that are provided
but for which the provider does not expect a pay-
Comparison of For-Profit
ment. Generally, the decision about whether ser-
and Nonprofit Organizations
vices qualify as charity care is made prospectively
or as early in the delivery of care as possible when The fundamental structure of nonprofits suggests
a prospective decision is not feasible. The provider that these organizations should behave in a man-
does not bill the patient or insurer, nor does the ner that differs from for-profit entities. The chari-
provider pursue collection of payment from an table mission—to provide a community benefit—of
external source. Hospitals often use a sliding scale a nonprofit differs from that of a for-profit, whose
based on income to determine whether an indi- implicit or explicit mission is to increase the
vidual is eligible for charity care and, if so, the wealth of its shareholders. The difference in mis-
amount of the discount. In addition, hospitals may sions suggests that nonprofit organizations should
use an asset test to determine eligibility. Bad debt, provide more services to the community in which
on the other hand, is care for which payment is they reside. In addition, because of the sharehold-
expected to be collected by either the patient or the er-driven mission, for-profits conceptually have a
insurer but is ultimately not paid. Hospitals make greater incentive to provide more and more profit-
an effort to collect these payments using internal able services than their nonprofit counterparts,
and/or external collections processes. Some argue which may mean providing fewer unprofitable
against the inclusion of bad debt as uncompen- services and serving fewer indigent patients.
sated care, because organizations make an active From a practical perspective, whether for-profit
attempt to collect payment from the patient and/or and nonprofit healthcare organizations are intrin-
insurer and, after a sufficient amount of time, elect sically different has long been debated. Some argue
to write off the uncollectible amount. that the economic incentives inherent in the distri-
Medicaid-covered services are classified as a bution of profits to shareholders are vastly differ-
community benefit, because reimbursement from ent from the incentives for organizations that do
state Medicaid programs is often below the cost of not answer to shareholders. Others maintain that
providing the care. In addition, certain unprofit- the ultimate motivation of both types of organiza-
able services lines, such as the emergency depart- tions is similar—both strive to maximize earnings
ment, high-level trauma, and labor and delivery, over expenses (i.e., accounting profits) and must
are considered as community benefits. Most non- meet the needs of the patient to remain profitable
profit hospitals also provide additional community and, therefore, should be expected to behave simi-
outreach programs, such as community health larly. In addition, the lines between nonprofits and
screenings, health education programs, immuniza- for-profits have blurred, due to relationships
tions, and community health assessments of unmet between the two.
needs. Research that generates findings available
to the community may also be included as a com-
Importance of Profit
munity benefit.
The valuation of community benefit is highly Regardless of the type of organization, both for-
variable across organizations. No consistent guide- profits and nonprofits must earn a profit or sur-
lines exist for how to quantify or report the dollar plus in the long run to remain financially viable.
value of these benefits. While nonprofit organiza- To achieve this goal, both types of organizations
tions may report a dollar amount of community must respond to their community’s needs and
Nonprofit Healthcare Organizations 853
provide high-quality care. While for-profits return have found no significant difference. Studies of
a portion of their profits to shareholders, they nonprofit to for-profit hospital conversions have
must also make investments in their organizations suggested that those converting to for-profit enti-
to remain competitive. Likewise, nonprofits could ties do not change their level of uncompensated
not achieve their missions without earning profits care provided to the community.
for future investments to remain competitive.
The Future of Nonprofit Healthcare
Hybridization of Ownership Type In recent years, nonprofit hospitals have been
While some organizations are purely nonprofit under increased scrutiny to explicitly quantify their
or for profit, others may have elements of both benefit to the community. Two findings have led
within the same corporation. Examples include a federal and state governments to investigate whether
nonprofit organization owning a for-profit subsid- nonprofits are meeting their community benefit
iary; a nonprofit organization contracting with a obligations. First, evidence has suggested that non-
for-profit organization to provide specific services, profit and for-profit hospitals provide similar levels
as when a community hospital contracts with a for- of uncompensated care, calling into question the
profit anesthesiology group to provide anesthesiol- marginal contributions that nonprofits make to the
ogy coverage in the surgical suite; and joint ventures community, which are required to qualify for tax-
between nonprofit and for-profit organizations. exempt status, and whether their marginal contri-
bution is equivalent to the tax benefits they receive
from possessing tax-exempt status. Second, because
Efficiency insurers negotiate payment rates with hospitals
While some claim that for-profits provide less that are lower than those charged by the hospitals,
efficient care, in terms of either providing more uninsured individuals have often been obligated to
services and more expensive care than needed or pay more for care than otherwise similar individu-
charging prices that are disproportionately higher als with insurance. Coupled with this issue, there
than costs compared with nonprofits, others argue have been complaints about aggressive debt collec-
that for-profits are more efficient because of their tion practices by nonprofit hospitals that contra-
underlying mission to generate a profit for share- dict the organizations’ charitable mission. Nonprofit
holders. Systematic evidence comparing the qual- hospitals’ billing and collection processes have
ity of care among nonprofit and for-profit hospitals been questioned in light of these organizations’
does not exist, however, to support these claims. tax-exempt status.
States have implemented a variety of require-
ments for nonprofit hospitals, in particular to
Quality of Care ensure that they are meeting their community
It has been argued that for-profits provide lower benefit obligations. State-mandated methods of
quality of care than their non-profit counterparts. demonstrating community benefit include the
However, there is little consistent evidence to sup- requirement of a written charity care policy that is
port this claim. While some studies have found accessible to patients; mandating a minimum
higher quality of care in nonprofit hospitals, other threshold for the value of community benefit as a
studies have found no difference or higher quality percentage of net patient revenue or operating rev-
in for-profits. enue; mandating that community benefit is at least
equivalent to the value of the tax-exempt benefits
received by the hospital; and routine documenta-
Uncompensated Care
tion of the hospital’s community benefit contribu-
Research has been mixed on whether nonprofit tions. As hospital competition continues, nonprofit
organizations provide more uncompensated care and for-profit hospitals will increasingly become
than their for-profit counterparts. Some studies less differentiated. The need for nonprofit hospi-
have found that provision of uncompensated care tals to be price, quality, and outcomes competitive
is greater among nonprofits, while other studies with for-profit hospitals will also continue. These
854 Nurse Practitioners (NPs)
organizations will need to justify their benefits to

the community while at the same time providing Nurse Practitioners (NPs)
care that is both of high quality and efficient.
Nurse practitioners (NPs) are nonphysician clini-
Tricia J. Johnson cians who are nurses with graduate degrees in
advanced-practice nursing. The primary function
See also Charity Care; For-Profit Versus Not-For-Profit
Healthcare; Hospitals; Multihospital Healthcare
of nurse practitioners is to promote wellness
Systems; Nursing Homes; Regulation; Uncompensated through patient health education. Their role has
Healthcare; Uninsured Individuals expanded to include the following: taking patients’
comprehensive health histories, performing physi-
cal examinations, ordering laboratory tests and
Further Readings procedures, and formulating and managing care
regimens for acutely and chronically ill patients.
Alexander, Jeffrey A., and Shoou-Yih D. Lee. “Does Nurse practitioners work in a variety of settings,
Governance Matter? Board Configuration and including physician offices, clinics, hospitals, and
Performance in Not-for-Profit Hospitals,” Milbank nursing home facilities. In 2008, there were about
Quarterly 84(4): 733–58, December 2006. 160,000 nurse practitioners in the United States.
Congressional Budget Office. Nonprofit Hospitals and
the Provision of Community Benefits. Pub. No. 2707.
Washington, DC: Congressional Budget Office, 2006. History
Cutler, David M. The Changing Hospital Industry:
The nurse practitioner movement began in the
Comparing Not-for-Profit and For-Profit Institutions.
United States in the mid-1960s, with the prepara-
Chicago: University of Chicago Press, 2000.
Peregrine, Michael W. “IRS Increases Emphasis on Not-
tion of pediatric nurse practitioners at the
for-Profit Health Care,” Healthcare Financial
University of Colorado. Initially, the profession
Management 61(8): 72–6, August 2007. was developed in response to a shortage of physi-
Potter, Sharyn J. Can Efficiency and Community Service cians, especially in rural areas where healthcare
Be Symbiotic?: A Longitudinal Analysis of Not-for- access was limited. Over time, other states also
Profit- and For-Profit Hospitals in the United States. began nurse practitioner training programs, and
New York: Garland, 2000. their role in healthcare greatly expanded. Today,
Salinsky, Eileen. “What Have You Done for Me Lately? nurse practitioners are integral to all kinds of
Assessing Hospital Community Benefit,” Issue Brief practices, including those located in underserved,
No. 821. Washington, DC: George Washington rural, and inner-city areas and in private collabo-
University, National Health Policy Forum, 2007. rations, independent practices, hospitals, and
Santerre, Rexford E., and John A. Vernon. “Ownership continuing care and nursing home facilities.
Form and Consumer Welfare: Evidence From the Additionally, other countries such as the United
Nursing Home Industry,” Inquiry 44(4): 381–99, Kingdom, Canada, Australia, and New Zealand
Winter 2007–2008. have embraced nurse practitioners.
Web Sites
Clinical Roles

The most significant clinical role of nurse practi-
http://www.nonprofithealthcare.org tioners relates to their professional efficacy and
American Hospital Association (AHA): autonomy in practice. They can diagnose, treat,
http://www.aha.org prescribe medications, order diagnostic testing,
Catholic Health Association of the United States (CHA): and refer patients to other healthcare profession-
http://www.chausa.org als. Nurse practitioners monitor and adopt evi-
Internal Revenue Service (IRS): http://www.irs.gov/ dence-based practice and bring the framework of
publications/p557/ch03.html prevention, early intervention, and patient/family
National Association of Community Health Centers health education into their work. In the United
(NACHC): http://www.nachc.com States and other countries, nurse practitioners
Nurse Practitioners (NPs) 855
have a specific license for practice. In the United framework for nurse practitioners are as follows:
States, most such licenses are granted and super- (1) the process of care, including assessment of
vised by a state’s board of nursing. This licensing health status, diagnosis, development of a treat-
distinguishes nurse practitioners from physicians’ ment plan, implementation of the plan, and fol-
assistants, who typically practice under direct low-up evaluation of the patient; (2) care priorities,
supervision of physicians and whose practices are including patient and family education, provision
authorized by a state’s board of medicine. of competent care, facilitation of entry into the
While nurse practitioners can and often do healthcare system, and a safe environment; (3)
work independently, most have collaborating phy- interdisciplinary and collaborative responsibili-
sicians who review cases and provide ongoing ties as a member of the healthcare team; (4) accu-
consultation. The nursing board in a particular rate documentation; (5) patient advocacy; (6)
state may or may not require the existence of a quality assurance and continued competence; (7)
relationship with a physician colleague. However, adjunct roles, including mentor, educator,
most advanced-practice nurses and physicians researcher, manager, and consultant; and (8)
alike find the relationship stimulating and infor- research as a basis for practice. These standards
mative. The teamwork nature of such collabora- reflect an origin in the general practice of nursing.
tion often is visible in primary-care practices or Nurse practitioners do not replace nurses in prac-
hospital specialty services, where physicians and tice settings. Rather, nurses and nurse practitio-
nurse practitioners work in the same setting. ners provide a broadened skill mix from which to
Patient satisfaction and patient outcomes in these serve patients.
collaborative practices are similar to or better than
in many traditional, physician-only practices.
Doctorate in Nursing Practice
From the comprehensive nature of these stan-
Preparation
dards, nursing educators realized that the depth
Nurse practitioners are prepared at the master’s and extent of preparation warranted redefining
level or beyond. The educational programs are the earned education credential as a practice doc-
designed to make the graduate eligible for certifi- torate similar to that given in other professions,
cation as a nurse practitioner in a specific area, such as pharmacy, medicine, and dentistry.
such as care of families, children, or adults, in The American Association of Colleges of
psychiatry, or in women’s health. Certification is Nursing (AACN) approved a policy statement
gained by completing the requisite educational saying that the doctor of nursing practice (DNP)
program and passing an examination offered by degree be required for entry into nursing practice
specific certifying bodies. These entities are gener- as an advanced practice nurse by 2015. With this
ally associated with a specific practice, such as policy statement, the AACN outlined the eight
midwifery. A significant educational requirement essential elements of doctoral education for
is actual practice under the close supervision of a advanced practice nurses. These elements include
licensed and certified nurse practitioner, with a (1) the scientific underpinnings for practice,
minimum of 1 year of practice, or a physician. (2) organizational and systems leadership for
Four hundred or more hours of such practice are quality improvement and systems thinking,
required. Some specialties require additional train- (3) clinical scholarship and analytical methods for
ing, such as working with a minimum number of evidence-based practice, (4) information systems/
mothers in childbirth to qualify in midwifery. technology and patient care technology for the
improvement and transformation of healthcare,
(5) healthcare policy for advocacy in healthcare,
Practice Standards
(6) interprofessional collaboration for improving
The American Academy of Nurse Practitioners patient and population health outcomes, (7) clini-
(AANP) defines the standards of practice for cal prevention and population health for improv-
nurse practitioners and updates or revises them ing the nation’s health, (8) and advanced nursing
periodically. The eight standards defining the practice.
856 Nurses
Disadvantages of the requirement of the DPN typical concern is the authority of nurse practitio-
degree may include the increased costs to the stu- ners to prescribe medications. While all states have
dents due to longer programs of study. There is a authorized them to write prescriptions, this author-
nationwide shortage of faculty in nursing schools. ity was approved on a state-by-state basis. Florida
Initially, the costs of educating DNP degree stu- also has restrictions on the number and types of
dents by doctorate of philosophy (PhD)–prepared nurse practitioner-managed offices that physicians
faculty may prove challenging, but the growing may supervise, and other states may choose to fol-
numbers of DNP graduates will quickly offset this low this example.
shortage. Finally, the costs to the nation’s health-
care system may be increased by DNPs who Anne R. Bavier
command higher salaries than current nurse prac- See also American Association of Colleges of Nursing
titioners. The additional preparation, however, (AACN); American Nurses Association (ANA);
should bring additional clinical leadership and Hospitals; Medicare; National Institutes of Health
skills to ensure that the latest scientific findings are (NIH); Nurses; Quality of Healthcare
readily translated into patient services.
Further Readings
Future Implications
American Nurses Credentialing Center. A Role
While licensed independently, nurse practitioners Delineation Study of Seven Nurse Practitioner
only recently gained legal authority to bill sepa- Specialties. Silver Spring, MD: American Nurses
rately from physicians. A provision in the federal Credentialing Center, 2004.
Balanced Budget Act of 1997 states that nurse Buppert, Carolyn. Nurse Practitioner’s Business Practice
practitioners can receive direct Medicare Part B and Legal Guide. 3d ed. Sudbury, MA: Jones and
reimbursement, which is 85% of the physician Bartlett, 2008.
rate. Prior to this legislation, nurse practitioners Chase, Susan K. Clinical Judgment and Communication
had to file under a physician’s Medicare provider in Nurse Practitioner Practice. Philadelphia: F. A.
number. Some private insurance companies, how- Davis, 2004.
ever, did not follow the change in Medicare regu- Fairman, Julie. Making Room in the Clinic: Nurse
lations and do not allow nurse practitioners to Practitioners and the Evolution of Modern Health Care.
seek payment under their own provider number. New Brunswick, NJ: Rutgers University Press, 2008.
Variations also exist among state Medicaid pro- Mezey, Mathy B., Diane O. McGivern, Eileen M.
grams. California, for example, authorized nurse Sullivan-Marx, et al., eds. Nurse Practitioners:
practitioners to bill its Medicaid program, Medi- Evolution of Advanced Practice. 4th ed. New York:
Cal, directly, and be reimbursed at 100% of the Springer, 2003.
physician reimbursement rate.
Many areas of the nation are expanding the role
of nurse practitioners. As of 2006, all 50 states Web Sites
have awarded nurse practitioners prescription American Academy of Nurse Practitioners (AANP):
authority, with varying limitations. Many states http://www.aanp.org
also include controlled substances among the American Association of Colleges of Nursing (AACN):
medications nurse practitioners can prescribe. http://www.aacn.nche.edu
Because they possess independent licenses, nurse American Nursing Association (ANA):
practitioners are viewed as challenges to health- http://www.nursingworld.org
care quality by some groups, most notably the
American Medical Association (AMA). The AMA’s
concern is that nurse practitioners do not have the
same preparation as physicians and should, there- Nurses
fore, be closely supervised. State legislatures, where
efforts to shape nurse practitioner practices are Nurses are an integral part of the nation’s health-
revisited often, can reflect this tension. An area of care system, providing treatment and care to ill or
Nurses 857
injured patients. There are currently more than knowledge that underpins the practice. Her view
2.9 million nurses in the United States, which was bolstered by her singular focus to catalog rel-
includes registered nurses (RNs), licensed practical evant information from all disciplines. She and her
nurses (LPNs), nurse practitioners (NPs), and oth- colleagues accomplished this work long before
ers. While the definitions and theories about the computerized databases or nursing and allied
field of nursing continue to grow and change, the health indexes existed. She defined nursing for
role of the nurse remains vital for medical care. practitioners worldwide as assisting individuals,
sick or well, in the performance of those activities
contributing to health or its recovery (or a peace-
History
ful death) that they would perform unaided if they
The modern term nurse is derived from the Latin had the necessary strength, will, or knowledge,
word nutrire, meaning to nourish or nurture. and to do this in such a way as to help them gain
Florence Nightingale (1820–1910) is considered the independence as rapidly as possible. Henderson’s
founder of modern nursing. Recent analysis of definition embraces the concept that nurses meet
Nightingale’s letters to the Sisters of Mercy, who patients wherever they are on a health, illness, and
accompanied her to battlefields in the Crimea, death continuum. It resonated with nurses world-
reveal that she was greatly influenced by these reli- wide, resulting in many translations of her work.
gious women, who provided crucial skills in orga- Single-handedly, Henderson stimulated the inter-
nizing and implementing care for the injured and national recognition of the common threads that
wounded. On her return to England, Nightingale join all nurses.
used this experience and knowledge to become a
clear advocate for patient care, specifically the kind
Struggle to Advance the
done by nurses. In 1859, Nightingale articulated the
Science of Nursing Practice
defining characteristic of nursing knowledge as
“putting the constitution in such a state as it will Continuing Henderson’s work, early nursing
have no disease,” or that it can recover from dis- scholars based their science on social, biological,
ease. She provided the profession significant public and medical sciences. Yet they remained chal-
respect at a time when nurses were viewed as lenged to articulate what was specific to the prac-
untrained and incompetent. After the Crimean War, tice of nursing. Beginning in the 1950s, the
around 1856, the public view of nursing evolved scholars in nursing began to develop and dissemi-
from the negative portrayal to that of an angel of nate various nursing models. In particular, efforts
mercy, largely due to Nightingale’s influence. were aimed at theory development so that nursing
The image of nursing continued to form and could develop specific evidence to guide its prac-
re-form. Today, nurses are largely viewed as tice. Interestingly, most of the nursing research
careerists. During the 1920s, nurses were often conducted into the mid-1980s focused on the indi-
viewed as women whose priorities were romance, viduals who were either nurses or nursing stu-
marriage, and motherhood. By the end of World dents, not on the nursing actions they performed.
War II, however, nurses were seen as heroines and This approach changed dramatically after 1986,
professionals. This portrayal soon reverted to a when the U.S. Congress created the National
“sex object” image, where nurses were seen as Center for Nursing Research within the National
women who were satisfying the needs of men and Institutes of Health (NIH). Nursing research then
male physicians. The careerist image, however, became part of the largest biomedical science
began to compete with the “sex object” image entity in the nation. NIH funds support rigorous
throughout the mid-1960s and into the 1980s, scientific efforts to promote the understanding of
when it finally became predominant. what happens to patients, without regard for the
characteristics of the provider. Financial support
of investigations of nursing workforce issues
Contemporary Definition of Nursing
remained in other parts of the U.S. Department of
Virginia Henderson (1897–1996), another pio- Health and Human Services (HHS), such as the
neer in nursing, was dedicated to the scientific Agency for Healthcare Research and Quality
858 Nurses
(AHRQ) and the Health Resources and Services Contemporary Nurses and Nursing
Administration’s Bureau of Health Professions
The contemporary nurse is a well-educated pro-
(BHPr).
fessional, either male or female. With more than
2.9 million nurses in the United States, RNs are
Nursing Theories the largest constituent of the nation’s healthcare
professions. Nursing distinguishes itself with a
The nursing conceptual models describe the
holistic focus on the patient and families and
interrelationship of concepts and the application
attention to actual or potential health problems.
of theory to identify, analyze, interpret, and
Nurses meet healthcare needs in virtually all set-
evaluate client-based interventions and out-
tings, with more than half employed in hospitals,
comes. Four concepts appear in most nursing
followed by community and public health cen-
theories or models: the person, the environment,
ters, ambulatory care, nursing homes, and nurs-
the nurse, and health. These theories are gener-
ing education. Today’s nurse uses assessment
ally classified as middle-range or practice theo-
skills to diagnose a patient’s response to illness
ries. This remains a major descriptor of nursing
and potential health conditions or needs and
theories today. A thorough review of nursing
then develops an individualized plan of care.
theories demonstrates the continuing impact of
Nurses also collaborate with other healthcare
other health disciplines, with reliance on devel-
professionals. A rich lexicon of nursing diagno-
opmental scholars, such as Helen Erikson and
ses and evidence supports professional nursing
Abraham Maslow, and the behavioral and socio-
practice. The professional nurse continuously
cultural sciences.
evaluates and modifies the patient’s care plan
Dorothy Johnson’s Behavioral System Model,
and adjusts interventions to achieve the best pos-
established in 1959, focuses on common human
sible outcomes.
needs, care and comfort, and stress and tension
reduction. In 1964, Imogene King’s Systems
Framework, on the other hand, examined per-
sonal, interpersonal, and social systems. Myra
Current Nursing Shortage
Levine sought the need to move nursing away The United States currently faces a major crisis in
from the medical model and, in 1996, developed nursing—the shortage of nurses presently and the
her Conservation Model, which focuses on adap- increasing shortage predicted in the next 25 years.
tation as a means to preserve the integrity and This shortage began in the late 1990s and is unlike
wholeness of the person. Levine’s work often is previous shortages. Historically, classic principles
used in combination with standardized nursing of supply and demand mediated the crisis.
nomenclatures, such as the Nursing Intervention Employers made economic and other enticements
Classification, to capture the practical benefits of to make nursing a more desirable profession, and
this model. The Betty Neuman Systems Model, educational institutions increased enrollments to
developed in 1972, also includes the concepts of meet the demand. However, multiple factors make
adaptation, client holism, and stress in the client the current shortage different from those experi-
environment. enced in the past.
Dorthea Orem began developing her theory in Not only is the nation’s general population
the 1950s and formally presented her Self Care aging, but the nursing workforce itself is aging as
Model in 1970. The theory focused on nursing well. Data from the 2004 National Sample Survey
practice to move patients toward independence. of Registered Nurses indicate that the population
That same year, Martha Rogers presented her of nurses is aging quickly. For example, the aver-
theory of the Science of Unitary Human Being, age age of nurses in the nation is 46.8 years, with
which is not built on causality but is congruent approximately 41% over 50 years of age. Only
with an action worldview. Another product of the 8% are less than 30 years of age. It is anticipated
1970s was the Sister Callista Roy Adaptation that there will be more than 1 million RN vacan-
Model, which concentrates on the adaptation pro- cies by 2010. From 2000 through 2004, the aver-
cesses of individuals, families, and groups. age age of graduating nurses was 32.6 years, in
Nurses 859
contrast to 27.8 years in 1984. In sum, the current Academy of Nursing (AAN) aimed to identify the
nursing population is aging, and those who enter characteristics of hospitals associated with best
the field are older than before. Clearly, there is a practices, and strong patient outcomes were iden-
pressing need to expand the pipeline of those tified. Now, those hospitals can become desig-
entering the nursing profession, especially at a nated as Magnet Hospitals, through the American
younger age. The potential for women to enter the Nurses Credentialing Center. The designation is
historically male-dominated professions, such as awarded by examining both qualitative and
medicine and other fields, has changed nursing quantitative evidence of meeting 65 standards
demographics and presents a challenge to increas- that define the highest quality of nursing practice
ing the number of nurses. and patient care.
Nursing school leaders indicate that a national Another strategy to overcome the nation’s
faculty shortage is the major reason that more than shortage of nurses is to recruit and retain nurses
32,000 qualified applicants are not enrolled annu- who were educated in other countries. The number
ally. Nursing faculty are on average 55 years of age of foreign nurses in the United States totaled
or older, with 20% anticipating retirement in the approximately 90,000 in 2004, and they were
next 10 years. Competition for clinical placement most common in California, Florida, New York,
sites and space in general science laboratory Texas, New Jersey, and Illinois. In some countries,
courses compounds the difficulties faced by aca- such as the Philippines, there is a deliberate effort
demic administrators as they attempt to expand to prepare individuals to work in their native
enrollment. country as well as in the United States. In general,
Changes in the nation’s healthcare delivery sys- nurses are lured from poor nations by the promise
tem have shifted most medical care from hospitals of higher wages. However, such migration patterns
to outpatient settings. Those patients who are can deplete nations of their own healthcare work-
admitted to hospitals today experience illness force.
intensities comparable with those in intensive-care
units less than 50 years ago. Multiple societal fac-
Nursing Education
tors, such as major changes to how Medicare cal-
culates reimbursements to hospitals, converged to Early nursing education began as informal confer-
create new strategies for cost containment and ences and lecture-style training by physicians
control throughout healthcare, especially in hospi- to nursing students in hospital-based programs.
tals. As nurses are the largest component of most The nation’s first formal nursing school was
hospitals’ personnel expenditures, multiple established in 1872 at the New England Hospital
approaches were undertaken to shift from an for Women and Children in Boston. Using
expensive, intensive RN workforce to less expen- Nightingale’s model of nursing preparation, other
sive and less well-educated personnel. schools were soon established, including the New
Nurses and other healthcare workers became York Training School at Bellevue Hospital, the
alarmed at the diminishing quality of care associ- Connecticut Training School for Nurses, and the
ated with the decreasing numbers of nurses Boston Training School for Nurses at Massachusetts
directing patient care. In some states, such as General Hospital.
California, nurses successfully lobbied for state Hospital-based nursing training programs used
laws that specify the ratio of nurses to patients. the apprenticeship model in awarding the graduate
Other advocates, such as the national Institute of a diploma. In the middle of the 20th century, there
Medicine (IOM), called for systematic and sys- was a shift from the diploma program to college or
temic efforts to manage patient care and decrease university preparation, with the introduction of
medical errors. Health services researchers have the 2-year associate degree. Many hospital-based
examined patient outcomes in relation to the nursing programs were shortened from 3 to 2
preparation of the nursing staff. These studies years to compete, but eventually most closed or
documented better outcomes when patient care is merged into academic programs. In 2006, diploma
directed by nurses with a baccalaureate or higher programs made up only 4% of all the basic RN
degree. Seminal work supported by the American education programs in the nation.
860 Nurses
In 1952, the associate degree in nursing was 710,000 LPNs in the nation in 2005. There is a
developed at Teacher’s College, Columbia separate licensing examination for LPNs and LVNs
University in New York. To alleviate the nursing that is overseen by the National Council of State
shortage of that time, this degree was designed to Boards of Nursing (NCSBN). Their scope of practice
prepare technical nurses in 2 years. Typically, is regulated by State Boards of Nursing, which typi-
associate-degree nursing programs are offered at cally describe LPN practice as under the direction of
community or technical colleges. Graduates may the RN with great emphasis on physical care and
take the RN licensure examination, because they related medical procedures.
are taught nursing theories and have gained practi- The percentage of nurses who had earned a high
cal and technical experience and skills. In 2005, school diploma decreased from 63.2% in 1980 to
associate-degree programs made up 58.9% of all 25.2% in 2004. During that same period, nurses
U.S. basic nursing education programs. The graduating with an associate’s degree increased from
increased demand for nurses is felt keenly at the 18.6% to 42.2%, and nurses entering the profession
community college level, where waiting lists for with a baccalaureate degree or higher increased
admission may have more than 1,000 individuals from 17.4% to 31%. With the findings that better
for 60 openings. patient outcomes are associated with nurses with a
As the demand for further professionalism baccalaureate or higher degree directing care, there
grew, many programs developed to offer a bacca- is concern that the continuing large percentage of
laureate degree in nursing. The University of diploma and associate-degree nurses entering the
Minnesota School of Nursing opened in 1909 and field may be a disadvantage to patients.
is considered the first university-based nursing
education program in the nation. The Yale
Licensure
University School of Nursing opened in 1924 and
offered the first program contained within an To practice as RNs, all graduates must prove their
autonomous academic unit. The baccalaureate competency by passing a national examination.
degree with a major in nursing reflects the richness The examination is administered by the NCSBN
of the academy’s curriculum with liberal arts and and called the National Council Licensure
science courses designed to prepare individuals as Examination for Registered Nurses (NCLEX-RN).
critical thinkers, both in nursing and in life. Today, Successful completion of the examination is nec-
the degree is earned in 4 years. However, 5-year essary for licensure in all states. Individual state
programs existed through most of the 1960s, as laws and regulations govern the practice of nurs-
nursing faculty struggled to merge clinical content ing in each state. State differences concern topics
into educational models of academia. In 2005, such as the requirements for continuing educa-
there were 573 U.S. colleges and universities offer- tion, the delegation of authority to other provid-
ing a baccalaureate degree in nursing. ers, and the scope of advanced practice. A
Within the nursing profession, there has been compact now exists among several states so that
lengthy debate to define the appropriate education participating states automatically recognize and
level for entry into practice. The American Nurses accept the nursing license of individuals from
Association (ANA) and the National League for another compact state. Most states, however,
Nursing (NLN) both support the baccalaureate accept only the test results and require an applica-
degree to enter general practice as an RN. Others, tion for practice within its boundaries. With
such as the American Association of Colleges of nurses increasingly using telecommunications to
Nursing (AACN), support entry into general prac- address patient issues across state lines, the
tice at the master’s level and into advanced prac- demand for more compact state agreements will
tice at the doctoral level. likely grow.
It is important to note that preparation for
LPNs—called licensed vocational nurses (LVNs) in
Future Implications
some states—occurs nationwide often in the last year
of a high school program or the 1st year of an Nursing is a dynamic profession that remains
associate-degree program. There were approximately focused on patient outcomes, including peaceful
Nursing Home Quality 861
death. Nursing scholars continuously develop the

evidence necessary to refine the practice, while Nursing Home Quality
healthcare leaders support and recognize the
importance of nursing to the totality of healthcare Life in all its richness occurs in nursing homes.
in the United States. Sickness, love, caring, kindness, anger, abuse,
indifference, excitement, boredom, laughter, sex,
Zepure Boyadjian Samawi, and death all transpire in nursing homes. Time-
Katie Rich, and Anne R. Bavier study data indicate that the average nursing home
resident receives less than 1½ hours of care each
See also American Association of Colleges of Nursing
day from nursing staff, indicating that treatment is
(AACN); American Nurses Association (ANA);
Hospitals; National Institutes of Health (NIH);
a relatively small proportion of what fills the
Nightingale, Florence; Nurse Practitioners (NPs); everyday life of nursing home residents. Thus,
Quality of Healthcare although excellent care and treatment are impor-
tant, quality of care is only one aspect of quality
in the nursing home. Because nursing homes are
Further Readings where people live, as well as receive health and
rehabilitative care, discussions of nursing home
Buerhaus, Peter I., Douglas Staiger, and David I. quality become at the most global level delibera-
Auerbach. The Future of the Nursing Workforce in tions about how to measure and ensure residents’
the United States: Data, Trends, and Implications.
well-being, in the fullest sense of the term.
Sudbury, MA: Jones and Bartlett, 2009.
While nursing homes serve a variety of popula-
D’Antonio, Patricia, Ellen Baer, Sylvia Rinker, et al., eds.
tions, quality of care for long-stay residents is the
Nurses’ Work: Issues Across Time and Place. New
focus here. This entry first provides basic informa-
York: Springer 2006.
Kalisch, Philip A., and Beatrice J. Kalisch. American
tion on nursing homes and their occupants. Next,
Nursing: A History. 4th ed. Philadelphia: Lippincott
it discusses how quality of care is usually measured
Williams and Wilkins, 2003. in nursing homes. It then discusses the larger issue
Katz, Janet R. A Career in Nursing: Is It Right for Me? of quality of life. Last, it discusses the current qual-
St. Louis, MO: Mosby Elsevier, 2007. ity assurance process in nursing homes and the
Roux, Gayle M., and Judith A. Halstead. Issues and future of nursing home care.
Trends in Nursing: Essential Knowledge for Today and
Tomorrow. Sudbury, MA: Jones and Bartlett, 2009.
Nursing Homes and Nursing Home Residents
Ryan, Adam J., and Jack Doyle, (eds. Trends in Nursing
Research. New York: Nova Science, 2008. This discussion of nursing home quality necessar-
Styles, Margretta M. Specialization and Credentialing in ily occurs within the context of the current nursing
Nursing Revisited: Understanding the Issues, home industry and resident population. On any
Advancing the Profession. Silver Spring, MD: given day, approximately 16,000 nursing homes in
American Nurses Association, 2008. the United States provide care for roughly 1.6 mil-
lion residents. Most nursing homes are for-profit,
investor-owned enterprises operated by multifacil-
Web Sites ity chains. The average size of nursing homes is
American Academy of Nursing (AAN):
approximately 100 beds, with an occupancy level
http://www.aannet.org below 90%. Over two thirds of longer-stay nurs-
American Association of Colleges of Nursing (AACN): ing home residents receive their care under the
http://www.aacn.nche.edu auspices of state Medicaid programs. Recent data
American Nurses Association (ANA): indicate that state Medicaid programs pay on
http://www.nursingworld.org average about $120 per day (over $40,000 annu-
Bureau of Health Professions (BHPr): http://bhpr.hrsa.gov ally) for care. Private-pay residents now pay an
National Institute of Nursing Research (BHPr): average of about $190 per day (almost $70,000
http://www.ninr.nih.gov annually). The federal Medicare program pays the
National League for Nursing (NLN): http://www.nln.org bulk of costs for shorter-stay residents.
862 Nursing Home Quality
Almost all nursing homes accept Medicaid and/ quality of care. In nursing home research, the
or Medicare funds. Receipt of these public funds structural quality measure with the greatest impact
requires that a nursing home be licensed by the on process and outcome quality is nurse staffing.
state and certified to participate in and receive pay- Turnover of direct-care staff, nursing supervisors,
ment from these programs. Licensure and certifica- and administrators are also structural measures
tion carry with them an elaborate array of that gather considerable attention as instances
requirements about financial reporting and resi- where quality of care is put at risk. Some evidence
dent care. The most basic of these requirements indicates that for-profit ownership also tends to
involve annual cost reports and annual on-site sur- be associated with poorer-quality care, but part of
veys by multimember teams who evaluate the that relationship may be attributed to the gener-
degree to which a nursing home meets state licen- ally lower staffing levels and higher staff turnover
sure and federal certification standards. at for-profit homes. Process quality measures that
Most admissions to nursing homes (just over receive the most attention are the presence of uri-
50%) come from hospitals. A large number of nary incontinence without a scheduled toileting
individuals, over the course of a year, come into plan, the use of physical restraints, psychotropic
nursing homes and then either die or leave within medication use, the prevalence of feeding tubes, or
weeks. These short-stay individuals who return the use of urinary catheters.
home are largely in the nursing home to recover Outcome measures of importance for measuring
from some acute disease episode such as the flu or nursing home quality include mortality, declines in
to recover from an acute exacerbation of a chronic functional status or activities of daily living (e.g.,
disease condition such as diabetes or from physi- ADLs), worsening cognitive status, worsening con-
cal, speech, or occupational rehabilitation after a ditions (e.g., continence), accidents, falls, or hospi-
fall or stroke. On any given day, these short-stay talizations for ambulatory-care-sensitive conditions
residents constitute about 10% of a nursing (e.g., diabetes). Unfortunately, little research finds
home’s population, but they constitute over 60% strong links between these outcomes and the vari-
of all individuals admitted annually to nursing ous process quality measures noted above. For both
homes. Only about one quarter to one third of short- and long-stay residents recovering from an
those admitted to a nursing home will be in the acute disease episode, significant improvement is a
same nursing home 3 months after admission. common outcome. However, that is not the case for
Only about 10% of long-stay nursing home the average long-stay nursing home resident.
residents are under 65 years of age. The average Analyses of nursing home quality are almost
long-stay nursing home resident is a female over invariably observational studies. To enhance their
75 years of age. Generally, she suffers from multi- validity, observational studies involving process
ple chronic diseases and has a number of health quality or outcome quality measures usually require
problems, which are likely to include arthritis, some type of case-mix or acuity adjustment. A
hypertension, heart disease, and diabetes as well as major difficulty arises in studies of nursing home
decreased ability to see and hear. Like the majority quality focused on outcomes. In these studies, it is
of the residents surrounding her, she has episodes difficult to determine the degree to which any
of urinary incontinence and some level of cognitive undesirable outcome resulted from poor nursing
impairment. She also needs significant physical home performance rather than from the natural
assistance with a number of activities of daily liv- processes of declining health beyond the nursing
ing (ADLs). home’s control. For example, a resident’s decline in
ADL function does not mean with certainty that
poor care occurred. Instead, unavoidable decline
Quality of Care
in one of the resident’s chronic disease or health
Like other health services researchers, investiga- conditions (e.g., congestive heart failure) may have
tors conceptualize nursing home quality in terms adversely affected his or her ADL function. For
of Avedis Donabedian’s triad of structure, only a few outcome quality measures is poor qual-
process, and outcome, with most researchers con- ity of care a truly necessary condition (e.g., medi-
sidering outcomes the most telling indicator of cation errors).
Nursing Home Quality 863
Those researchers involved in the necessary risk Each of these approaches, however, is troublesome.
adjustment process in nursing home outcome stud- Observers cannot assess all aspects of quality
ies have two options. Either they can include vari- of life. More fundamentally, observers (even
ables in their models that may overadjust, giving family members) are not the true recipients of
some nursing homes undeserved credit for bad- care and may not share residents’ perceptions
quality care, or they can omit some variables from of services or living arrangements. Residents are, of
their models, possibly underadjusting and failing course, the ideal reporters. However, a large pro-
to give some nursing homes credit for good-quality portion of residents suffer from levels of cognitive
care. For example, when looking at pressure ulcer impairment that make interviewing them difficult
rates in a nursing home, should one adjust for or impossible.
residents being bedfast? Being bedfast clearly raises The most extensive effort aimed at developing an
the likelihood of a pressure ulcer. But why is a interviewing strategy for quality of life resulted in
resident bedfast? The resident may be bedfast 10 dimensions. However, the measurement scales
because of some natural process of declining reflecting only a few of these dimensions demon-
health, such as increased respiratory distress, or he strated good internal consistency. Additionally,
or she may be bedfast because the nursing home facility characteristics explained very little of the
failed to provide an aggressive mobility program variance in quality of life. Reasonably, residents’
that would have kept the resident mobile. Thus, characteristics were much stronger predictors of
including whether a resident is bedfast in an acuity their quality-of-life scores. Such measures, as the
adjustment model for the presence of pressure developers indicate, are at this point probably best
ulcers may be overadjusting, but omitting it from used to identify cognitively intact residents within
the model may mean underadjusting. the nursing home who might be the focus of indi-
Researchers can avoid confounding the impact vidualized interventions. While these measures are
of individual factors and nursing home perfor- not yet well-suited for assessing nursing homes’
mance by looking at changes over time in resident performance in general, they are important steps in
status, using only admission information as base- the process of moving quality of life into the main-
line data. For almost all residents, provider perfor- stream of nursing home quality measurement.
mance and resident characteristics are orthogonal
at admission. However, using this approach,
Quality Assurance
researchers must show that the early months of
care that serve as the focus of most such efforts do As the national Institute of Medicine (IOM),
not differ dramatically from outcomes later in a Committee on Nursing Home Regulation met over
resident’s nursing home stay. 20 years ago, the committee chair Sidney Katz
described quality assurance in nursing homes as a
three-legged stool requiring good assessments,
Quality of Life
good standards, and good enforcement. The IOM
Quality-of-life issues for nursing homes and their report from this committee provided a blueprint
residents can incorporate a long list of dimen- for a new approach to ensuring quality in nursing
sions. These include, but are not limited to, help- home care. The Nursing Home Reform Act in the
ing preserve residents’ dignity, respecting their Omnibus Budget Reconciliation Act of 1987
privacy, maintaining positive relationships with (OBRA-87) was a direct descendant of the IOM
staff or other residents, serving high-quality food, committee’s report. OBRA-87 mandated a compre-
enhancing opportunities for resident autonomy, hensive assessment system titled the Resident
assuring their security, and providing a clean and Assessment Instrument or Minimum Data Set
pleasant physical environment. (MDS), which served as the first leg of Katz’s stool.
Quality-of-life data can be gathered in two New standards in OBRA-87 that included quality-
ways. Researchers can observe some of these of-life issues and focused more heavily on outcomes
dimensions, such as staff-resident interactions, than paper compliance formed the second leg.
using standardized tools. Residents can also report Then, new enforcement remedies, which included
on their perceptions concerning all these dimensions. fines, temporary management, and placing a hold
864 Nursing Home Quality
on Medicaid admissions to a nursing home, were each published indicator. That this assumption is
added to the traditional remedies of deficiency state- rarely tested is, at this point, a problematic aspect
ments from the annual certification and licensure of nursing home performance measurement.
survey conducted by the states and de-certification
of the nursing home, to give the stool a truly solid
Future Implications
base. The MDS was implemented in 1989. However,
the enforcement standards and remedies were held The past few years have been marked by the nurs-
up for many years by the nursing home industry. ing home industry’s emphasis on quality improve-
When finally implemented, they were watered ment rather than quality assurance, the seeming
down, and the expanded range of remedies has not failure of the current enforcement model, and the
been used vigorously by most states. lack of serious enforcement activities. At the same
Current activities in quality assurance in nursing time, a group of innovators have begun to offer
homes have begun to focus more heavily on quality alternative models of nursing home operations
indicators reporting and public information. The that focus directly on resident-centered care and
Centers for Medicare and Medicaid Services’ enhanced quality of life. The Eden Alternative, the
(CMS) Nursing Home Compare (NH Compare) Pioneer Network, the Wellspring Initiative, and the
Web site allows individuals to obtain detailed Green House Movement are important examples
information about the past performance of every of such alternative models of nursing home opera-
Medicare- and Medicaid-certified nursing home in tions. All these models focus on more resident-
the nation. The reports in NH Compare include centered care that emphasizes quality-of-life issues
data on deficiencies cited during the annual (9–15 and better working conditions for nursing home
months apart) survey visits, quality indicators staff. The Green House Movement takes a lesson
(QIs) from the MDS, and staffing data gathered from the group home model in community mental
during the annual survey visits. While MDS data health and goes so far as to deconstruct the aver-
may reflect what is in the medical records, recent age 100-bed nursing home into a series of cottages
research indicates that the staffing data reported to with permanently assigned nurse aides and “cir-
CMS by for-profit and larger nursing homes, when cuit-riding” clinical staff.
compared with Medicaid cost report data, may Where these innovations have successfully been
overreport staffing levels. A number of state-level implemented and sustained, they have resulted in
reporting systems are somewhat more elaborate changes in the quality of life for residents. However,
than NH Compare. Some state systems provide most nursing homes lack the willingness or ability
relative rankings of nursing homes (e.g., one to implement and sustain such innovations. With
through four stars) and include data on financial an industry dominated by for-profit, owned busi-
performance and expenditure patterns as well as ness entities and with high average turnover rates
more traditional and staffing data. Initial research for senior administrative and clinical staff (ranging
findings indicate that such reports may affect nurs- from 6 to 18 months), the likelihood of sustained,
ing home activities, but there is no convincing evi- pervasive change in the nursing home industry
dence that such reports affect consumer choices. seems relatively low. Some nursing homes, often
In addition, a few researchers are now empha- not-for-profits in the least need of transformation,
sizing the degree to which nursing home perfor- may change and sustain those innovations. Many
mance affects traditional quality indicators. Early nursing homes will likely focus on avoiding bad
research indicates that a relatively small percentage survey results and lawsuits, while maintaining the
of the variation in ADL function over time may be level of quality that allows them to receive an
attributable to nursing home performance. To the appropriate return on their investments.
degree that this conclusion is supported by further A panel of distinguished experts in long-term
research into other quality indicators, the quality- care were recently asked what they thought would
reporting movement in the nursing home sector be the “one thing” that might have the greatest
may be at some risk. These reporting systems likelihood of enhancing quality in long-term care.
implicitly assume that nursing home performance The most frequent answer was additional staff-
explains a meaningful proportion of the variance in ing, followed closely by additional funding. But
Nursing Homes 865
some of the less frequent answers were interesting Gabriel, Celia S. “An Overview of Nursing Facilities:
as well. One expert said that the real problem lies Data From the 1997 National Nursing Home
in the dominance of investor-owned businesses in Survey.” Advance Data From Vital and Health
the nursing home industry. Another expert sug- Statistics, No. 311. Hyattsville, MD: National Center
gested that the greater involvement of communi- for Health Statistics, 2000.
ties in nursing homes would bring considerable National Commission on Long-Term Care Quality. From
benefit. Isolation to Integration: Recommendations to
Some policy analysts, however, consider nurs- Improve Quality in Long-Term Care. Washington,
DC: National Commission on Long-Term Care
ing quality to be something of a vestigial issue.
Quality, 2007.
They believe that the current “rebalancing” of
Wunderlich, Gooloo, and Peter O. Kohler, eds.,
long-term care reimbursement to provide more
Committee on Improving Quality in Long-Term Care.
incentives for home care, combined with the
Improving the Quality of Long-Term Care.
growth of the assisted living industry, will sound Washington, DC: National Academies Press, 2001.
the death knell for the nursing home industry.
However, many doubt that either home care or
assisted living can be the panacea that these ana- Web Sites
lysts believe. They argue that home care cannot be
American Association of Homes and Services for the
effective without adequate staff and considerable
Aged (AAHSA): http://www2.aahsa.org
family support; and the availability of individuals
American Health Care Association (AHCA):
to provide either paid or informal support, both of http://www.ahcancal.org
which are largely provided by females 40 to 60 Association of Health Facility Survey Agencies (AHFSA):
years of age, will not be increasing at the rate of http://www.ahfsa.org
increase in the number of impaired elderly 75 years Centers for Medicare and Medicaid Services (CMS),
old or older. Nursing Home Compare: http://www.medicare.gov
Nursing homes most likely will not be vanishing Eden Alternative: http://www.edenalt.org
soon from the long-term care tableau. They may Green House Project: http://www.ncbcapitalimpact.org/
change in relatively unforeseen ways as the popu- thegreenhouse
lations whom they serve change. They may, as they The National Citizens’ Coalition for Nursing Home
have in the past, go through cycles of popularity Reform, Consumer Voice for Quality Long-Term
with investors on Wall Street. Much about the Care: http://www.nccnhr.org
future of long-term care in the nation is unclear, Pioneer Network: http://www.pioneernetwork.net
and much about long-term care may change as Wellspring Initiative: http://www.wellspringis.org
policymakers begin to address the aging of society.
But nursing homes and the quality of care they
provide will likely not disappear from the public
policy agenda. Nursing Homes
Charles D. Phillips and Catherine Hawes Nursing homes are licensed residential facilities
See also Activities of Daily Living (ADL); Centers for with professional staff that provide continuous
Medicare and Medicaid Services (CMS); Donabedian, nursing care and health-related services for indi-
Avedis; Katz, Sidney; Long-Term Care; Nursing viduals who do not require hospitalization but
Homes; Public Policy; Structure-Process-Outcome cannot be cared for at home. These facilities pro-
Quality Measures vide 24-hour care for adults 18 years of age or
older who are not in the acute phase of illness but
who have significant functional deficiencies.
Further Readings Functional deficiencies are generally measured by
Committee on Nursing Home Regulation, the Institute individuals’ ability to perform basic activities of
of Medicine. Improving the Quality of Care in daily living (ADLs), such as the ability to indepen-
Nursing Homes. Washington, DC: National dently dress, eat, bathe, get around, and use the
Academies Press, 1986. toilet themselves. Individuals may need nursing
866 Nursing Homes
home care for a short period of time, such as for may temporarily need custodial care. For other
rehabilitation or recovery after an injury or ill- individuals who are losing their ability to function
ness. Other individuals may require long-term or independently due to chronic or progressive dis-
permanent care for chronic or progressive physi- ease or frailty due to advanced age, custodial care
cal or mental illness or infirmity. may be a long-term need. For some, ongoing pro-
fessional nursing and other services may be required
along with custodial care. If custodial-care resi-
Types dents become ill or injured, they may spend a
Nursing homes provide different levels of care period of time in skilled care and then return to
designed to meet the wide range of needs of indi- custodial care.
viduals. They may specialize in short-term or acute Many nursing homes also provide specialized
nursing care, intermediate care, or long-term, cus- services such as hospice and respite care. Hospice
todial nursing care. Many of the nation’s nursing care offers supportive services for terminally ill
homes provide more than one level of care. patients and their families. Nursing homes may
also provide respite care for individuals who are
being cared for at home to allow a family caregiver
Skilled-Nursing Facilities relief for short periods of time. Some nursing
Skilled-nursing facilities (SNFs) provide rela- homes have specially equipped units for persons
tively short-term nursing and rehabilitative care. who are ventilator-dependent, have Alzheimer’s
Skilled care is generally provided to assist patients disease, or have spinal cord injuries.
during recovery following hospitalization for acute
medical conditions. These facilities are state- Services Provided
licensed, and registered nurses (RNs), licensed
practical nurses (LPNs), and certified nurse aids Nursing homes provide a wide range of services,
(CNAs) provide care. The services of other health- including medical-care services; nursing-care ser-
care professionals such as therapists, social work- vices; other professional healthcare services; per-
ers, and dietitians are also available. Hospitals sonal-care services; spiritual, social, and recreational
often have arrangements with skilled-nursing facil- services; and residential-care services.
ities to provide follow-up care for patients who no
longer need acute hospital services. Skilled-nursing Medical-Care Services
facilities provide skilled care and rehabilitation
until the patient is able to return home or requires Regardless of the level of care required, all nurs-
longer-term placement. ing home residents are under the supervision and
care of a physician. Physicians certify the continu-
ing need for nursing home care and are responsible
Intermediate-Care Facilities for the resident’s overall care plan. Physicians also
Intermediate-care facilities provide care for evaluate and prescribe for the resident’s medical
individuals who are recovering from acute medical conditions and determine the types of restorative
conditions but do not need continuous care or and rehabilitative services that are required. All
daily therapeutic services. Intermediate care is pro- nursing homes must have a medical director who
vided by skilled professionals such as RNs, LPNs, can address medical issues and other concerns with
therapists, and other health professionals under the resident, the resident’s family, and the attend-
the supervision of a physician. ing physician.
Custodial-Care Facilities Nursing-Care Services

Custodial-care facilities provide assistance to In the United States, all nursing homes are
patients in activities of daily living, such as bath- required to have a licensed practical or vocational
ing, dressing, eating, and toileting. Individuals who nurse (LPN/LVN) on duty 24 hours a day and an
are recovering from a disabling injury or illness RN on duty for at least one shift each day. Nursing
Nursing Homes 867
services include the regular assessment of residents’ catheter care, rehabilitation, or nasogastric tube for
needs, administration of medications and treat- gastrostomy feedings.
ments, and coordination of care.
Paying for Nursing Home Care
Other Professional Healthcare Services Many Americans incorrectly assume that the fed-
Nursing homes provide rehabilitative and restor- eral Medicare program or standard or supplemen-
ative services such as physical, occupational, respi- tal health insurance policies will pay for nursing
ratory, recreational, and speech therapy. In addition, home care. Consequently, many people do not
dental services, dietary consultation, laboratory, plan ahead financially or purchase long-term care
X-ray, and pharmaceutical services are available. insurance to provide for their care in the event of
infirmity or an extended illness. Nationally the
costs of nursing home care often exceed $50,000
Personal-Care Services annually, or more than $4,000 a month.
Nursing assistants also provide personal-care
and supportive services for residents who require Medicare
help with activities of daily living, such as eating, The federal Medicare program is available to
bathing, walking, and toileting. those nursing home residents who are eligible for
the program, either through age or disability, and
who require a skilled level of nursing home care.
Spiritual, Social, and Recreational Services
Generally, Medicare covers services after hospital-
Nursing homes offer a wide range of services ization. The number of days that Medicare will
and programs to meet the spiritual and social pay for skilled-nursing facility care is limited to no
needs of residents. Clergy and social workers are more than 100 days per episode of care. During
also available to support family members and the first 20 days of care, Medicare pays 100% of
friends. Most nursing homes also offer a wide vari- care. Between 21 and 100 days, Medicare requires
ety of in-house recreational activities and orga- a copayment. Many older persons have a Medicare
nized trips. supplement or Medigap insurance policy. This
supplemental insurance pays in conjunction with
Medicare, but most supplements stop paying when
Residential-Care Services
Medicare reimbursement ends. Medigap insurance
Nursing homes provide general supervision policies are sold by private insurance companies.
within a safe and secure environment along with To buy a Medigap insurance policy, the individual
basic housing and sustenance. must already have Medicare Part A and B insur-
ance. Finally, each individual must buy separate
Medigap insurance policies, as coverage will not
Eligibility be provided under a spouse or family member’s
Each state has its own nursing home eligibility cri- insurance policy. Neither Medicare nor Medigap
teria. A prescreening assessment is completed for insurance policies will pay for custodial nursing
every individual being considered for nursing home home care.
admission. The assessment includes the evaluation
of an individual’s physical and cognitive limita-
Medicaid
tions, medical conditions, the type and level of
assistance required, and skilled-care needs. Although If persons have exhausted their Medicare pay-
there is some variation across states, the requirements for nursing home care, or if they do not
ments are very similar overall. For skilled-nursing require skilled care, they may qualify for Medicaid
facilities, a state’s requirements include a need for coverage to pay for their nursing home care.
at least one skilled service ordered by a physician, However, Medicaid is only available to persons
such as the administration of medications, special who have low incomes or limited resources. To
868 Nursing Homes
qualify for Medicaid, individuals may have to concerns are voiced or if complaints are made
spend out-of-pocket for care until their income about the care provided. The inspection process
drops to the level required for Medicaid eligibility. includes observations of care processes, staff/resi-
States vary in how they consider an individual’s dent interactions, and the physical environment.
assets, such as the spousal home, when determin- The inspection team also interviews a sample of
ing eligibility for Medicaid. Persons who stay in nursing home residents and family members about
nursing homes for an extended period, often until the care in the home. Care providers and adminis-
death, are typically supported by Medicaid. trators are interviewed, and clinical records are
reviewed based on standardized protocols. The
inspection team, which includes an RN, also
Long-Term Care Insurance
examines food preparation and storage, fire safety,
A relatively small number of individuals choose safe construction standards, and issues related to
to purchase long-term care insurance in the event possible resident abuse. If problems are identified,
that they may need long-term care in the future. the CMS can take action against the facility. This
This insurance must be purchased prior to needing can range from imposing a fine, to denying pay-
long-term care, and eligibility for this type of ment, to assigning a temporary manager or install-
insurance is based on health status at the time of ing a state monitor. If the problems are not
purchase. Some financial planners recommend corrected, the CMS can terminate its agreement
purchasing long-term care insurance when a per- with the nursing home. At that point, the nursing
son is in his or her late 50s or early 60s. Premiums home is no longer certified to provide care to
are based on age, health status, and type of plan Medicare beneficiaries and Medicaid recipients,
purchased. and these residents will be transferred to other
Individuals often consider three things when facilities. With the loss of those residents, the
deciding which long-term care insurance to pur- nursing home is very likely to close.
chase: the daily benefit, the benefit period, and the
elimination or deductible period. The daily benefit
Selecting a Nursing Home
is the amount of money that the individual will
receive from the insurance company for care on a Although the individual requiring nursing home
daily basis. The benefit period is the length of time care should be involved as much as possible,
that benefits will be provided (options generally selecting a nursing home often becomes the
include 1, 2, or 3 or more years of coverage, or a responsibility of a family member or friend.
lifetime plan). And the elimination or deductible Fortunately, there are many resources available to
period is the number of days the individual is assist in making the decision.
responsible for paying for long-term care before A number of steps in choosing a nursing home
the insurance begins to pay for the care. have been identified. Generally, the first step in
choosing a nursing home is to discuss with a physi-
cian the specific types of services that are required
Licensing and Certification
and the level of care that is needed. Alternatives to
State governments are responsible for overseeing nursing home care should also be discussed at this
the licensing of nursing homes. Each state is con- time. Home care services or adult day care should
tracted by the U.S. Department of Health and be considered as a possible alternative, and finan-
Human Services’ Centers for Medicare and cial arrangements must also be taken into account.
Medicaid Services (CMS) to monitor its nursing Once it is determined that nursing home care is
homes. Facilities that want to provide care and be required, the next step is to identify local nursing
reimbursed by Medicare and Medicaid must homes that provide the types of services that are
adhere to at least minimum state quality require- needed. There are a number of resources that can
ments. States conduct onsite inspections to deter- provide information. These include state long-term
mine whether a facility meets quality and care ombudsman programs, health departments,
performance standards. Inspections are typically hospital discharge planners, social workers, geriat-
yearly, but can occur more frequently, especially if ric case managers, state or local departments of
Nursing Homes 869
aging, the Medicare Web site and informational Home Compare” Web site. Survey results address
materials, and Web sites of individual facilities. all aspects of care provided by the nursing home,
Friends, neighbors, and clergy may also offer rec- from what might be considered minor infractions
ommendations. to major issues of concern. A staff representative
When the list has been narrowed to those local can answer questions and provide additional infor-
facilities that provide the needed services, family mation about the report and about whether identi-
members and future residents will want to evaluate fied problems have been corrected.
services and amenities. They should talk with Often the potential nursing home resident is
administrative personnel at each facility to arrange unable to be involved in every step of the selection
for a tour. They should plan to visit each facility process; it is essential, however, to the degree that
two or three times at different times of the day and it is possible, that he or she be involved in the final
arrange visits to observe meals and recreational choice. Many people are reluctant to enter a nurs-
activities. Personal observations and interactions ing home, even if it is necessary. Of the options
with staff will provide the most valuable informa- available, the facility chosen must be a place where
tion about the quality of care provided by the nurs- the individual believes that he or she will be most
ing home. comfortable.
For example, family members and individuals
will need to determine if the nursing home is in a
Ombudsmen
quiet, safe area that is accessible, as continued con-
tact with family and friends is a vital aspect of a In 1978, the U.S. Congress amended the Older
resident’s well-being. They will also need to note if Americans Act to include a requirement that each
the building is in good repair, has adequate space, state develop a long-term care ombudsman pro-
and appears clean and safe. Potential residents and gram. Provisions of the act require that each state
families will also want to pay attention to social institute a program that defines the function and
interactions within the facility and the availability responsibilities of ombudsmen, addresses com-
of group activities. Residents should all have the plaints, and advocates for improvements in the
opportunity to take part in activities that provide long-term care system.
mental, physical, and social stimulation and The ombudsman program is administered by
decrease the likelihood of isolation. Monthly pro- the federal Administration on Aging, and most
grams and activities should be posted at each nurs- state ombudsman programs are housed in their
ing home. state unit on aging. There are 53 state long-term
During these initial visits and tours, families and care ombudsman programs and about 600 regional
individuals should talk to all levels of staff, includ- programs in the nation. Over 8,400 volunteers
ing the director and nursing assistants; they should have been certified to handle complaints. Nation
observe the staff interactions with the residents, ally, the ombudsman program handles over
meal presentation and preparation, and resident 264,000 complaints annually. An individual 18
interactions in the dining room and other common years of age or older who has the time and interest
spaces. Potential residents and family members may volunteer to become an ombudsman. Although
should talk directly to the other residents, inquir- specific requirements vary from state to state, gen-
ing about their experience in the facility and their erally ombudsmen may not have a family member
daily activities. Finally, they should be aware of who is a resident in a local nursing facility, and
any special services the nursing home offers to they must not be employed by or have ownership
residents, such as religious services, particular diet in a long-term care facility. Volunteers must pro-
preferences, or field trips. vide references, and criminal background checks
It is also important to evaluate quality when are required. Once accepted into the program,
selecting a nursing home. Every nursing home ombudsman volunteers receive training and are
facility is inspected annually by its state health certified.
department. The survey results are available at the Long-term care ombudsmen serve as advocates
facility and the public may review the report of the for nursing home residents. The ombudsmen pro-
facility’s performance using Medicare’s “Nursing vide a wide range of services for nursing home
870 Nursing Homes
residents and their families, from advising in the See also Centers for Medicare and Medicaid Services
selection of an appropriate nursing home to (CMS); Continuum of Care; Long-Term Care;
resolving complaints made by or for residents. Long-Term Care Costs in the United States; Medicaid;
They may also address a wide range of quality of National Citizens’ Coalition for Nursing Home
Reform (NCCNHR); Nursing Home Quality;
care and quality-of-life concerns that can include
Skilled-Nursing Facilities
unanswered call buttons, roommate problems,
staffing issues, food concerns, and unsanitary
conditions. They often visit nursing homes to
Further Readings
reach out to residents and families, as well as
receiving complaints by telephone, mail, and Allen, James E. Nursing Home Administration. 5th ed.
e-mail. New York: Springer, 2008.
Ombudsmen conduct educational sessions for Baker, Beth. Old Age in a New Age: The Promise of
nursing home staff, family, resident councils, and Transformative Nursing Homes. Nashville, TN:
others. Programs include residents’ rights, restraint Vanderbilt University Press, 2008.
reduction, abuse and neglect regulations, and how Cowles, C. McKeen, ed. Nursing Home Statistical
to deal with difficult behaviors. They also provide Yearbook. McMinnville, OR: Cowles Research
general information to the public on nursing Group, 2006.
homes and other long-term care facilities and ser- Grabowski, David C., Jonathan Gruber, and Joseph J.
Angelelli. Nursing Home Quality as Public Good.
vices, residents’ rights, and legislative and policy
NBER Working Paper No. 12361. Cambridge, MA:
issues. Nursing homes are required to clearly post
National Bureau of Economic Research, 2006.
information about the ombudsmen program and
Kane, Robert L. and Joan C. West. It Shouldn’t Be This
how residents or other concerned individuals may
Way: The Failure of Long-Term Care. Nashville, TN:
contact an ombudsman. Vanderbilt University Press, 2005.
Katz, Paul R., Mathy D. Mezey, and Marshall B. Kapp,
eds. Vulnerable Populations in the Long-Term Care
Cultural Change Movement Continuum. New York: Springer, 2004.
The cultural change movement is a grassroots Roe, Brenda H., and Roger Beech. Intermediate and
effort to transform the culture of aging. This Continuing Care: Policy and Practice. Malden, MA:
Blackwell, 2005.
effort, led by a group called the Pioneer Network,
grew out of a small group of providers and
researchers who were interested in changing the
culture of nursing home care into places for living Web Sites
and growing rather than decline and death. This AARP: http://www.aarp.org
group has identified 13 core values for improving Administration on Aging (AOA): http://www.aoa.gov
the quality of long-term care in persons’ homes, American Association of Homes and Services for the
assisted living, nursing home, and other facilities. Aging (AAHSA): http://www.aahsa.org
The Pioneer Network also acts as a liaison American Health Care Association (AHCA):
between long-term care researchers and nursing http://www.ahcancal.org
homes to encourage nursing homes to participate National Center for Health Statistics (NCHS):
in research and to help researchers and providers http://www.cdc.gov/nchs
to translate findings into practice. National Council on Aging (NCOA): http://www.ncoa.org
Nursing Home Compare: http://www.medicare.gov/
Frances M. Weaver and Elaine C. Hickey nhcompare
O
Assessment of Risk
Obesity
An important measure of weight and obesity is the
Obesity is a major public health problem in the body mass index, or BMI. The BMI is used to
United States; it has a significant impact on access, assess a person’s risk of weight-related comor-
cost, and quality of healthcare. The prevalence of bidities based on his or her relative weight to
obesity has increased over the past 30 years to the height. The formula for calculating the BMI is
point where many refer to it as an obesity epi- BMI = weight (kilograms)/[height (meters)]2. The
demic. Today, more than 65% of adults in the nonmetric conversion formula is BMI = weight
nation are either overweight or obese. Additionally, (pounds)/[height (inches)]2 × 703. For example, a
33.6% of children between 2 and 19 years of age person who weighs 175 pounds and is 66 inches
are at risk of being overweight or are overweight. tall (or 5 foot 6 inches) has a BMI of 28: weight
Obesity is currently the second leading cause of (175 pounds)/[height (66 inches)]2 × 703 = 28.
preventable deaths in the nation, and it may sur- A healthy BMI for adults is between 18.5 and
pass smoking as the leading cause of preventable 24.9. A BMI less than 18.5 is considered under-
death in the future. weight and may be associated with decreased
The link between lifestyle and obesity starts in immune function, osteoporosis, decreased muscle
the prenatal period. Children are exposed to strength, and trouble regulating body temperature.
parental behaviors, which they may model later in At BMIs greater than 25, a person’s risk of weight-
life. School lunch programs aim to meet nutritious related illness or comorbidities increases. Between
guidelines but often do so with limited resources. 25.0 and 29.9 adults are classified as overweight,
An emphasis on academic standards frequently and people with a BMI of 30.0 or higher are con-
reduces time for free play and activity in school, sidered obese.
either during recess or gym class. Computers, tele- In children, the BMI is stratified by age and
vision, and video games are widely available to gender. This is done to control for the changes in
children, who often prefer these activities to physi- body fat that are expected as children grow. It also
cal activity after school and on weekends. Adults allows for the differences in body fat between boys
are bombarded with fast-food establishments, con- and girls. BMI-for-age tables are available from
venience foods, and demanding time constraints, the Centers for Disease Control and Prevention
which may lead to poor food selection and inactiv- (CDC) and are used to help healthcare practitio-
ity. Taken together, the typical American family ners assess adiposity (fatness) in children. A BMI-
has significant barriers to making healthy food for-age that is less than the 5th percentile is
choices and participating in physical activities. considered underweight. Healthy weights include
871
872 Obesity
BMI-for-age from the 5th percentile to less than 4 ounces (500 calories). This results in an increase
the 85th percentile. A child is at risk of being over- of almost 600 calories for the same meal.
weight with a BMI-for-age from the 85th percen- Consumers also equate size to value. When
tile to less than the 95th percentile. A BMI-for-age people eat in restaurants or purchase prepackaged
greater than or equal to the 95th percentile is clas- foods, they expect a large portion for their money.
sified as being overweight. There is no obese clas- Small portions are seen as cheap or insufficient, so
sification for children (2–19 years of age). restaurants respond by offering 12-ounce steaks
Adipose tissue (fat) that is deposited around the and family-size bowls of pasta as single entrees.
midsection of the body is more metabolically active There is also an incentive to buy big at fast-food
than fat that is distributed in the extremities. restaurants. Customers are offered the opportunity
Abdominal fat that is out of proportion to total to upsize an order at minimal cost. Oversized por-
body fat is an independent risk factor for obesity- tions are not limited to food. Beverage portions are
related morbidity and mortality, even in individu- also increasing. Soft drinks used to be served in
als with a normal BMI. Waist circumference is used 6- to 8-ounce portions; today consumers can
to assess the risk from abdominal obesity. Relative- choose between 12-, 20-, and 24-ounce containers.
risk cutoffs for waist circumference are gender People can easily drink 150 to 180 calories per
specific, whereas BMI is independent of gender. 12-ounce portion.
Nutrition Breastfeeding and Infant Formula

At the most basic level, weight gain occurs when The overconsumption of beverages starts in
calories taken in exceed calories expended. When infancy. Formula-fed infants have their intake
a person eats more calories than he or she expends measured by how many ounces they consume from
(through basal metabolism, thermic effect of food, the bottle at each feeding. Parents often think that
and physical activity), he or she gains weight. If a babies need to drink the entire bottle, even if the
person eats fewer calories, he or she loses weight. child shows signs that he or she is finished. When
During the last 30 years, there have been changes this happens, babies do not learn what satiety (full-
in the nutrient composition of meals and portion ness) feels like, and they may overeat when they
sizes, which has contributed to the increasing cal- are older. Breastfeeding provides an opportunity
orie intakes of individuals. A public misperception for babies to self-regulate caloric intake. Mothers
regarding portion size and serving size further are unable to measure how much milk is consumed
adds to the confusion. from the breast, allowing babies to stop eating
when they feel full. Some mothers may gauge con-
sumption by monitoring how long each nursing
Portion Size
session lasts; however, babies adjust their suck rate
Portion size is the amount of food or beverage as hunger subsides. Nursing in response to hunger
that is consumed in a single eating event. Serving (nutritious nursing) may result in a higher milk
size is the standardized unit for measuring food intake than comfort nursing. The protective effects
that is used in dietary guidance. For example, a of breastfeeding on excessive weight gain in child-
person might eat one bowl of pasta and consider it hood may be dose dependent. The greater the
a serving; however, a serving size for pasta is half opportunity children have to self-regulate intake,
a cup. The bowl of pasta is the portion size that the more they are able to recognize hunger and
was consumed. Consider a typical breakfast from satiety cues.
30 years ago—coffee and a muffin. An 8-ounce
cup of coffee with whole milk and sugar has
Parental Influence
approximately 45 calories. The portion size of a
muffin 30 years ago was approximately 1.5 ounces Parental choice once children are weaned from
(210 calories). At many restaurants today, a breast milk or formula also affects the risk of
medium coffee (16 ounces) may have upward of excessive weight gain. When juice and juice drinks
350 calories, while the muffin size has increased to replace breast milk and formula, children consume
Obesity 873
large amounts of calories with little nutritional the nation’s fast-food industry, have changed many
value. These calorie-dense beverages often take the individuals’ lifestyles, contributing to the increase
place of nutritious foods. Children also lose out on in obesity. Important elements of lifestyle are
the beneficial effects of fiber and phytochemicals physical activity, screen time, and eating habits.
that are found in fruits and vegetables. Putting
infants and children to sleep with bottles of juice or
Physical Activity
milk contributes to excessive weight gain and tooth
decay. For many children, their only exposure to The CDC and the USDA recommend at least 30
vegetables is in the form of French fries. Children minutes of moderate-intensity activity for adults
often mimic their parents and caregivers when most days of the week to maintain health. To
deciding what to eat. When children see their par- improve health and lose weight, 60 to 90 minutes
ents eating high-fat, sugary foods, they will want to of moderate-intensity activity are necessary.
do the same. If healthy foods, including fruits and Children and adolescents should engage in moder-
vegetables, are regularly offered, children will ate-intensity activities daily for optimal health.
develop an affinity for their taste. Including chil- One way to measure daily physical activity is with
dren in the food-purchasing and -preparation pro- a pedometer. A pedometer is a device that mea-
cess can also entice them to eat a variety of healthy sures how many steps the wearer takes each day.
foods. After age 2, most children can safely switch Ten thousand steps per day correspond to approx-
to low-fat or fat-free dairy products. Parents imately 60 minutes of moderate-intensity activity,
should avoid adding salt to food, both during the or the amount recommended for healthy living and
cooking process and at the table. A preference for weight loss. By adjusting activities of daily living,
salty foods is an acquired taste—if children do not it is possible to meet the recommended activity
eat salty foods when they are young, most will levels for most adults without exercising.
continue to avoid them as adults. Individuals who are successful in maintaining
their weight loss long-term have incorporated
exercise into their lifestyle. Exercise enhances
Dietary Guidelines
weight loss efforts by building muscle and bone
The Dietary Guidelines for Americans have been mass and improving cardiovascular endurance.
published at least every 5 years since 1980. This Exercise also helps control blood sugar levels,
joint venture by the U.S. Department of Health and reduces blood pressure, and lessens feelings of
Human Services (HHS) and the U.S. Department of depression and anxiety. Fifteen minutes of brisk
Agriculture (USDA) aims to educate Americans on walking or climbing the stairs for 15 to 20 (cumu-
healthy eating habits. There is also an emphasis on lative) minutes per day expends about 100 calo-
how dietary intake can help reduce the risk of sev- ries. The benefits of exercise are cumulative, so
eral chronic diseases, including obesity. These people can perform different activities throughout
guidelines, commonly known as the Food Guide the day (in 10-minute increments) and still improve
Pyramid, received a major revision that was released their well-being.
in 2005. The My Pyramid food guidance system is
an interactive, Web-based system that allows users
Screen Time
to customize calorie recommendations by age and
gender. It also provides recommendations for preg- The American Academy of Pediatrics (AAP)
nant and lactating women. This system incorpo- recommends no more than 2 hours of quality
rates physical activity recommendations to further screen time for children over the age of 2 each day
encourage Americans to improve their health and no screen time for children under the age of
through lifestyle modification. two. Screen time includes television viewing
(including movies), computer usage, and playing
video games. Data from the 1988 to 1994 National
Lifestyle
Health and Nutrition Examination Survey found
Technological advances, such as television, com- that 26% of children watch more than 4 hours of
puters, and automobiles, as well as the growth of television per day. These children had greater
874 Obesity
BMIs than children whose television viewing was 10 high-priority public health issues) are physical
limited to less than 2 hours per day, and they were activity and overweight and obesity. The Safe
less likely to engage in vigorous physical activity. Routes to School Program is one example of a
Children who engage in regular physical activity Healthy People 2010 initiative to increase physical
that incorporates free play and structured activities activity and reduce overweight status in children.
are more likely to engage in regular physical activ- This $612 million program has been implemented
ity as adults. As opportunities for physical activity in more than 20 states, providing support to local
decrease during the school day, it is important that communities that are interested in increasing the
parents encourage their children to engage in number of children who walk or ride their bicycles
active behaviors after school and on weekends. to school. The Small Step campaign encourages
Parents can model good behaviors by designating Americans to make small efforts to improve their
family activity times and making healthy choices health and reduce their risk of weight-related
for themselves. Praising children when they accom- medical problems.
plish new goals will further encourage them to Many states are now requiring BMI report
participate in physical activities. cards; students have their BMI assessed annually at
school, and the results are sent home to parents.
Physicians in West Virginia will be provided with
Eating Habits BMI wheels and training to encourage BMI assess-
The increase in the number of fast-food estab- ments on all patients. And the Florida Department
lishments, loss of family meal times, and increase of Health has created the Hispanic Obesity
in the availability of convenience foods have all Prevention and Education Program to help address
contributed to obesity. Many people do not eat the increasing prevalence of obesity among that
breakfast because of time constraints or because ethnic group.
they think it will help them lose weight. However, Nationally, Mexican American girls (under age
skipping breakfast contributes to overeating later 20) have the highest percentage of overweight; for
in the day, both at mealtimes and with snacking. It boys, non-Hispanic Blacks have the highest per-
has been found that children who skip breakfast centage, followed by Mexican American boys.
have lower test scores and more difficulty concen- There is a similar trend in adult females—the age-
trating in school. adjusted prevalence of overweight and obesity is
Where people eat is almost as important as higher in non-Hispanic Black and Mexican
what they eat. Eating a majority of meals away American women than in non-Hispanic White
from home tends to result in higher caloric intakes women. There is little difference in prevalence
than if the majority of meals are eaten (and pre- among men in these three groups.
pared) at home. The loss of the family mealtime
has been identified as a contributory factor in Research
childhood obesity. Family mealtime provides an
opportunity for the entire family to step back Several genes are being studied to gain a better
from their hectic daily schedules and focus on the understanding of their role in regulating weight
family unit. It also provides an opportunity for and appetite. These genes include leptin, proopi-
parents to model healthy eating behaviors for omelanocortin (POMC, a leptin receptor), prohor-
their children. mone covertase 1, melanocortin receptors 3 and 4,
and transcription factor single-minded 1. The
insulin gene is also being studied. Neurotransmitters
such as serotonin, norepinephrine, and dopamine
Prevention
play a role in weight control and satiety and are
There are many national-, state-, and local-level the focus of several pharmaceutical products
initiatives under way to combat the obesity epi- designed to treat obesity. The central cannabinoid
demic. Nationally, Healthy People 2010 is setting (CB1) receptors are thought to play a role in the
the stage for improving the health of all Americans. regulation of food consumption and may have a
Among their Leading Health Indicators (a list of role in reducing hunger sensations.
Obesity 875
Treatment component). Bariatric surgery should be restricted

to individuals with a BMI of 40 or higher or a BMI
While many people are able to ameliorate their of 35 or more with obesity-related comorbidities.
risk of weight-related illnesses by making healthy Bariatric surgery programs should include educa-
lifestyle choices, some are unable to achieve a tion on lifestyle modification and behavioral
healthy weight on their own. The 1998 National therapy. Only the adjustable gastric banding is
Institutes of Health’s (NIH’s) Clinical Guidelines reversible.
on Managing Overweight and Obesity recom-
mended that the U.S. Food and Drug Administration
(FDA) approve weight loss drugs so that they may Future Implications
be used as an adjunct therapy to lifestyle modifi-
cation in patients with a BMI of 30 or higher with The etiology of obesity is multifactorial and diffi-
no weight-related comorbidities or in patients cult to treat. There is a clear environmental impact
with a BMI of 27 or higher with obesity-related on the increasing rates of overweight and obesity.
comorbidities (or risk factors). Obesity-related Expansive unhealthy food selections and decreased
comorbidities include diabetes mellitus, sleep opportunities for physical activity are significant
apnea and obesity-related hypoventilation, contributory factors to America’s expanding
asthma, nonalcoholic fatty liver disease, gallblad- waistline. What is not fully understood is the role
der disease, orthopedic problems, hyperinsuline- of genetics in the obesity epidemic. Animal studies
mia, polycystic ovary syndrome, and metabolic looking at the role of various genes in appetite
syndrome (which may include hypertriglyceri- regulation and weight control are not easily repro-
demia, low-HDL cholesterol, hypertension, duced in humans. Until scientists are able to dis-
impaired glucose tolerance, and/or increased waist cern the true role of genes in the obesity epidemic,
circumference). it is up to families and each individual to make
Currently, the only FDA-approved medica- healthy lifestyle decisions to reduce the risk of
tions for weight loss are sibutramine (Meridia) becoming obese.
and orlistat (Xenical). Sibutramine is a norepi- Elisa Stamm Kogan
nephrine, dopamine, and serotonin reuptake
inhibitor that works by decreasing appetite. See also Chronic Diseases; Diabetes; Disease
Orlistat is a gastric lipase inhibitor that reduces Management; Health; Healthy People 2010; Inner-City
fat absorption in the intestines. Orlistat recently Healthcare; Preventive Care; Public Health
received FDA approval to be sold over the coun-
ter as Alli, although at lower doses than the pre-
scription version. Further Readings
In addition to pharmaceutical therapy, some
Barrett, Deirdre. Waistland: The(R)evolutionary Science
obese individuals may benefit from bariatric
Behind Our Weight and Fitness Crisis. New York: W.
(weight loss) surgery. There are four surgical pro-
W. Norton, 2007.
cedures commonly performed in the United States
Blue Cross and Blue Shield Association, Technology
for obesity: Roux-en-Y gastric bypass, adjustable
Evaluation Center. Laparoscopic Gastric Bypass
gastric banding, sleeve gastrectomy, and biliopan-
Surgery for Morbid Obesity. Chicago: Blue Cross and
creatic diversion (with or without duodenal switch). Blue Shield Association, 2006.
The adjustable gastric banding and sleeve gastrec- Buchwald, Henry, George S. M. Cowan, and Walter J.
tomy work by restricting the amount of food that Pories, eds. Surgical Management of Obesity.
can be consumed at any given time by decreasing Philadelphia: Saunders Elsevier, 2007.
the size of the stomach pouch. The Roux-en-Y Greer, Nancy L. Behavioral Therapy Programs for
gastric bypass and biliopancreatic diversion pro- Weight Loss in Adults. Bloomington, MN: Institute
vide restriction in addition to malabsorption. In for Clinical Systems Improvement, 2005.
both of these procedures, the size of the stomach Jordan, Amy B. Overweight and Obesity in America’s
pouch is reduced (restrictive component), and Children: Causes, Consequences, Solutions. Thousand
parts of the intestines are bypassed (malabsorptive Oaks, CA: Sage, 2008.
876 O’Leary, Dennis S.
Web Sites O’Leary became president of the Joint

American Society for Metabolic and Bariatric Surgery Commission in 1986. During his 21 years at the
(ASMBS): http://www.asbs.org Joint Commission, he greatly expanded its scope
Centers for Disease Control and Prevention (CDC): and size. Under his leadership, the organization
http://www.cdc.gov moved beyond its original hospital base to
Healthy People 2010: http://www.healthypeople.gov accredit a wide range of extended-care and
My Pyramid Food Guidance System: ambulatory-care service organizations. It initi-
http://www.mypyramid.gov ated an international accreditation program and
a consultation services program. And the organi-
zation undertook a series of projects with the
World Health Organization (WHO). Under
O’Leary, Dennis S. O’Leary, the Joint Commission’s budget and
staff quadrupled in size.
Dennis S. O’Leary is the former long-time presi- During his career, O’Leary received many
dent of the Joint Commission, the leading health- awards and honors. He is a member of the
care accrediting body in the United States. Under National Academy of Sciences, Institute of Medicine
his leadership, the Joint Commission’s accredita- (IOM). He also is a master of the American College
tion process successfully changed from being pri- of Physicians and a fellow of the American College
marily focused on the structural measures of of Physician Executives, the American College of
healthcare organizations to process measures and Healthcare Executives, and the American Dental
care-related outcomes. He also started cutting Association. In 2000, Modern Healthcare maga-
edge healthcare standards relating to pain man- zine identified him as one of the nation’s 25 most
agement, patient safety, emergency preparedness, influential leaders in healthcare during the past
and the use of patient restraints. And he launched quarter-century. In 2005, he was given the
a series of public policy initiatives. Distinguished Service Award, the highest honor
A Kansas native, O’Leary earned a bachelor’s from the American Medical Association (AMA),
degree from Harvard University and a medical for his advancement of healthcare quality and
degree from Cornell University Medical College in patient safety. And in 2006, he received the Ernest
New York. After 2 years of internal medicine Armory Codman Award from the Joint Commission
training at the University of Minnesota Hospital, for his leadership role in using performance mea-
he completed his residency and a hematology fel- sures to improve healthcare quality and safety.
lowship at Strong Memorial Hospital in Rochester, After leaving the Joint Commission at the end
New York. He is board certified in Internal of 2007, O’Leary was appointed to the board of
Medicine and Hematology. directors of the Consumers Advancing Patient
Prior to joining the Joint Commission, O’Leary Safety (CAPS), an organization that promotes
spent 15 years at the George Washington University patient-centered healthcare.
Medical Center in Washington, D.C. At the medi-
cal center, he was a professor of medicine, and he Ross M. Mullner
served as a senior manager in several positions. He
was the medical director of the university’s hospi- See also Accreditation; Joint Commission; National
tal for 10 years, the dean for clinical affairs at the Patient Safety Goals; ORYX Performance
Measurement System; Outcomes Movement; Patient-
university, and the vice president of the university’s
Reported Outcomes (PRO): Quality of Healthcare;
health plan, an academic health maintenance Structure-Process-Outcome Quality Measures
organization (HMO). In 1981, O’Leary received
national attention for his role as the university
hospital’s spokesman for the care given to President
Ronald Reagan after he was shot in a failed assas- Further Readings
sination attempt. He frequently briefed the national O’Leary, Dennis S. “Organizational Evaluation and a
and international news media about the president’s Culture of Safety and Reducing Errors in Health
medical progress. Care.” In Proceedings of Enhancing Patient Safety
ORYX Performance Measurement System 877
and Reducing Errors in Health Care, edited by Adam Commission’s criteria. This information was to be
L. Scheffler and Lori Zipperer, 34–37. Chicago: collected on monthly data points and transmitted
National Patient Safety Foundation, 1999. on a quarterly basis in an electronic machine-
O’Leary, Dennis S. “Accreditation’s Role in Reducing readable format via the Internet or electronic bul-
Medical Errors,” British Medical Journal 320(7237): letin board services to an approved Performance
727–28, March 18, 2000. Measurement System (PMS). The Joint Commission
O’Leary, Dennis S. “The Will to Change,” Health delayed the reporting of core measures for long-
Affairs 23(2): 288, 2004. term care, home care, and behavioral-health orga-
O’Leary, Dennis S. “Is ‘First Do No Harm’ a Lost
nizations so that applicable core measures could be
Concept in Medical Education?” Medscape General
identified. This was in response to the lack of
Medicine 8(3): 77, September 8, 2006.
national consensus on appropriate performance
measures for nonhospital settings of care. ORYX
provides healthcare organizations with a greater
Web Sites
degree of flexibility in selecting measures, which
Consumers Advancing Patient Safety (CAPS): was identified as a problem in the past under the
http://www.patientsafety.org Indicator Measurement System (IMSystem).
Joint Commission: http://www.jointcommission.org In July 2002, the first ORYX measures on
accredited hospitals were collected. Hospitals are
required to collect and report on at least three core
measures or up to nine measures if not participat-
ORYX Performance ing in core measurement activities, to satisfy the
requirements of accreditation. Nonhospitals must
Measurement System collect six measures to satisfy accreditation require-
ments. To reduce the burden of reporting require-
ORYX is a tool used by healthcare organizations ments for hospitals and other healthcare
to evaluate their ongoing performance and to organizations, the Joint Commission has worked
inform continuous quality improvement efforts. closely with the Centers for Medicare and Medicaid
The ORYX initiative was developed and imple- Services (CMS), the National Quality Forum, and
mented by the Joint Commission and came into other entities to develop and standardize these core
use in 1997. This system for the first time included measures.
performance and outcome measures in the accred- One criticism of the ORYX program is that
itation process that was applied to hospitals, long- healthcare organizations may focus their quality
term care organizations, and healthcare networks. improvement efforts on only the reported mea-
ORYX was later expanded to also include behav- sures of quality or selected measurements that they
ioral healthcare and home care organizations. perform well on. In addition, critics cite that the
The concept of ORYX was to be a continuous, measures only represent a small number of medical
data-driven process that evaluates a healthcare conditions. The Joint Commission concedes these
organization’s standard of compliance and the facts; however, it is acknowledged that healthcare
outcomes of this process. Joint Commission offi- organizations will eventually have to report mea-
cials note that ORYX provides purchasers and sures on a greater percentage of their population.
consumers of care with another level of assurance Some professionals question how performance
that Joint Commission–accredited organizations data will correlate with hospital accreditation and
are evaluated on outcomes in addition to the on- the ability of the Joint Commission, a private orga-
site surveys that take place. nization supported by the hospital industry, to
Initial policies regarding ORYX called for objectively evaluate hospital performance.
accredited healthcare organizations to select two
of the approved measures, also known as noncore
History
measures, and to report data on at least 20% of
the patient population from a list of 60 perfor- The Joint Commission’s history of performance
mance measurement systems that met the Joint measurement can be traced back to the early days
878 ORYX Performance Measurement System
of Ernest Codman, who established the concept of Performance Measures and Associated Evaluation
the data-driven “end-result” system in the 1900s. Criteria were used to evaluate candidate measures
The Joint Commission’s Agenda for Change had as potential core measures. After the core measures
at its centerpiece the goal of incorporating perfor- were developed, the Joint Commission initiated a
mance measurement into its accreditation process. pilot project to test the feasibility and usefulness of
During the period leading up to this, beginning in these measures. Out of the 11 state hospital asso-
1986, the Joint Commission was in the process of ciations that were interested in participating in
developing, testing, and implementing standard- this project, 5 (Connecticut, Michigan, Missouri,
ized performance measures and also establishing Georgia, and Rhode Island) were randomly selected
the infrastructure to transmit and collect these to participate and identify a single performance
performance measurement data. This initiative measure system and participant hospitals. Through
was known then as the Indicator Measurement this pilot demonstration, the Joint Commission
System (IMSystem). The reason for the develop- was able to receive feedback, as well as modify and
ment of the IMSystem was that until this point assess the reliability of the core measures. After this
compliance with standards was the basic measure feedback period, the Joint Commission made a
of healthcare quality. This new paradigm to look series of revisions to the initial core measures prior
at the actual results and outcome of care called for to the full-scale implementation of this project.
a more integrated approach to evaluation of During 1995, a request for PMSs to participate
healthcare organizations. The use of performance in the ORYX initiative was made. Candidate PMSs
data by the Joint Commission would facilitate the were evaluated against specified characteristics
quality improvement efforts of healthcare organi- known as the Attributes of Conformance. The
zations, ensure accountability, and combine per- Attributes of Conformance were created by the Joint
formance with standards compliance in the Commission to ensure that PMSs had the technical
accreditation process. and operational infrastructure necessary to sup-
The IMSystem was to be a national compara- port this performance measurement initiative in
tive measurement system comprising indicators of the present as well as the future. The attributes of
outcome and process measures that would reflect PMSs typically included appropriate performance
the appropriateness or effectiveness of perfor- measures that focused on organization perfor-
mance. Outcome indicators were also to be appro- mance, clinical processes and/or outcomes, opera-
priately risk adjusted to account for differences in tional database, processes that ensure data quality,
patient-level factors. The set of performance mea- risk adjustment methods, feedback to participating
sures under the IMSystem included perioperative organizations, and usefulness and relevance to the
care, obstetrical care, trauma care, oncology care, accreditation process. The initial attributes were
infection control, and medication use. The goal at defined at the minimal level; however, they have
the time was that hospitals would collect and start been modified several times because of the grow-
to transmit data on these measures beginning in ing need to maintain data quality.
1995 but they would retain choice and flexibility After candidate PMSs passed this initial evalua-
in selecting appropriate measures to report on. The tion, a “request for indicators” was issued to
IMSystem did not take off due to the quickly receive PMS extant measures for review, evalua-
changing measurement environment and because tion, and approval for use in ORYX. Once they
many hospitals felt that this project was not prac- were approved, healthcare organizations could
ticably feasible. Although the IMSystem never select these measures to satisfy the requirements of
reached fruition, it served as the predecessor for ORYX. The Joint Commission’s database stores
the new ORYX initiative. With changing knowl- more than 15,000 extant performance measures.
edge, the Joint Commission revised its original PMSs that satisfied the selection criteria were
performance measures and pursued a collaborative listed for accredited healthcare organizations to
approach in the ORYX initiative. select and contract with in order to meet accredita-
In 1999, the Joint Commission sought input tion requirements. PMSs serve as an intermediary
from healthcare professionals about the initial set between the Joint Commission and accredited
of hospital core measures. The Attributes of Core healthcare organizations to receive and aggregate
ORYX Performance Measurement System 879
transmitted data. PMSs ensure data quality, ana- included a control and comparison chart for each
lyze and risk adjust the data, and provide feedback measure selected. The control chart examined the
to participating organizations. At present, more organization’s performance over time, while the
than 400 PMSs have been evaluated, and 98 PMSs comparison chart compared the organization with
currently participate in the ORYX initiative. other organizations collecting the same measures.
Once the Joint Commission receives the aggre- The Joint Commission also commenced to use
gated data from the PMSs, the data are passed ORYX data to detect sentinel events at facilities. If
through an automated filter process. The Joint the Joint Commission learns of a sentinel event
Commission developed a software application to through the quarterly reporting by hospitals, this
compare incoming data against specific statistical will be considered to be self-reported by the
process control decision rules, known as the Auto- healthcare organization and would require a root-
Stat process. All the data reported are run through cause analysis and action plan or an evaluation of
this application, which provides comparative infor- the response.
mation and helps identify any outliers. Only data Some limitations of the ORYX initiative are that
that have passed through this filtering process are small rural hospitals do not typically have enough
then included in the Joint Commission’s database. cases of events to draw any meaningful conclusions.
The Joint Commission conducts three types of Thus, hospitals with an average daily census of
analyses on its data: data quality assessment, fewer than 10 patients and a monthly ambulatory
intraorganizational analyses, and interorganiza- population of fewer than 150 patients are currently
tional analyses. These data are important in the exempted from submitting data on the ORYX
Joint Commission’s Priority Focus Process aligned requirements. Additionally, the issue of multiple
with its new accreditation process, Shared Visions- comparisons of organizations across time and
New Pathways. cross-sectionally may have resource implications.
Data quality is assessed through the data filter As new technologies rapidly emerge and
process, through PMS audits, and during the on- advances are made in healthcare, the Joint
site survey of accredited healthcare organizations. Commission must continue to find ways to adapt
Intraorganizational analyses involve the use of to reflect the growing sophistication of perfor-
control charts to assess the processes involved in mance measurement. To meet this challenge, the
the results being measured. This analysis includes Joint Commission’s Performance Measurement
evaluating the data to examine trends and patterns Strategic Issues Work Group has developed areas
in organizational performance and identifying of focus for the next 5 years. These focus areas
areas for improvement. The organization-specific include refining the receiving of standardized-per-
data are also used to develop a customized on-site formance measurement data from participating
survey agenda and will be factored into the accred- healthcare organizations, expanding the breadth
itation decision-making process. To evaluate of measure sets available that healthcare organiza-
whether an organization is performing within an tions may select, creating applications that will be
acceptable range during a given period of time, the able to use measurement data in the accreditation
Joint Commission conducts a comparative interor- process as well as public reporting efforts, coordi-
ganizational analysis. This analysis entails compar- nation of data demands and prioritization of mea-
ing an individual organization with a comparison surement areas to reduce data collection burden
group’s data, which is then summarized in a com- and eliminate duplication for healthcare organiza-
parison chart. The comparison chart includes an tions, and continued support for the role of the
organization’s observed rate, the expected rate, National Quality Forum as the leader in setting
and the expected range or acceptance interval measurement objectives.
associated with the expected rate.
When the Joint Commission initially began to
Ongoing Activities
use performance measurement data, it was focused
primarily on the presurvey report during the on-site At present, the Joint Commission has identified
visit. This presurvey report was tailored specifically five core performance measure sets for hospitals:
for each accredited healthcare organization and (1) myocardial infarction, (2) heart failure,
880 ORYX Performance Measurement System
(3) pneumonia, (4) pregnancy and related condi- outlined the quality improvement objectives for the
tions, and (5) surgical infection prevention. nation. With many actors now involved in health-
Additionally, intensive-care unit (ICU), pain man- care quality, the Joint Commission became engaged
agement, children’s asthma care, and hospital- in initiatives such as the Hospital Quality Alliance.
based psychiatric-service measures are scheduled The federal CMS heads a program similar to the
to be implemented soon. Joint Commission’s ORYX, known as the Hospital
The process involved in creating these measures Quality Alliance: Improving Care Through
includes working with a technical expert panel, Information. This is a public-private partnership
testing, and development of technical specifica- aimed at improving care in the nation’s hospitals
tions. All these core measures have been reviewed by measuring and publicly reporting on this care.
and approved by the National Quality Forum. This program collects information on hospital per-
Quality Check® was established the same year formance measures for heart attack, congestive
as the ORYX initiative and serves as a directory of heart failure, pneumonia, and surgical infections,
accredited organizations and performance reports and it plans to continue to expand in the future.
available for public use on the Joint Commission’s This initiative grew out of the collaboration between
Web site. In 2004, the debut of Quality Report the CMS, American Hospital Association (AHA),
became available to the general public at www. Federation of American Hospitals, and Association
qualitycheck.org, which allowed easy access to of American Medical Colleges (AAMC) and is sup-
organization-specific data that included composite ported by the Agency for Healthcare Research and
scores for each set of reported measures. This Quality (AHRQ), National Quality Forum, Joint
result is displayed against comparative state and Commission, American Medical Association (AMA),
national data. American Nurses Association (ANA), National
The use of measurement data in the accredita- Association of Children’s Hospitals and Related
tion process has also grown with the evolution of Institutions, Consumer-Purchaser Disclosure Project,
these measures. In addition to being used for con- American Federation of Labor and Congress of
tinuous quality improvement efforts of healthcare Industrial Organizations (AFL-CIO), AARP, and
organizations and the Joint Commission’s presur- U.S. Chamber of Commerce. A Hospital Compare
vey report, performance measures are also used to report, which provides an easy to use interface on
focus on the on-site accreditation survey through hospital performance, can be found at www.hospi-
the Priority Focus Process (PFP). The PFP compiles talcompare.hhs.gov.
data from various sources and identifies one or
more focus areas for the on-site survey.
Future Goals
Data management efforts of ORYX data have
also evolved over time with newer methods. In the The Joint Commission envisions that performance
beginning of the ORYX initiative, data quality was measurement will become a seminal part of the
focused primarily on missing data and outliers. information technology infrastructure. Some
Data integrity became even more important with future objectives of the Joint Commission’s per-
public reporting and the core measures. As a result, formance measurement data include the follow-
the Joint Commission continues to monitor data ing: the creation of a national standardized data
quality after each quarter of data submission. set, continuous data monitoring and follow-up
Currently, the issues involved in the data manage- with healthcare organizations to identify areas for
ment of ORYX include the aggregation of data ongoing improvement, refining standards through
and the reliability of data collection. the use of measure data, including measurement
data in the AHRQ’s National Health Care Quality
and Disparities Reports, the use of measurement
Other Health Quality Initiatives
data to improve the quality of care through
In 1999, the National Quality Forum was formed research, the use of measurement data to identify
to review and approve performance measures. high-reliability healthcare organizations, the use
The National Academy of Sciences, Institute of measurement data to identify evidence-based
of Medicine’s report Crossing the Quality Chasm practices and establish national benchmarks,
Outcomes-Based Accreditation 881
establishing processes to support increased use of Caron, Aleece, and Duncan V. Neuhauser. “Health Care
measurement data by consumers, and the use of Organization Improvement Reports Using Control
measurement data to ascertain healthcare organi- Charts for Key Quality Characteristics: ORYX
zation reimbursements levels. Measures as Examples,” Quality Management in
The development of new core measures will Health Care 9(3): 28–39, Spring 2001.
eventually replace noncore measures in nonhospital DeMott, Karen. “JCAHO Introduces ORYX for
areas (long-term care, ambulatory care, home care, Outcomes-Based Accreditation,” Quality Letter for
and behavioral health). Additionally, the Joint Healthcare Leaders 9(3): 18–19, 1997.
Lee, Kwan, Jerod Loeb, and Deborah Nadzam. “Special
Commission plans to seek patient-level data, which
Report: An Overview of the Joint Commission’s
will ensure higher levels of data quality; informa-
ORYX Initiative and Statistical Methods,” Health
tion regarding development; increased research
Services & Outcomes Research Methodology 1(1):
related to performance measurement and quality
63–73, 2000.
improvement efforts; increased support for the Loeb, Jerod, and Alfred Buck. “Framework for Selection
Joint Commission’s new accreditation process; and of Performance Measurement Systems: Attributes of
ongoing support of efforts to ensure the relevance, Conformance,” Journal of the American Medical
usefulness, reliability, and validity of the measures. Association 275(7): 508, February 21, 1996.
With the increasing sophistication of medical Morrissey, John. “Quality Measures Hit Prime Time:
care, the Joint Commission will continue to identify JCAHO’s ORYX Lights Fire Under Providers,”
measures that are no longer relevant and will find Modern Healthcare 27(18): 66–72, May 5, 1997.
ways to randomly collect data on these “retired” National Academy of Sciences, Institute of Medicine.
measures. Additionally, the Joint Commission Crossing the Quality Chasm. Washington, DC:
expects to implement patient perception of care as Institute of Medicine, 1999.
a core measure over the next several years through Schyve, Paul, Jerod Loeb, and Bryan Simmons. “A
a standardized hospital patient experience-of-care Collaborative Project to Study Hospital Performance
tool, known as the CAHPS Hospital Survey. Measures,” Journal of the American Medical
As the Joint Commission continues to work Association 274(19): 1497, November 15, 1995.
with its national partners in quality improvement
and performance measurement efforts, it is guided
by the continued expansion and coordination of Web Sites
nationally standardized core measurement capa-
Hospital Compare: http://www.hospitalcompare.hhs.gov
bilities and increasing the use of measurement
data for quality improvement efforts, benchmark-
National Healthcare Quality Report:
ing, accountability, decision making, accredita- http://nhqrnet.ahrq.gov/nhqr/jsp/nhqr.jsp
tion, and research. It is anticipated that the
attainment of these goals will lead to the contin-
ued improvement in patient safety and quality of
healthcare organizations.
Outcomes-Based Accreditation
Jared Lane K. Maeda
See also Joint Commission; National Quality Forum Outcomes-based accreditation is an objective,
(NQF); O’Leary, Dennis S.; Outcomes-Based data-driven process of externally evaluating pro-
Accreditation; Outcomes Movement; Quality viders, healthcare facilities, or health plans through
Indicators; Quality Management; Quality of the use of performance measures. Risk-adjusted
Healthcare outcome measures, such as mortality, quality of
life, patient functional ability, and patient satisfac-
tion, are used to compare among providers of care
Further Readings and healthcare organizations to make choosing
Campbell, Sandy. “Outcomes-Based Accreditation Evolves a provider more meaningful to patients since
Slowly with JCAHO’s ORYX Initiative,” Health Care patients are ultimately concerned about their
Strategic Management 15(4): 12–13, 1997. health outcomes.
882 Outcomes-Based Accreditation
History outcomes measures in HEDIS was the lack of

information technology infrastructure to capture
Florence Nightingale was the first to study health
these measurements. NCQA’s report A Road Map
outcomes by measuring mortality and infection
for Information Systems: Evolving Systems to
rates in British military hospitals during the Crimean
Support Performance Measurements outlined the
War. In the early 20th century, a pioneering physi-
upgrades needed to meet the demand of outcomes
cian at the Massachusetts General Hospital in
measurement.
Boston, Ernest Codman, proposed an end-results
The Joint Commission, an independent, private,
system to examine patient outcomes of surgical
nonprofit organization, accredits and evaluates
procedures. At the time, Codman’s idea was viewed
approximately 15,000 healthcare organizations
as radical and against the medical establishment.
and programs in the United States. In 1997, the
Building on Codman’s idea, Avedis Donabedian
ORYX Performance Measurement System for the
developed a framework for quality assessment that
first time integrated performance measures into
included structure, process, and outcomes. Structure
the Joint Commission’s accreditation process.
refers to the structural characteristics of healthcare
Beginning in July 2002, the first core measures on
organizations, such as the number of certified staff,
accredited hospitals were collected.
equipment, and medical technologies; process
The purpose of ORYX is to link patient out-
includes all the processes involved in providing
comes with accreditation to make the accreditation
care to the patient; and outcomes are the results of
process more valuable while focusing on patient-
the care rendered by the provider.
centered care. ORYX is used as a supplement to the
Historically, accreditation reviews were primar-
standards-based survey by continuously monitor-
ily based on structural features since they were
ing the performance of organizations, facilitating
easy to measure; however, recently there has been
continuous quality improvement, and targeting the
a movement to further examine process and out-
on-site survey. To meet accreditation requirements,
comes measures that give a more comprehensive
some healthcare organizations must submit data on
view of patient care quality and enable consumers
a specified minimum number of measures to a per-
and purchasers to make informed healthcare deci-
formance measurement system or the Joint
sions. By using the framework of Donabedian and
Commission, and these data are reviewed by the
Codman’s end-result system, organizations such as
surveyor(s) at the on-site survey. Using data reported
the National Committee for Quality Assurance
from the organization’s core measures, the survey-
(NCQA) and the Joint Commission have started
ors assess the performance improvement activities
using outcomes to accredit health plans and
of the organization during the on-site survey.
healthcare facilities.
The Joint Commission intends to use ORYX to
identify data trends that will enable organizations
to improve the quality of care. To reduce the bur-
Accrediting Organizations
den of reporting requirements for hospitals, the
The NCQA, a private, nonprofit organization, is Joint Commission has worked closely with the
dedicated to improving healthcare quality by Centers for Medicare and Medicaid Services (CMS)
accrediting and certifying a wide range of health- to align performance measures.
care plans through its set of performance measures
known as the Health Plan Employer Data and
Issues of Using Outcomes
Information Set (HEDIS). The mission of the
NCQA is to provide information to purchasers The contention surrounding the use of patient out-
and consumers on the quality of care of managed- comes in accreditation includes the issues of risk
care organizations that will allow them to make adjustment, the case-mix of patients, and the small
informed purchasing decisions. Beginning with number of cases of individual providers. Risk
HEDIS 3.0, the NCQA started to make progress adjustment is a statistical method that tries to con-
by including the outcomes measures of patient trol for the differences in patient characteristics or
function and satisfaction in its evaluation process. case-mix that may unduly affect outcomes. For
The major barrier to the initial implementation of example, a provider that treats a greater number
Outcomes Movement 883
of sicker patients may appear to have worse out- See also Accreditation; Case-Mix Adjustment; Healthcare
comes than a provider that treats relatively health- Effectiveness Data and Information Set (HEDIS); Joint
ier patients. Therefore, risk adjustment statistically Commission; National Committee for Quality
adjusts for these underlying differences in the case- Assurance (NCQA): ORYX Performance
Measurement System; Outcomes Movement;
mix of patients.
Structure-Process-Outcome Quality Measures
The issue of small numbers is also a problem
that arises where providers may not treat a suffi-
cient number of cases to draw statistically valid
Further Readings
conclusions regarding a provider’s performance.
This may limit the comparisons that can be made Clancy, Carolyn M., and John M. Eisenberg. “Outcomes
among providers for a given set of conditions. Research: Measuring the End Results of Health
Other issues concerning the use of outcomes Care,” Science 282(5387): 245–46, October 9, 1998.
include the fact that a patient’s outcome is shaped DeMott, K. “JCAHO Introduces ORYX for Outcomes-
by many other factors outside the provider’s con- Based Accreditation,” Quality Letter for Healthcare
trol, even if appropriate care was given. Conversely, Leaders 9(3): 18–19, March 1997.
a patient may still have a good outcome despite the Donabedian, Avedis. “The End Results of Health Care:
poor processes of care delivered by the provider Ernest Codman’s Contribution to Quality Assessment
and Beyond,” Milbank Quarterly 67(2): 233–56,
due to the resiliency of the human body.
1989.
Additionally, it may take many years before a par-
Harris, Marilyn D., ed. Handbook of Home Health Care
ticular health outcome is observed, and therefore,
Administration. 4th ed. Sudbury, MA: Jones and
outcomes may need to be tracked longitudinally
Bartlett, 2005
for an extended period. Furthermore, data on
O’Malley, Colleen. “Quality Measurement for Health
health outcomes can be labor intensive, costly, and Systems: Accreditation and Report Cards,” American
difficult to collect. Journal of Health-System Pharmacy. 54(13):
The field of outcomes measurement is still 1528–35, July 1, 1997.
young, where there are only a few available mea- National Committee for Quality Assurance. A Road
sures for specific conditions. Measuring outcomes Map for Information Systems: Evolving Systems to
for the purposes of accreditation relies on the col- Support Performance Measurements. Washington,
lection of valid and reliable data; standardized DC: National Committee for Quality Assurance,
data elements and definitions; appropriate risk 1997.
adjustment methods; information technology infra- Rozovsky, Fay Adrienne, and James R. Woods Jr., eds.
structure; and the ability to compare outcomes The Handbook of Patient Safety Compliance: A
across providers, organizations, and health plans. Practical Guide for Health Care Organizations. San
Francisco: Jossey-Bass, 2005.
Future Implications
Outcomes measures in accreditation will continue Web Sites
to play an important role in evaluating healthcare Joint Commission: http://www.jointcommission.org
providers, organizations, and health plans. The National Committee for Quality Assurance (NCQA):
development of additional measures of outcomes http://www.ncqa.org
will be needed to broaden the set of conditions
available. With the greater availability of outcomes
measures through accrediting bodies, consumers
and purchasers will be able to make more informed
decisions of where to seek and purchase their care
Outcomes Movement
and will continue to pressure healthcare providers,
organizations, and health plans to continuously The outcomes movement is an initiative designed
improve the quality of care they deliver. to improve the quality of healthcare by identify-
ing what works (and encouraging its use) and
Jared Lane K. Maeda what doesn’t (and discouraging the use of those
884 Outcomes Movement
treatments). It establishes links between health- and led to the outcomes (the effects of the care on
care practices and procedures with specific outpatients). Donabedian stated that outcomes are
comes, for the patients as well as the healthcare crucial to judging the value of medical care and
system. It involves evaluating in a scientific man- noted that mortality data alone are not sufficient.
ner the consequences of medical care, diagnostic Quality-of-life indicators and patient satisfaction,
testing, and other services. This information is though less easily measured, are also relevant and
then pooled and analyzed and made available to should be studied as well, in his view. At this
the medical-practice community, healthcare point, the outcomes movement focused primarily
administrators, and third-party payers. The goal on the patient rather than the healthcare delivery
is the development of care guidelines that improve system as a whole.
patient outcomes and result in effective and effi- The rapid rise in healthcare costs in the 1970s
cient healthcare organization and delivery. and 1980s has put the outcomes movement into an
In the past, medical-care practices often devel- additional context. The focus now includes the
oped because of anecdotal information and the financial issues and the concomitant effects on the
experience of the individual physician and his or medical system, insurance reimbursement, and fed-
her colleagues. At times, this led to geographic dif- eral programs. Technological innovations, the cost
ferences in the use of a particular medical interven- of new drugs and therapies, and the aging of the
tion. In such cases, the geographical area in which nation’s population have thrust the issue of medical-
the patient would be treated served as an important care costs into the forefront. Insurance companies
predictor of the selected treatment protocol. The and other third-party payers as well as clinicians
outcomes movement is an attempt to develop, as and hospital administrators have sought to distin-
an alternative, a data-driven approach that makes guish between available therapies and those that
sense across the board. This is done by systemati- work and matter. Researchers began to take note
cally collecting information about patients and the of the fact that different geographical areas exhib-
medical interventions they experience. The out- ited wide variation in the use of resources and in
comes of those interventions for the patient and the the rates of certain medical procedures. After much
healthcare system are then documented and made investigation, however, the researchers did not find
available to the medical/patient community. These any meaningful differences in population charac-
data are analyzed and the results used to develop teristics and patient outcomes. This suggested, for
best practices to improve the quality of care. example, that some surgical procedures were unnec-
essary, and limiting them to situations in which
they would provide benefit could help contain ris-
History
ing costs. Other research claimed to demonstrate
The value of outcomes measurement was recog- the lack of efficacy of some traditionally used inter-
nized in the early 1900s, when Ernest A. Codman ventions. By the 1990s, assessment and data-driven
(1869–1940), a New England surgeon, said that healthcare became the new mantra, and the out-
treatment results and benefits should be docu- comes movement came of age.
mented. Codman created “end-result cards,”
which contained basic patient demographic data,
Current Usage
the diagnosis, the treatment, the short-term out-
comes, and, when possible, the outcomes after 1 The outcomes movement provides an important
year. He contended that this type of information framework for reviewing and refining medical
was necessary to make sound judgments about care. Simply put, positive outcomes support the
treatment efficacy. The movement became ener- treatment or policy being studied, and negative
gized in the 1960s with the work of Avedis outcomes suggest modification/elimination of that
Donabedian (1919–2000), a physician and public approach. At its best, outcomes research can pro-
health academician with a strong interest in vide information about the efficacy of the treat-
healthcare quality. Donabedian’s quality model ment and care, improve quality, save money, alter
began with structure (the medical facilities and public policy in beneficial ways, and guide decision
personnel), continued with process (the treatment), making.
Outcomes Movement 885
As physicians and patients increasingly are able quality of care as well as to study and monitor
to obtain aggregated information about the harms resource utilization.
and benefits of a medical intervention, they can Economic studies can be done in various ways;
make appropriately informed decisions. The medi- they can take into account cost-to-outcome data,
cal community also uses this information to which focus on the cost of treating a disease. Cost-
develop best practices—that is, the identification effectiveness studies compare the cost of one treat-
of treatment guidelines that work most effectively ment over another and the benefit of that treatment
and with maximum benefit to the patients in spe- over the other in terms of a specific outcome. Cost-
cific situations. This information likewise is being utility studies weight outcomes according to how
used to develop and modify public policy as agen- they are valued. The structure-process-outcome
cies strive to incorporate evidence in their public taxonomy has been found to be useful in studying
health initiatives. This includes disease prevention administrative and economic effects on systems.
as well as the development of cost-effective and Administrative outcomes studies focus on struc-
efficient disease-screening recommendations. ture, process, and personnel. Economic outcomes
The trend toward shared or patient-centered may include the cost of care, unnecessary or inap-
decision making, likewise, has spurred interest in propriate care, length of patient stay, patient read-
outcomes data. Patients increasingly are doing mission, return to work, and the ability to provide
their own searches to ascertain the benefits and self-care.
harms of specific treatment alternatives and seek- Government financial support has been an inte-
ing that kind of data from the medical profession. gral part of these initiatives, with research funded
Outcomes data about survival and function prob- though organizations such as the Agency for
abilities are intrinsic to these efforts. Healthcare Research and Quality (AHRQ).
Health outcomes data are now multifaceted and Research supported by the AHRQ and other gov-
include not just mortality data but also quality-of- ernment organizations has become part of the
life measures, such as the ability to function. In report card for healthcare purchasers and consum-
addition, outcome data about patient attitudes and ers to judge healthcare quality.
satisfaction are becoming increasingly important The AHRQ has established evidence-based
to clinicians and hospital leadership, in part due to practice centers, which are designed to analyze
the competitive healthcare environment. Data can information and develop recommendations that
come from administrative and clinical databases, are relevant to decision makers. The focus areas
disease registries, clinical trial data, and census now include the U.S. Preventive Service Task
information, with an emphasis on large and more Force, which reviews evidence in clinical preven-
inclusive databases. tion initiatives and provides technical support; the
However, some critics of outcomes-based rec- Technology Assessment Program, which studies
ommendations argue that solely relying on aggre- the clinical utility of medical interventions to help
gated data doesn’t allow for the flexibility that is the Centers for Medicare and Medicaid Services
necessary to adapt to the needs of the individual (CMS) make outcomes-based decisions for the
patient. The desire to eliminate variation can lead Medicare program; the Generalist Program, which
to treatment protocols that are too standardized, reviews a broad spectrum of clinical, behavioral,
in this view. Counterarguments state that out- economic, and health system delivery issues; the
comes data are principally valuable when medical Effective Health Care Program, which provides
interventions have been carefully and thoroughly comparisons of effectiveness studies for patients,
studied. Many ambiguities exist in diagnosis and clinicians, and policymakers to use in making their
treatment; so individual physician interpretation decisions; and the Scientific Resources Center,
is and will continue to be crucial in complex which provides scientific and methodological assis-
cases. Other critics have argued that outcomes tance to several of the above programs.
research initiatives have design limitations and These efforts, and others that will occur in
are primarily cost containment strategies. Public the future, are designed to provide the basis for
programs such as Medicaid and Medicare require continuous quality improvement, as medicine
that outcomes data be designed to improve the strives to improve patient outcomes and to do so
886 Outcomes Movement
within an efficient and effective healthcare deliv- MacKinnon, Joyce, David Shelledy, Cara Case, et al.
ery system. “Allied Health Outcomes Research Using a
Collaborative Distance Approach,” Journal of Allied
Mary C. Odwazny Health 29(2): 99–102, Summer 2000.
Tanenbaum, S. J. “Evidence and Expertise: The
See also Agency for Healthcare Research and Quality Challenge of the Outcomes Movement to Medical
(AHRQ); Centers for Medicare and Medicaid Services Professionalism,” Academic Medicine 74(7): 757–63,
(CMS); Codman, Ernest Amory; Cost-Benefit and
July 1999.
Cost-Effectiveness Analysis; Donabedian, Avedis;
Wilson, Ira B., and Paul D. Cleary. “Linking Clinical
Health Report Cards; Quality Indicators: Quality of
Variables With Health-Related Quality of Life. A
Healthcare
Conceptual Model of Patient Outcomes.” Journal of
the American Medical Association. 273(1): 59–65,
January 4, 1995.
Further Readings
Bachner, Paul. “Patient Outcomes and Pathology
Practice: An Introduction to the College of American Web Sites
Pathologists Conference XXXIV on Molecular
Pathology: Role in Improving Patient Outcomes,” AcademyHealth: http://www.academyhealth.org
Archives of Pathology and Laboratory Medicine 123: Agency for Healthcare Research and Quality (AHRQ):
996–99, November 1999. http://www.ahrq.gov
Bourne, Robert B., William J. Maloney, and James G. American College of Emergency Physicians (ACEP):
Wright. “An AOA Critical Issue the Outcome of the http://www.acep.org
Outcomes Movement.” The Journal of Bone and Centers for Medicare and Medicaid Services (CMS):
Joint Surgery (American) 86(3): 633–40, March 2004. http://www.cms.hhs.gov
Jeffort, Michael, Martin R. Stockler, and Martin H. Health Grades: http://www.healthgrades.com
Tattersall. “Outcomes Research: What Is It and Why Joint Commission: http://www.jointcommission.org
Does It Matter?” Internal Medicine Journal 33(3):
110–18, March 2003.
Lee, Stephanie J., and Craig C. Earle. “Outcomes
Research in Oncology: History, Conceptual
Framework and Trends in the Literature.” Journal of Outpatient Care
the National Cancer Institute 92(3): 195–204,
February 2002. See Ambulatory Care
P
In the coalition’s 1st years, the process of
Pacific Business Group obtaining information from health plans was not
on Health (PBGH) in place and was not yet possible. In 1991, the
PBGH introduced the Consumer Assessment
The Pacific Business Group on Health (PBGH) is Health Plan Survey, which began with a survey of
a large California healthcare business coalition. the use of prevention guidelines by health plans.
The PBGH includes more than 30 large companies The survey revealed large variations. The PBGH
as well as a subcoalition of more than 20 high- used this information to bring together health
tech businesses. In total, these members represent plans to set guidelines on preventive services and
more than 3 million employees, dependents, and to communicate these guidelines to providers.
retirees, accounting for about $10 billion in Observing the lack of data collection and reporting
annual healthcare expenditures. To become a in California, the PBGH formed the California
member of the PBGH, an employer must have at Cooperative Healthcare Reporting Initiative
least 2,000 covered lives in California. Excluded (CCHRI) in 1993. The CCHRI, which is managed
from membership are healthcare consulting by the PBGH, is a collaborative of healthcare pur-
groups, insurance companies, health plans, hospi- chasers, health plans, and many healthcare provid-
tals, medical groups, and any other healthcare ers that produces a yearly report of performance
industry employers. The coalition is active in data through a single process. Data collection and
healthcare purchasing, quality improvement, and reporting has become a collaborative rather than
consumer engagement in health decision making. competitive process for this group. In 2001, the
CCHRI agreed on standardized diabetes treatment
guidelines for the state’s health plans and medical
groups. The Ambulatory Quality Alliance (AQA)
Overview
named the CCHRI as one of six organizations in
The PBGH was founded in 1989 in San Francisco, the country to pilot physician-level performance
California, with the mission of seeking to improve information in 2006.
the quality and availability of healthcare while In 1996, the PBGH launched its consumer
moderating costs. The actions taken to realize this information initiative through its HealthScope.
mission have evolved from evaluating health plans The information on the Web site is generally used
to assessing other levels of healthcare delivery, by members of the PBGH to customize informa-
such as hospitals, provider groups, and individual tion for their own employees so they can make
providers, as well as engaging the individual con- value-based decisions about their health plan. In
sumer in the process of quality assessment and later years, HealthScope began to include quality
cost moderation. information on hospitals and medical groups.
887
888 Pacific Business Group on Health (PBGH)
Moving forward, the PBGH now also plans to Future Implications

assess how best to communicate physician-level
The PBGH has written and published many arti-
choice information.
cles, reports, and press releases. The organization
In 1997, the PBGH won a state bid to privatize
has provided testimony to many government com-
a small-group purchasing pool called the Health
missions and legislatures and has offered its exper-
Insurance Plan of California. The PBGH renamed
tise through participation in many forums and
the pool Pacific Health Advantage and within 4
meetings. The PBGH, through pilot programs of
years enrolled 147,000 members through 11,000
healthcare measurement and consumer participa-
small employers.
tion, is an active participant in practical health
The PBGH also helped form the Leapfrog
services research. While the PBGH represents
Group in 2000 to communicate hospital perfor-
many companies with several million covered
mance measures to consumers. During this time
lives, its influence on healthcare delivery, both
period, the PBGH also partnered with the State of
statewide and nationally, eclipses this direct ser-
California to ask hospitals to voluntarily report
vice to its members. The PBGH is shaping the
performance measures related to coronary artery
healthcare environment of tomorrow by provid-
bypass graft (CABG) surgery. The PBGH followed
ing leadership on health services measurement and
in the footsteps of New York State and published
the process of involving consumers in using that
risk-adjusted outcomes reports available on its
information.
HealthScope Web site. Two out of every three hos-
pitals voluntarily participated, and, following the Gregory Vachon
successful publication by the PBGH, legislation
was passed in California to make the reporting See also Cost of Healthcare; Health Report Cards;
mandatory starting in 2003. Leapfrog Group; Midwest Business Group on Health
That same year, the PBGH piloted a program to (MBGH); National Business Group on Health
measure the clinical performance of individual (NBGH); National Coalition on Health Care (NCHC);
physicians. This effort was furthered by convening Outcomes Movement
a national meeting in 2004 to outline the technical
and methodological issues facing the task of assess-
ing individual physician performance. The report, Further Readings
Advancing Physician Performance Measurement:
Using Administrative Data to Assess Physician Pacific Business Group on Health. Advancing Physician
Quality and Efficiency, presented significant chal- Performance Measurement: Using Administrative
lenges and a road map for the future. In 2005, the Data to Assess Physician Quality and Efficiency. San
PBGH worked with the California Medical Francisco: Pacific Business Group on Health, 2005.
Pacific Business Group on Health. Expectations for
Association and other stakeholders to deliver
Healthcare Value: Advancing Health Plan and
unprecedented consensus on physician perfor-
Providers. San Francisco: Pacific Business Group on
mance measurement. The PBGH is already provid-
Health, 2006.
ing national leadership in developing measurement
Pacific Business Group on Health. Evaluation of
and reporting systems for individual physicians, Consumer Decision Support Tools: Helping People
and an expanding leadership role figures largely in Make Health Care Decisions. San Francisco: Pacific
their plans for the future. Business Group on Health, 2007.
The PBGH’s role in purchasing healthcare and Pacific Business Group on Health. We Must Build
controlling costs is directly manifest in The Healthcare Value. San Francisco: Pacific Business
Negotiating Alliance, a mutual benefit corpora- Group on Health, 2007.
tion. The Negotiating Alliance promotes value- Stewart, Diane. Aligning Physician Incentives: Lessons
based purchasing through an annual Request for and Perspectives from California. San Francisco:
Proposals and a negotiating process on behalf of Pacific Business Group on Health, 2005.
400,000 covered lives. The alliance leverages the Thomas, J. William. Hospital Cost Efficiency
power of 19 large employers to obtain the best Measurement: Methodological Approaches. San
pricing as well as accountability for quality. Francisco: Pacific Business Group on Health, 2006.
Pain 889
Web Sites such as acupuncturists and massage therapists.

HealthScope: http://www.healthscope.org The annual cost associated with pain exceeds $5
Pacific Business Group on Health (PBGH): billion in the United States.
http://www.pbgh.org There are several burdens associated with pain,
including costs of healthcare, disability, and lost
productivity. Pain is one of the leading causes of
disability and functional problems. Furthermore,
Pain back, neck, and upper extremity pain are cited as
the most common reasons for being sick and tak-
The word pain derives from Sanskrit and Latin ing time off from work, resulting in work and
roots: pu, meaning purification, and poena, mean- productivity losses. An estimate from a national
ing punishment. Pain can be physical, psychologi- health survey found that about 18% of U.S. work-
cal, or sociocultural. Pain can be manifest in a ers experienced approximately 149 million days of
variety of forms, such as back pain, bone pain, lost work due to back pain.
and tooth pain. Pain is a subjective and variable
experience and depends on the individual, as indi- Models of Pain
viduals may have different thresholds. Pain is a
symptom of many medical conditions, and it can Historical models of pain include Descartes’s
have a significant impact on an individual’s qual- mind-body model. The Cartesian model of pain
ity of life and daily functioning. The diagnosis and held that there is a direct connection between the
treatment of pain is based on its classification nerves and the brain and had a dualistic view of
according to its duration, intensity, type, source, mind and body. Pain is the result of an injury that
and location. For example, pain can be classified causes a sensation in the person’s mind. The
as either acute or chronic. Most bodily pain is able model assumed that the greater the injury, the
to be resolved with little or no intervention and is greater the pain that is experienced by the indi-
generally considered to be acute pain. Chronic vidual. Pain was thought to result in direct tissue
pain, also known as persistent or intractable pain, damage to the body. This model also held that
on the other hand, is considered to be an illness pain is either physical or psychological in nature.
and not a symptom. Modern models of pain integrate the biological,
Pain can be defined in many different ways. cognitive, emotional, behavioral, and social aspects
One commonly used definition defines pain as an of this phenomenon. Studies have shown that
unpleasant experience that can be sensory or emo- many factors may have an influence on pain per-
tional in nature, is generally associated with pos- ception and that this is the result of not only
sible or actual damage to bodily tissues, and is physiological aspects but cognitive and behavioral
expressed through an individual’s behavior. aspects as well. The modern models tend to view
pain as a sensory and emotional experience that is
not necessarily the result of tissue injury or a nerve
Importance
signal.
Pain plays an important role in health services
research. Specifically, it directly affects access,
cost, quality, and outcomes of healthcare. For
Pain Scales
example, the occurrence of pain is one of the most Pain has been recognized as a vital sign that
common reasons for a physician visit by individu- should be properly monitored and alleviated. Pain
als, resulting in about half of all Americans seek- management has been acknowledged to result in
ing medical care each year. In addition, pain faster recovery, improved quality of life, and
causes visits by individuals to other ancillary increased productivity of the individual. Healthcare
healthcare providers, including physical thera- providers seek to diagnose pain according to its
pists, occupational therapists, nurses, and psy- onset, duration, character, location, and severity
chologists, among others, as well as visits to as well as the symptoms associated with it.
complementary and alternative medical providers The diagnosis of pain requires that the healthcare
890 Pan American Health Organization (PAHO)
provider examine a patient’s symptoms, condi-

tion, and medical history. Pain assessment gener- Pan American Health
ally also examines a person’s pain threshold in Organization (PAHO)
addition to his or her pain tolerance.
A number of pain scales have been developed to The Pan American Health Organization (PAHO)
assess and evaluate an individual’s level of pain, is the world’s oldest international public health
using various methods. For example, the McGill agency, and it is recognized as part of the United
Pain Questionnaire is a tool that is often used to Nations system. PAHO has over a century of
gain a verbal assessment of an individual’s pain. experience in working to improve the health and
The Brief Pain Inventory uses an interview tech- living standards of the people in the Americas.
nique to evaluate how pain affects an individual’s PAHO serves as the World Health Organization’s
daily functioning. Scales have also been created to (WHO) Regional Office of the Americas as well
rate an individual’s pain, such as the Numeric as the health organization of the Inter-American
Rating Scale and the Faces Pain Scale, that assess system. The agency has scientific and technical
the intensity of pain as minimal to severe as well as experts located at its headquarters in Washington,
monitoring a person’s pain over time to evaluate if D.C., at its 27 country offices, and at its 9 scien-
the individual responds to treatment. These pain tific centers that work on health issues of pri-
scales also enable medical researchers to compare mary concern to countries in Latin America and
the results between groups of patients. the Caribbean. The mission of PAHO is to
Kenneth L. Vaux strengthen local and national health systems and
to improve the health of the people of the
See also Acute and Chronic Diseases; Complementary Americas through various joint collaborative
and Alternative Medicine; Disability; Measurement in efforts.
Health Services Research; Patient-Reported Outcomes;
Quality of Healthcare; Quality of Life, Health Related
History
Further Readings PAHO was established in 1902 to work with all
countries in the Americas to raise the living stan-
Gelinas, Celine, Carmen G. Loiselle, Sylvie LeMay, et al.
dards and improve the health of their peoples.
“Theoretical, Psychometric, and Pragmatic Issues in
Pain Measurement,” Pain Management Nursing 9(3):
PAHO comprises member states that include all
120–30, September 2008.
35 countries (Antigua and Barbuda, Argentina,
Greco, Palo S., and Francesco M. Conti, eds. Pain Bahamas, Barbados, Belize, Bolivia, Brazil,
Management: New Research. New York: Nova Canada, Chile, Colombia, Costa Rica, Cuba,
Science, 2008. Dominica, Dominican Republic, Ecuador, El
Laccetti, Margaret Saul, and Mary K. Kazanowshi. Pain Salvador, Grenada, Guatemala, Guyana, Haiti,
Management. 2d ed. Sudbury, MA: Jones and Honduras, Jamaica, Mexico, Nicaragua, Panama,
Bartlett, 2008. Paraguay, Peru, Saint Lucia, St. Vincent and the
Wittink, Harriet M., and Daniel B. Carr, eds. Pain Grenadines, St. Kitts and Nevis, Suriname,
Management: Evidence, Outcomes, and Quality of Trinidad and Tobago, the United States, Uruguay,
Life: A Sourcebook. New York: Elsevier, 2008. and Venezuela) in the Americas, with the addition
of Puerto Rico as an associate member; participat-
ing states (France, the Netherlands, and the
Web Sites United Kingdom and Northern Ireland); and
American Academy of Pain Medicine (AAPM): observer states (Spain and Portugal). PAHO’s
http://www.painmed.org policies are set through its governing bodies. To
American Chronic Pain Association (ACPA): advance its organizational mission, PAHO main-
http://www.theacpa.org tains collaborative efforts with Ministries of
American Pain Society (APS): http://www.ampainsoc.org Health, universities, nongovernmental organiza-
NIH Pain Consortium: http://painconsortium.nih.gov tions (NGOs), governmental agencies, and others.
Pan American Health Organization (PAHO) 891
PAHO works to promote primary healthcare PAHO’S Work

strategies in communities by increasing access to
PAHO distributes scientific and technical infor-
care and encouraging the efficient use of limited
mation that is made available through its publica-
resources. The organization has been involved in
tions, Web site, libraries, and documentation
assisting countries to combat reemerging infec-
centers. It also provides technical assistance in the
tious diseases such as cholera, tuberculosis, and
various areas of public health, in addition to orga-
dengue as well as emerging infectious diseases
nizing disaster relief coordination and emergency
such as AIDS, through technical assistance, sup-
preparedness programs.
port, and work with NGOs. In addition, PAHO
PAHO supports initiatives to control malaria,
works to prevent the spread of chronic diseases
Chagas’ disease, urban rabies, leprosy, and other
that have begun to afflict populations in the
diseases affecting people in the Americas.
developing countries of the Americas. The work
Additionally, it is collaborating with others to
of PAHO is supported by the contributions of its
address nutritional deficiencies, including iodine
member governments as well as outside funding
and vitamin A deficiencies, as well as protein-energy
that aids special programs.
malnutrition. The organization has also been work-
The PAHO focuses its efforts to target the most
ing with countries to cope with health problems
vulnerable members of society, including women,
that have resulted from industrial development,
children, workers, the elderly, refugees, and dis-
including cardiovascular disease, cancer, and sub-
placed persons as well as to address equity issues
stance abuse. It also conducts projects on behalf of
in terms of access to care. The Pan American
other United Nations agencies, international orga-
approach of having countries cooperate and work
nizations, government agencies, and foundations.
together toward shared goals has been an essential
PAHO works to enhance the health sector
part of PAHO’s history. The agency has been piv-
capacity in countries to address their priority
otal in initiating multinational collaborative health
areas. The agency is involved in training health
ventures in Central America, the Caribbean, the
professionals as well as increasing the capacity of
Andean Region, and the Southern Cone. The height
national training institutions. PAHO is also work-
of political collaboration resulted when the
ing to further integrate women into society and
American heads of state accepted the “Health
improve the health status of women.
Technology Linking the Americas” initiative at the
Summit in Santiago.
The eradication of smallpox from the Americas
Priority Areas
in 1973, with worldwide eradication 5 years later,
has been one of PAHO’s great successes. Another An important priority area of PAHO is to reduce
major effort, begun in 1985, to eradicate polio, infant mortality and prevent an additional 25,000
was accomplished in September, 1994, when the infant deaths a year through the use of the
Americas were declared to be polio free by the Integrated Management of Childhood Illness strat-
International Commission. PAHO is close to its egy. The agency is also marshalling the necessary
goal of eliminating measles from the Americas and resources to train healthcare workers to evaluate
continues to introduce vaccines that are available the health status of children brought in to a health
against other diseases, including the Haemophilus post or clinic as well as to diagnose, treat, and
influenza B. vaccine to prevent meningitis and prevent disease.
respiratory infections. PAHO continues to assist Recognizing the health consequences and costs
countries to secure the necessary resources to pro- associated with tobacco use, the governing bodies
vide for the immunization and treatment of all of the Pan American Health Organization have
vaccine-preventable diseases. The agency is also directed it to curtail the use of tobacco. Additionally,
working to reduce morbidity and mortality from with an emphasis on equity, a continued priority
diarrheal diseases, including cholera, through case area of PAHO includes adequate sanitation,
management and oral rehydration therapy, as well improvement of drinking water supplies, and
as to ensure the diagnosis and treatment of respira- increased access to healthcare for the poor.
tory infections. Furthermore, advocacy efforts have been directed
892 Patient-Centered Care
to reduce gender inequity and address the unique concept is starting to be recognized by the medical
health problems of women. community. Studies have shown that patient-
centered care results not only in increased patient
Jared Lane K. Maeda satisfaction but also in improved patient medical
outcomes. Licensing and regulatory bodies, as
See also Access to Healthcare; Emergency Preparedness;
Emerging Diseases; Infectious Diseases; International well as board certification agencies, have begun to
Health Systems; Public Health; Tobacco Use; World include patient-centered criteria in their approval
Health Organization (WHO) processes for medical professionals. Despite these
various efforts, many physicians and other health-
care providers are still not currently practicing
Further Readings patient-centered care.
Alleyne, George A. O. “The Pan American Health
Organization’s First 100 Years: Reflections of the Overview
Director,” American Journal of Public Health
The following highlights an example of patient-
92(121): 1890–94, December 2002.
centered care. A patient presents with throbbing
Andrus, Jon Kim, and Ciro A. de Quadros. Recent
Advancements in Immunization. 2d ed. Geneva,
pain in his right leg in a hospital emergency
Switzerland: World Health Organization, 2006.
department. The nurses and physicians deal with
Cueto, Marcos. The Value of Health: A History of the him gently, as they seek his medical history, and
Pan American Health Organization. Rochester, NY: discern the source of his problem. This kind of
University of Rochester Press, 2005. calm, tender treatment of the ill and infirm is at
Pan American Health Organization. The Quest for a the core of patient-centered care.
Healthy America: Celebrating 100 Years of Health. Although patient-centered care is starting to be
Washington, DC: Pan American Health Organization, recognized as an important aspect in healthcare, it
2002. has been slow to be fully embraced. National sur-
Pan American Health Organization. Health in the veys conducted by the Commonwealth Fund found
Americas, 2007. Washington, DC: Pan American that about 1 in 5 adults has difficulty in communi-
Health Organization, 2007. cating with his or her physician. And about 1 in 10
Velzeboer, Marijke. Violence Against Women: The adults has been treated disrespectfully during a
Health Sector Responds. Washington, DC: Pan healthcare visit. There have also been reports of
American Health Organization, 2003. patients who receive conflicting information from
their healthcare providers or of the results of
medical tests and medical records not being avail-
Web Sites able at the time of the patient’s visit.
Pan American Health Organization (PAHO): As a result of these shortcomings, patients are
http://www.paho.org being asked to become active partners in their
Pan American Journal of Public Health: healthcare. Through a patient-centered health sys-
http://journal.paho.org tem, there would be increased patient-provider
World Health Organization (WHO): http://www.who.int communication and greater availability of educa-
tional materials and tools to help patients make
more informed decisions. A patient-centered health
system would increase access to care and include
Patient-Centered Care timely appointments and off-hour services. The
increased use of information technology would be
Patient-centered care is care that is sensitive and essential to achieve this model.
responsive toward the individual needs, prefer- A patient-centered health system would also
ences, and values of the patient. The national include greater continuity of care among primary
Institute of Medicine (IOM) named patient- care and specialist physicians, post-hospital-
centered care as one of the six domains of health- discharge follow-up, and disease management.
care quality. Additionally, the importance of this Making sure that patients have a medical home is
Patient-Centered Care 893
key to developing a patient-centered care model. Improved Medical Outcomes

Furthermore, providing patients with pertinent
Some experts say that patient-centered care needs
information on the quality of providers as well as
to be presented differently to physicians. Rather
regular feedback would contribute to an improved
than being an abstract concept, patient-centered
healthcare system.
care should be shown as something that affects
According to a study in 2006, physicians say
medical outcomes. Demonstrating this will increase
that they favor patient-centered care, but only
the number of physicians who adopt the practice.
22% of physicians actually incorporate these stan-
For example, health services researchers note
dards into their daily practices. Some practices of
that nearly 6% of hospital admissions are caused
patient-centered care, such as same-day appoint-
by patients failing to take prescribed medications
ments, have been integrated; however, other aspects
(also known as noncompliance). The word compli-
related to care coordination, team-based care, and
ance connotes that the patient should do exactly
information systems have yet to be widely imple-
what the physician orders; however, physicians
mented. Some other key findings from this study
know that an authoritarian approach does not
were that physicians in group medical practices of
necessarily translate to the best medical outcomes.
50 or more are more likely to adopt components
By being more patient-centered, physicians would
of patient-centered care than solo practitioners
treat patients as partners by involving them in
and that, although 73% of primary-care physi-
planning their healthcare and encouraging them to
cians think that team-based care results in better
take responsibility for their health. Experts note
care decisions, 33% think that the team process
that a growing body of research, published during
makes care cumbersome, and 21% think that it
the past three decades, has shown that the nature
increases the likelihood of medical errors. Only
of the physician–patient conversation has a direct
2% of primary-care physicians are paid for e-mail
bearing on compliance.
correspondence with patients. Additionally, 87%
Studies have also shown that patients are more
of primary-care physicians think that improved
likely to take their medications, abstain from poor
teamwork or communication among providers
nutrition, and show up for appointments on time
would be effective in improving the quality of
when allowed to help set their treatment plans.
patient care.
This ultimately promotes patient compliance and
leads to better quality of care. Physicians generally
Patient Feedback underestimate the number of patients who refuse to
comply with their regimens. It has been estimated
There is reported to be a significant gap between
that between 40% and 50% of diabetic patients do
physicians’ endorsement of the concept of patient-
not abide by their medication regimens. Similarly,
centered care and their actual adoption of prac-
the figure for hypertensive patients is about 40%.
tices to implement it. For example, only 36% of
In addition to better medical outcomes, a
primary-care physicians and 20% of specialists
patient-centered system leads to decreased costs. It
indicated that they receive data based on patient
has been noted that it is much less expensive to
satisfaction surveys, but more than one-quarter
promote compliance than to hospitalize patients
indicated that they were actually rewarded based
because they have not taken their blood pressure
on patient survey data.
pills. One study found that at least half of the
Furthermore, physicians report that there is an
patients who were given a prescription did not
array of barriers to their adoption of patient-
receive the full benefit because they did not take it,
centered care practices, including lack of training,
they did not take the right dosage, or they stopped
knowledge, and costs. It has been suggested that
taking it prematurely.
different incentives might help to facilitate increased
adoption of patient-centered practices. If physi-
cians are given the correct tools and practice envi-
Provider-Patient Communication
ronment, and also develop a partnership with their
patients, then a patient-centered system may be Communication with patients is the key to patient-
better able to take shape. centered care. There are five simple steps that
894 Patient-Centered Care
physicians and other healthcare providers can take diabetic patient is convinced that his or her disease
to communicate more effectively with patients. is fatal and that any treatment would be in vain.
First, the patient must determine whether he or An answer like that will inform the physician that
she agrees on what the health problem actually is there is a need to further discuss the disease and its
with the physician. A patient with a headache may management.
believe that it is caused by a sinus infection, which Additionally, a physician should probe by ask-
should be treated with an antibiotic. However, the ing, “On a scale of 1 to 10, how confident are you
physician may believe that it is a migraine and that you can adhere to this treatment regimen?” A
needs a different medicine. If this difference is not heavy smoker who is absolutely convinced that he
resolved, the patient may not take the product as or she needs to give up cigarettes may have a con-
prescribed. fidence level of 1 that this can be accomplished.
Second, once the patient and physician agree, However, by examining further, there may be
attainable treatment goals must be set. If a hyper- signs that additional counseling and support are
tensive patient has a diastolic blood pressure of needed to monitor the patient closely during the
120 mmHg, the physician may not want to try to withdrawal stages.
bring it down below 90 mmHg immediately.
Rather, the physician may suggest 110 mmHg as a Gene J. Koprowski
short-term goal. Once this has been reached, the See also Continuum of Care; Disease Management;
physician can use that to motivate the patient to Health Communication; Outcomes Movement;
reduce it even more. Primary Care; Primary-Care Physicians; Quality of
Third, there is generally more than one option Healthcare; Satisfaction Surveys
to treat a given condition. Physicians should review
a reasonable range of alternative treatment options
and discuss the benefits and possible side effects of Further Readings
each one in terms that the patient understands.
Audet, Anne-Marie, Karen Davis, and Stephen C.
Fourth, the patient and physician must decide
Schoenbaum. “Adoption of Patient-Centered Care
on a feasible course of treatment. They can choose
Practices by Physicians,” Archives of Internal
the medical option that makes the most sense. For Medicine 166(7): 754–59, 2006.
example, a patient with hypertension may have Davis, Karen, Stephen C. Schoenbaum, and Anne-Marie
just remarried and may not want a low-cost drug Audet. “A 2020 Vision of Patient-Centered Primary
that could reduce sexual drive. Therefore, he or Care,” Journal of General Internal Medicine 20(10):
she may opt for a high-cost product with no sexual 953–57, October 2005.
side effects. Dosage frequency requires a similar Frampton, Susan B., and Patrick Charmel Planetree, eds.
discussion. Putting Patients First: Best Practices in Patient-Centered
Last, the physician should test the patient’s Care. 2d ed. San Francisco: Jossey-Bass, 2009.
knowledge. He or she should ask patients to repeat Mitchell, Pamela H. “Patient-Centered Care: A New
what they have been told about their illness and Focus on a Time-Honored Concept,” Nursing
treatment plan. It is also important for patients to Outlook 56(5): 197–98, September–October 2008.
demonstrate any techniques they have been taught, Sidani, Souraya. “Effects of Patient-Centered Care on
such as injecting insulin or using a peak flowmeter. Patient Outcomes: An Evaluation,” Research and
For example, some physicians have diabetic Theory for Nursing Practice 22(1): 24–37, 2008.
patients practice needle sticks in their office using Wolf, Debra M., Lisa Lehman, Robert Quinlin, et al.
an orange. “Effect of Patient-Centered Care on Patient
There are also questions at the end of a patient Satisfaction and Quality of Care,” Journal Nursing
visit that allow physicians to screen for likely non- Care Quality 23(4): 316–21, October–December 2008.
compliance. An example of this is, “On a scale of
1 to 10, with 10 being the highest, how important
Web Sites
do you think it is for you to do the things we’ve
been talking about?” By gathering this type of American Academy of Family Physicians (AAFP):
information, the physician may discover that a http://www.aafp.org
Patient Dumping 895
Commonwealth Fund: http://www.commonwealthfund.org medical condition, nor are there reports on the
Institute for Healthcare Improvement (IHI): number of persons with emergency conditions who
http://www.ihi.org are discharged or transferred in an unstable state.
That patient dumping is a real problem is not a
matter of serious debate; indeed, the legal frame-
work for patient antidumping standards evolved
Patient Dumping from the reports of a series of spectacular inci-
dents. Antidumping laws are controversial, in part
Patient dumping—the denial of examination and because of the high level of stress faced by hospital
stabilization services for persons with medical emergency departments. Between 1991 and 2003,
emergencies for reasons unrelated to medical hospital emergency department visits in the nation
need—constitutes a long-standing issue in U.S. increased by 26%, reaching a 2003 level of about
health law and policy. It is relatively common to 114 million visits. Of the total number of emer-
see the concept of patient dumping expressed gency department visits, about one-third were
strictly in relation to financial motive. In fact, considered to be nonurgent, meaning that about
financial motive is not a prerequisite to either the 38 million visits annually are for conditions that,
concept of dumping or to legal liability. Legal vio- on examination, may be considered nonemergent.
lation can result even without financial motive, for Since antidumping duties commence with the obli-
example, if an HIV-positive patient with a medical gation to examine, the fact that many exams reveal
emergency is turned away because staff physicians nonemergent conditions is actually somewhat tan-
refuse to treat him or her. (In such a situation, a gential. Furthermore, emergency department sta-
hospital may be in violation not only of antidump- tistics are predicated on individuals who become
ing laws but also of federal and state civil rights registered emergency department patients. How
laws that protect persons with disabilities.) many individuals are actually dumped—that is,
turned away without any exam or diverted away
Nature and Extent
from a hospital while in an ambulance—must be
No one really knows the magnitude of patient factored into the equation when thinking about
dumping in the nation. Every so often, a headline- the true reach of antidumping laws.
making incident occurs. In 2006, for example, a
Los Angeles hospital was criminally charged with
discharging a medically unstable homeless woman The Antidumping Legal Framework
from her hospital bed—and still in her gown and
The No-Duty Principle
slippers—to a skid-row neighborhood. But quanti-
tative analyses do not exist, in part because there is The starting point for understanding the conse-
no good way to know how many people may be quential nature of antidumping obligation is the
turned away from hospitals with no service at all. common law principle of “no duty.” Under the
Thus, reliable statistics are lacking regarding the common law, that is, under the long-standing prin-
number of persons who may be turned away with- ciples of judicial law on which much of the U.S.
out treatment or who may be prematurely dis- legal system rests, healthcare professionals and
charged from hospitals in an unstable condition other healthcare providers have no duty to furnish
for reasons unrelated to medical need. Relatively care. That is, hospitals and physicians are not
precise standards outline the duties of hospitals considered “places of public accommodation” and
where emergency care is concerned, and to esti- thus have no legal duty to furnish care to any per-
mate the dumping problem accurately, incidents son they do not wish to serve. Once a provider-
would need to be aligned with an array of terms patient relationship is established, then, of course,
and standards that, in certain aspects, also turn on healthcare providers do have a legal duty to act in
medical judgment, an added confounder. The fed- a reasonable way. But this duty to behave in a rea-
eral government does not publicly report on the sonably professional manner does not trigger until
number of emergency department examinations a provider actually agrees to enter into a physi-
that fail to result in a finding of an emergency cian–patient relationship.
896 Patient Dumping
For example, a physician has no duty to come The earliest patient-dumping law came from
to the aid of a person suffering a medical emer- judicial decisions involving persons who died or
gency (in all jurisdictions, physicians who do pro- were severely injured as a result of the denial of
vide emergency aid are covered by Good Samaritan care. Among the principles applied to hospitals by
laws that protect against all but liability for gross the courts as a means of finding liability for turn-
negligence or willful or wanton misconduct). ing people away without care under their “no
Under common law, hospitals had no duty to treat duty” were the common law concepts of “detri-
emergencies. mental reliance,” “public accommodation,” and
“legal undertaking.” A detrimental reliance claim
was one in which the injured person or decedent’s
Evolution of the No-Duty Principle
estate argued that the very presence of the hospital
By the middle of the 20th century, a combina- emergency department created a legal duty because
tion of changing emergency care technology and the community came to rely on its presence in
fundamental shifts in social values led to a funda- times of emergency; thus, the hospital could not
mental legal rethinking of the no-duty principle by hold itself out as the place to come for emergency
courts and state legislatures, at least where hospital care—and indeed, establish a record of furnishing
emergency department care was concerned. (To such care—and then select its customers.
this day, physicians have no legal duty of care.) A public accommodation claim rested on the
The rise of the modern hospital, with its techno- notion that, like innkeepers and transportation sys-
logically advanced and lifesaving emergency depart- tems (which are prohibited at common law from
ment services, was perceived as fueling community refusing paying customers), hospitals with emer-
expectations of care. The community expectation gency department capacity were obligated to serve
was further fueled by the considerable community the public, even if the public could not pay at the
support received by hospitals in the form of insur- point of service. The public accommodation theory
ance payments, direct government support, and rested on the life and death role played by inns and
nonprofit tax exemptions. Indeed, the Hospital common carriers during the Middle Ages; thus, as
Survey and Construction Act of 1946 (more com- hospitals came to occupy a lifesaving role in soci-
monly known as the Hill-Burton Act) represented ety, they came to represent a similar social good.
a national commitment to hospital construction, An undertaking claim rested on the notion that
one that, over time, would come to be understood a hospital that turned someone away had actually
as creating emergency-care duties of its own. begun to undertake care. Thus, in one celebrated
In sum, by the middle of the 20th century, the court case, a hospital was found liable for essen-
nation’s hospitals ceased to exist merely as work- tially abandoning a patient when personnel ordered
places for physicians. As complex and essential the family of a dying man to place him on an
medical-care entities in their own right, hospitals empty stretcher in the emergency department and
were burgeoning, in great part because of a com- then ignored him until he died.
munity commitment to their growth. Furthermore, In the concept of emergency care, two specific
this national commitment of resources took a mas- types of duties became evident from these early
sive leap forward with the enactment of Medicare cases. The first was a duty to examine individuals
and Medicaid in 1965. who come to a hospital seeking care, that is, a duty
At heart, the law is simply a highly formalized to undertake care through an initial examination,
reflection of prevailing social values and beliefs. regardless of factors unrelated to need. The second
Thus, as hospitals changed as social institutions, so duty was a duty to stabilize emergency conditions
did their relationship to the law in many respects, in persons whose examinations revealed an emer-
including the law as it related to emergency hospi- gency (typically defined as a condition that would
tal care. Similarly, as market values have come to lead to death). From the perspective of the totality
dominate the hospital industry in recent years, the of healthcare, the duty was quite narrow: Hospitals
legal obligations of hospitals in response to emer- were not expected to cure or rehabilitate persons
gency cases also have undergone a certain amount with emergencies, merely examine and stabilize
of relaxation. them. But from the perspective of the no-duty
Patient Dumping 897
principle, the departure was profound, particu- unique in U.S. law. Indeed, EMTALA offers the
larly because it served to establish the physician– only example in which U.S. law creates a legally
patient relationship on which professional and enforceable individual right to healthcare.
corporate liability rest. Furthermore, depending EMTALA applies to all Medicare-participating
on the nature of the emergency, the examination hospitals that operate an emergency department,
and stabilization could consume considerable thus pushing its reach well beyond the limits of
resources and be quite lengthy. previous federal laws applicable only to hospitals
built with certain forms of public financing. It obli-
gates a covered hospital to provide an appropriate
The Hill-Burton Act and State
medical examination to any person who comes to
Anti–Patient Dumping Statutes
the hospital’s emergency department.
As judicial law shifted, so did statutory and It is difficult to overstate the extent to which
regulatory law. By the early 1980s a number of EMTALA departs from traditional U.S. health
state legislatures had enacted emergency-care stat- policy, given the no-duty principle described above.
utes that conditioned licensure on not only main- In short, EMTALA creates an affirmative duty of
tenance of hospital emergency departments but emergency care on the part of Medicare-partici
also the provision of screening and stabilization pating hospitals with emergency departments,
services to persons with emergency medical condi- thereby overriding the right of covered hospitals
tions, as defined under state law. and their staff to select the patients they will serve.
In addition, the Hill-Burton Act became the sub- This emergency duty of care principle, as noted,
ject of extensive litigation surrounding the meaning has evolved over decades, but EMTALA expands
of its statutory “community service obligation.” and clarifies the duty in ways not previously seen
This obligation, a companion to the act’s better- in law.
known “uncompensated care” obligation, required At the same time, EMTALA has real limits.
all federally funded hospitals to provide assurances EMTALA alone does not compel a hospital to
that they would serve their communities. In revised maintain an emergency department (state licensure
regulations issued in 1979, the U.S. Department of laws, laws governing the conditions of participa-
Health and Human Services (HHS) had interpreted tion for Medicare hospitals, and accreditation
the law as requiring the provision of certain emer- standards might, of course). Nor does EMTALA
gency-related screening and stabilization services, mandate that hospital emergency departments
without regard to whether individuals could pay meet certain staffing and equipment standards
for the care at the point of service. (again, accreditation, licensure, and Medicare con-
The Hill-Burton regulations reached thousands ditions of participation standards might set perfor-
of facilities built with Hill-Burton funding. But by mance levels). What EMTALA does require is the
the end of the 1970s, funding had ceased; even dur- undertaking of emergency care in a fair and non-
ing its operational period, Hill-Burton excluded for- discriminatory fashion.
profit facilities. Thus, hospitals built over the past
generation have received no Hill-Burton funds. Sara Rosenbaum
See also Access to Healthcare; Emergency Medical
The Emergency Medical Services (EMS); Emergency Medical Treatment and
Active Labor Act (EMTALA); Hospital Emergency
Treatment and Active Labor Act
Departments; Hospitals; Patient Transfers; Public
Enacted in 1986, the Emergency Medical Policy; Uninsured Individuals
Treatment and Active Labor Act (EMTALA) was
a response to the U.S. Congress’ concern over the
impact of the new Medicare prospective payment Further Readings
system (PPS) on hospital access among indigent Taylor, Mark. “Oklahoma Hospital Settles Dumping
and uninsured patients. Its enactment followed a Charges; HHS Negotiating With Other Facilities
series of highly publicized incidents of patient Accused of Dumping Emergency Room Patient,”
dumping. In its structure and terms, EMTALA is Modern Healthcare 30(33): 2, 12, August 7, 2000.
898 Patient-Reported Outcomes (PRO)
Taylor, Mark. “Patient Dumping Cases Shoot Up,” as survival, patient-reported outcomes represent
Modern Healthcare 31(29): 6, July 16, 2001. the patient’s perspective on the impact of disease
Taylor, Mark. “Slow Recovery: Patient Dumping and its treatment on his or her everyday function-
Settlement Plunge; Experts Remain Mixed on ing and well-being. Instruments, typically ques-
Factors,” Modern Healthcare 33(22): 8, 14, June 2, tionnaires, can be an important measure of generic
2003. quality of life or functional status. Alternatively,
Vesely, Rebecca. “Kaiser Probed Again: More Patient they may be specific to disease, treatment, or
Dumping Alleged in Los Angeles Area,” Modern symptom. Regardless, an instrument must be
Healthcare 37(29): 18–19, July 23, 2007.
grounded in clinical and psychometric theory, be
representative of domains relevant to what it
attempts to measure, and have been demonstrated
Web Sites
as valid, reliable, sensitive, and specific.
American Hospital Association (AHA):
http://www.aha.org
Centers for Medicare and Medicaid Services (CMS): Guidance Document
Patient-reported outcomes have been defined as a
Department of Health and Human Services, Office of
measurement of any aspect of a patient’s health
Inspector General (OIG): http://www.oig.hhs.gov
status that comes directly from the patient (i.e.,
without the interpretation of the patient’s responses
by a physician or anyone else). Following its
Patient-Reported European counterparts, the U.S. Food and Drug
Outcomes (PRO) Administration (FDA) released its guidance docu-
ment for incorporating PRO into clinical research
in 2006. This document outlines three key aspects
In clinical and translational outcomes research, of patient-reported outcomes that make it advan-
the success of a patient’s medical intervention or tageous to include instruments in clinical and
treatment has traditionally been assessed and outcomes research.
documented by a physician or other clinician.
Direct observation of response to an intervention
is limited to objective measures. An outside 1. Some Treatment Effects Are
observer cannot always measure outcomes of ill- Known Only to the Patients
ness, treatment, or health promotion that mini- For some interventions, resulting success or fail-
mize physical and emotional decline or loss of ure can only be elucidated by querying the patient
independence. Interventions affecting an individu- or subject. For example, level of anxiety and anxi-
al’s wellness, particularly in chronic disease pro- ety relief are the fundamental measures in under-
gression, may have benefits beyond what can be standing the benefit of cognitive behavioral therapy
objectively studied, including the preservation of for generalized anxiety disorder. Also, pain inten-
functioning, pain relief, mood enhancement, and sity and pain relief are nearly exclusively subjec-
overall improvements in quality of life and well- tive. There are little or no observable or physical
being. With respect to more subjective outcomes, measures that can be used to examine potential
including quality of life, functioning, and symp- benefit related to treatment.
tom reduction, tools that have been validated and
deemed sensitive are required to measure the
2. Patients Provide a Unique
impact of disease and illness from the afflicted
Perspective on Treatment Effectiveness
individual’s perspective. These measures are
termed patient-reported outcomes (PRO). Patient-reported outcome measures can reflect
Measurement of patient-reported outcomes what is important to a patient in terms of symp-
provides valuable insight into health and illness tom relief, functioning, and quality of life. Thus,
beyond traditional efficacy or effectiveness research. PRO can incorporate patient expectations related
In contrast to self-evident outcomes of illness such to their care. This becomes important when
Patient-Reported Outcomes (PRO) 899
clinically measurable differences related to an Classification of PRO Measurements

intervention (e.g., those quantified by a labora-
tory test) do not always translate into a perceiv- Patient-reported outcomes broadly encompass
able change in health or wellness status. A widely several types of instruments. These include symp-
cited example is that clinically meaningful tom scales as well as instruments that measure
improvements in lung function as measured by health-related quality of life, functional status
forced expiratory volume (FEV1) may not cor- (e.g., ability to conduct activities of daily living),
relate well with improvements in asthma-related satisfaction with treatment, compliance with the
symptoms and their impact on a patient’s ability intervention, and medication adherence and per-
to perform daily activities. Furthermore, signifi- sistence. They may be disease specific, such as the
cant improvements in clinically observable Asthma Control Test (ACT) or the Function
parameters may be correlated with a significantly Living Index: Cancer (FLIC); they may be treat-
negative impact on a patient’s subjective response ment specific, such as the Satisfaction With
to treatment, particularly if the treatment inter- Antipsychotic Medication (SWAM) scale, or they
vention is associated with bothersome or fre- may measure the overall status of a condition such
quent untoward side effects. as instruments that measure the presence or
absence of depression or angina.
Alternatively to these very specific applications,
3. Formal Assessment May Be More
patient-reported outcomes instruments may also
Reliable Than Informal Interview
be generic and applicable across a wide variety of
Obtaining information from patients on symp- disease categories. Most measurements of physical
toms and symptom relief is not new. Clinicians functioning and activities of daily living fall into
informally ask questions such as, “Do you get the category of generic measures. One of the earli-
short of breath when walking up a flight of stairs?” est and perhaps the most widely known and cited
or “Does your pain interfere with your ability to generic measure was created by John E. Ware and
get out of bed?” However, efforts to capture and colleagues as an outgrowth of the Medical
analyze subjective answers to questions such as Outcomes Study (MOS). Known as the Short
these are prone to inconsistency and measurement Form 36 (SF-36), this instrument encompasses 36
error in the absence of validated instruments. questions representing the domains of (1) physical
There is general agreement that scientific methods functioning, (2) role functioning, (3) bodily pain,
for assessing subjective outcomes (e.g., psychomet- (4) general health perception, (5) vitality, (6) social
rics and utility measurement) are well developed functioning, (7) role-emotional functioning, and
and can serve as the cornerstone for patient- (8) mental health. Item responses within these
reported outcomes assessment. Using existing eight domains are reported as two summary
methodology to systematically and formally gather measures—physical and mental health. Generic
information from patients about their symptoms measures such as the SF-36 have been validated
and the impact of those symptoms on function is within numerous disease states. Depending on the
the cornerstone of PRO. disease state, the SF-36 has been used to identify
Instruments completed by patients directly mea- both differences in overall outcome between inter-
sure perceived treatment response. Data captured vention groups and also changes within interven-
in this manner are likely to be more reliable than tion groups over time.
those obtained through indirect third-party mea- In addition to comparing patient-reported qual-
surements because they are not affected by inter- ity of life outcomes within an individual disease
rater inconsistency. Use of a well-constructed state, generic measures have proven valuable for
instrument is also valuable in detecting change in comparing health perceptions across disease states.
reported outcomes over time, particularly in pro- Instruments such as the SF-36 or, more commonly,
gressive disease. Change in functioning may be the Health Utilities Index (HUI) have been vali-
gradual, and an instrument sensitive to this change dated extensively and specifically to compare
can be useful in determining longitudinal impact quality of life across diseases. To accomplish this
on decline or improvement. comparison, results from generic measures are
900 Patient-Reported Outcomes (PRO)
converted to a 0 to 1 scale, with 1 representing the time, some of the time, or all the time), as well
perfect health and functioning and 0 representing as the intensity (e.g., mild, moderate, or severe) of
the state nearest to death. To illustrate comparison the experience. The respondent burden, the time
of utilities, individuals with advanced metastatic required to complete the instrument, must be
medulloblastoma brain tumor may have a health minimized to promote willingness to complete the
utility of 0.31, as compared with 0.58 for an indi- instrument and to facilitate the quality of the
vidual who is undergoing cardiac bypass surgery responses. The remaining, and perhaps most often
and 0.99 for someone without symptoms taking a overlooked, property of instrument development
cholesterol-lowering agent for hyperlipidemia. includes field testing to determine reliability,
These “utilities” are used to calculate quality- validity, and responsiveness (i.e., minimally detect-
adjusted life years (QALYs), which are used for able change). Creating and validating instruments
policy decisions surrounding drug formulary place- typically encompasses creating a draft with input
ment and treatment reimbursement, particularly in from leaders in the field of study, piloting the
Europe, Canada, and Australia. instrument in individuals afflicted with the condi-
tion of interest, interviewing pilot respondents to
identify potential problems with the instrument,
Methodological Considerations
and finally, performing a full-scale validation
in Developing PRO
study comparing responses to the instrument with
The mechanism with which patient-reported out- recognized gold standards, where available (con-
come data is captured typically includes a ques- current validity). Minimum requirements for vali-
tionnaire. Questionnaires may be self-administered, dation of instruments includes demonstration of
with a subject filling out a form with pen and reliability, construct validity, responsiveness over
paper or electronically via a computer. They may time, internal consistency, and test-retest reliabil-
be clinician administered via a healthcare worker, ity. Measurements of validity and reliability typi-
social scientist, or other trained individual reading cally make use of Cronbach’s alpha coefficient
questions or through conducting a formal, struc- and correlation or kappa coefficients. Agreement
tured interview either in person or telephonically. of .70 or greater is typically accepted for group
Methods available for questionnaire development comparisons. When investigator administered, a
generally are grounded in rigorous psychometric coefficient of .80 is typically acceptable to estab-
theory. The merit of patient-reported outcome lish interrater reliability.
questionnaires is determined based on three key Other considerations in validation include that
properties. First, outcomes must be conceptually instruments should be able to discriminate between
defined and be based on the most current under- subgroups of individuals based on severity. Also,
standing of domains of functioning and aspects of translation of instruments validated in one lan-
life quality relative to what is being assessed. guage should undergo linguistic validation during
Disease- or treatment-based instruments must also translation to alternate languages. Similarly, tools
be framed within the context of a thorough review validated using one administration mode (e.g., self-
of the medical or psychiatric literature. Second, administered) should be validated in an alternate
aspects of functioning, quality of life, or symp- mode (e.g., telephone interview administration)
tomatology must be suitably operationalized prior to incorporation into translational research.
through the questionnaire. This includes using In recent years, interest in incorporating patient-
phraseology and terminology that can be underreported outcomes into clinical trials designed to
stood and interpreted by the respondent. The time meet regulatory requirements in the approval pro-
period that the subject is required to recall in cess for marketing of medicines has led to an
order to respond to the question must be relevant explosion of instrument development. This devel-
to the health state studied but short enough to opment is geared toward developing tools sensitive
allow accurate reporting of experience. Scaling and specific to changes in PRO related to specific
must be representative of the respondent’s experi- pharmaceutical products. In response, regulators
ence. Scaling typically measures intensity of the and harmonization groups have begun to adopt
perceived health aspect (e.g., occurring none of standards by which PRO measures are developed.
Patient Safety 901
These measurement characteristics are grounded Lohr, K. N., N. K. Aaronson, J. Alonso, et al.
in solid theory and are now widely accepted. The “Evaluating Quality-of-Life and Health Status
ultimate objective is to develop and implement an Instruments: Development of Scientific Review
instrument that is accurate and validated of the Criteria,” Clinical Therapeutics 18(5): 979–92,
intended domains. September–October 1996.
Revicki, Dennis A. “Regulatory Issues and
Alicia Shillington Patient-Reported Outcomes Task Force for the
International Society for Quality of Life Research.
See also Activities of Daily Living (ADL); Measurement FDA Draft Guidance and Health-Outcomes
in Health Services Research; Outcomes Movement; Research,” Lancet 369(9561): 540–42,
Quality-Adjusted Life Years (QALYs); Quality February 17, 2007.
Indicators; Quality of Healthcare; Short-Form Health Revicki, Dennis A., David Cella, Ron Hays, et al.
Surveys (SF-36, -12, -8); Structure-Process-Outcome “Responsiveness and Minimal Important Differences
Quality Measures
for Patient Reported Outcomes,” Health and Quality
of Life Outcomes 4(70): 1–5, 2006.
Sprangers, Mirjam A., Carol M. Moinpour, Timothy J.
Further Readings
Moynihan, et al. “Assessing Meaningful Change in
Atkinson, Mark J., and Richard D. Lennox. “Extending Quality of Life Over Time: A Users’ Guide for
Basic Principles of Measurement Models to the Clinicians,” Mayo Clinic Proceedings 77(6): 561–71,
Design and Validation of Patient Reported June 2002.
Outcomes,” Health and Quality of Life Outcomes Ware, John E., and Barbara B. Gandek. “Overview of
4(65): 1–12, 2006. the SF-36 Health Survey and the International
Bergner, Marilyn. “Quality of Life, Health Status, and Quality of Life Assessment (IQOLA) Project,” Journal
Clinical Research,” Medical Care 27(3 Suppl.): of Clinical Epidemiology 51(11): 903–912, November
S148–S156, March 1989. 1998.
Chassany, Olivier, Pierre Sagnier, Patrick Marquis, et al.
“Patient-Reported Outcomes: The Example of
Health-Related Quality of Life—A European Web Sites
Guidance Document for the Improved Integration of
Cochrane Collaborative Patient-Reported Outcomes
Health-Related Quality of Life Assessment in the
Methods Group: http://www.cochrane-hrqol-mg.org
Drug Regulatory Process,” Drug Information Journal
Patient-Reported Outcomes Measurement Information
36: 209–238, January–March 2002.
System (PROMIS): http://www.nihpromis.org/
Food and Drug Administration. Guidance for Industry.
default.aspx
Patient-Reported Outcome Measures: Use in Medical
Patient-Reported Outcome and Quality of Life
Product Development to Support Labeling Claims.
Instruments Database (ProQolid): http://www.qolid.org
Draft Report. Washington, DC: U.S. Department of
U.S. Food and Drug Administration (FDA):
Health and Human Services, Food and Drug
http://www.fda.gov
Administration, 2006.
Guyatt, Gordon H., Carol E. Ferrans, Michele Y.
Halyard, et al. “Exploration of the Value of Health-
Related Quality-of-Life Information From Clinical
Research into Clinical Practice,” Mayo Clinic
Patient Safety
Proceedings 82(10): 1229–39, October 2007.
Kumar, Ritesh N., Duane M. Kirking, Steven L. Hass, The issue of patient safety has only gained national
et al. “The Association of Consumer Expectations, attention during the past decade, primarily due to
Experiences, and Satisfaction With Newly Prescribed the recognition that much hospital morbidity and
Medications,” Quality of Life Research 16(7): mortality is due to medical errors. Many organiza-
1127–36, September 2007. tions and programs have been established to
Lenderking, William. “Task Force Report of the Patient- address patient safety. Most healthcare institutions
Reported Outcomes (PRO) Harmonization Group: have instituted patient safety measures, which are
Too Much Harmony, Not Enough Melody?” Value key to maintaining their accreditation and there-
of Health 6(5): 522–31, September 2003. fore to their remaining financially solvent.
902 Patient Safety
Defining the Problem A HealthGrades Quality Study, which was

published in 2004 and investigated hospitalized
Patient safety and medical errors are closely Medicare patients between 2000 and 2002, found
linked, and in discussing one it is often necessary more than 1 million adverse events resulting in
to discuss the other. For this entry, patient safety up to 195,000 accidental deaths per year. Based
is defined as freedom from accidental injury due on the Agency for Healthcare Research and
to medical care or medical errors. Medical error is Quality’s (AHRQ’s) 20 evidence-based patient
defined as the failure of a planned action to be safety indicators, the study found that the three
completed as intended or the use of a wrong plan most common errors were failure to rescue (fail-
to achieve an aim, including problems in medical ure to diagnose and treat in time), decubitus
practice, products, procedures, and systems. ulcer, and postoperative sepsis. These three errors
The term patient safety was first used in the accounted for almost 60% of all patient safety
name of a professional medical organization in incidents among the hospitalized Medicare
1984, with the establishment of the Anesthesia patients, with an estimated excess annual cost of
Patient Safety Foundation by the American Society $2.85 billion.
of Anesthesiologists. Despite the recognition of
patient safety issues in the field of anesthesia, the
topic did not gain national attention until the late Addressing Medical Errors
1990s, solidified by the national Institute of The IOM report refuted the “bad apple” theory,
Medicine (IOM) landmark report To Err Is Human: which suggested that medical errors are due to
Building a Safer Health System, which was pub- specific faulty or inept practitioners; instead, it
lished in 2000. The report estimated that between determined that errors are usually the result of
44,000 and 98,000 people die in the United States faulty systems, processes, and conditions that lead
every year due to medical errors. It also estimated people to make mistakes or fail to prevent them.
that the national cost of medical errors to hospitals Also, errors are not limited to actions but also
was between $17 and $29 billion per year. include failure to act and avert preventable adverse
The IOM report cited commonly occurring outcomes.
errors, including adverse drug events and improper To improve patient safety, the report recom-
transfusions, surgical injuries and wrong-site sur- mended a four-tiered approach: (1) establish a
gery, suicides, restraint-related injuries or death, national focus to create leadership, research, tools,
falls, burns, pressure ulcers, and mistaken patient and protocols to enhance the knowledge base
identities. The report also cited an article in the about safety; (2) identify and learn from errors by
Quality Review Bulletin (1993) that categorized developing a nationwide public mandatory report-
medical errors broadly into diagnostic (e.g., error ing system and by encouraging healthcare organi-
or delay in diagnosis, failure to employ tests, using zations and practitioners to develop and participate
outdated tests, and failure to act on results), treat- in voluntary reporting systems; (3) raise perfor-
ment (error in performance or administration of mance standards and expectations for improve-
treatment, avoidable delay in treatment, error in ments in safety through the actions of oversight
dose or method of using a drug, and inappropriate organizations, professional groups, and group pur-
care), preventive (failure to provide prophylactic chasers of healthcare; and (4) implant safety sys-
treatment and failure to monitor), or other (failure tems in healthcare organizations to ensure safe
of communication and equipment failure) groups. practice at the delivery level.
Following the IOM report, further studies were Largely in response to the IOM report, the U.S.
conducted to track medical errors and patient Congress allocated $50 million to the federal
safety issues. A study published in the Journal of AHRQ in 2000 to support efforts to improve
the American Medical Association in 2003 found patient safety and reduce medical errors. A fol-
that the greatest injury due to medical errors was low-up report from the IOM in 2001 further advo-
postoperative sepsis leading to an excess length of cated the rapid adoption of electronic clinical
hospital stay of 11 days, excess charges of $57,727, records, electronic medication ordering, and com-
and excess mortality of 22%. puter- and Internet-based information systems to
Patient Safety 903
support clinical decisions to improve patient safety bodies after surgery such as sponges, (6) incom-
and reduce medical errors. patible blood transfusions, (7) air embolisms
The development of evidence-based recommen- blocking blood flow, and (8) infections caused by
dations for specific medical conditions, termed leaving catheters in blood vessels and bladders too
clinical practice guidelines or best practices, has long.
accelerated in the past few years. Also, the U.S. The Joint Commission, which was established in
Congress passed the Patient Safety and Quality 1951, is an independent, nonprofit organization
Improvement (PSQI) Act of 2005, establishing a that evaluates and accredits nearly 15,000 health-
database to improve patient safety by encouraging care organizations and programs in the nation.
voluntary and confidential reporting of medical Most healthcare organizations seek accreditation to
errors. receive federal Medicare and Medicaid funds. Many
of the Joint Commission’s standards for organiza-
tions directly relate to patient safety, response to
Public and Private Initiatives
adverse events, and the prevention of accidental
Since the publication of the landmark IOM report harm. During the past decade, the Joint Commission
in 2000, many government and private organiza- has established a number of programs addressing
tions have made patient safety a top healthcare patient safety, including the National Patient Safety
priority. Government organizations with specific Goals and the Speak Up initiatives, which urge
initiatives for patient safety include the AHRQ patients to take an active role in preventing medical
and the Centers for Medicare and Medicaid errors. In 2005, it established an International
Services (CMS). Center for Patient Safety to collaborate with inter-
Private organizations concerned with patient national patient safety organizations.
safety include the American Society of Medication The Leapfrog Group, which was established in
Safety Officers (ASMSO), Council on Graduate 2000, is a conglomeration of large U.S. corpora-
Medical Education (COGME), Institute for tions that agreed to base their purchase of health-
Healthcare Improvement (IHI), Institute for Safe care on principles that encouraged provider quality
Medication Practices (ISMP), Joint Commission, improvement and consumer involvement. It cre-
Leapfrog Group, National Academy of State ated the Leapfrog Hospital Rewards Program,
Health Policy (NASHP), National Advisory which mandates specific quality practices such as
Council on Nurse Education and Practice computerized physician order entry, evidence-
(NACNEP), National Patient Safety Foundation based hospital referral, and intensive-care unit
(NPSF), National Quality Forum (NQF), Safe (ICU) staffing by physicians experienced in critical-
Care Campaign, and the United States Pharmacopeia care medicine. Additionally, a Leapfrog Safe
(USP). Practices Score was developed as a hospital quality
ratings system to influence consumers’ choices.
The NPSF is a nonprofit organization founded
Selected Patient Safety
in 1996 by the American Medical Association
Organizations and Programs
(AMA), CNA HealthPro, and 3M. The foundation
The CMS currently has several demonstration pro provides leadership training, research support, and
jects underway, including a pay-for-performance education, and it publishes the Journal of Patient
program, which offers hospitals increased com- Safety, containing original articles and reviews on
pensation for improvements in patient care coor- the subject.
dination and the institution of quality measures. It The NQF is a nonprofit, membership organiza-
also initiated a new disincentive rule in 2008, tion established in 1999 to develop and implement
which stops hospitals from billing Medicare for a national strategy for healthcare quality measure-
any charges associated with eight serious prevent- ment and reporting. The NQF has focused on sev-
able conditions. The eight conditions include eral areas, including medical error rates, unnecessary
(1) pressure ulcers, (2) urinary tract infections, (3) procedures and undertreatment, and preventive
patient falls, (4) mediastinitis (an infection after care. In 2002, the NQF defined 27 events that
heart surgery), (5) objects left in the patient’s should never occur within a healthcare facility. It
904 Patient Safety
grouped the “never” events into six categories Future Implications

(officially called Serious Reportable Events): (1)
surgical events (e.g., surgery being performed on Many medical errors have been attributed to poor
the wrong patient), (2) product or device events handwriting, manual order entry, and nonstan-
(e.g., using contaminated drugs), (3) patient protec- dard abbreviations that are misinterpreted.
tion events (e.g., an infant discharged to the wrong Electronic clinical records are a new technology
person), (4) care management events (e.g., a medi- that has the potential to reduce some of these
cation error), (5) environmental events (e.g., elec- errors, not only by eliminating illegibility but also
tric shock or burn), and (6) criminal events (e.g., by having default doses for medications and alerts
sexual assault of a patient). for potential drug interactions or allergies.
Electronic clinical records could also reduce errors
by improving access to information and commu-
Important Concepts nication among providers.
“First, do no harm” is an often-quoted mantra As noted above, some organizations, including
attributed to Hippocrates, the father of Western the CMS, have pilot programs which use a pay-
medicine. The implication is that medical profes- for-performance system that includes financial
sionals should try to help but at a minimum incentives and disincentives relating to patient
should do no additional harm. Many medical safety and the occurrence of “never” events identi-
errors are the direct result of inappropriate actions fied by the NQF. This type of reimbursement is
such as administering the wrong dose of a medica- highly controversial. Proponents suggest that
tion or performing surgery on the wrong limb or financial incentives will change behavior and
patient. encourage systems improvements. Others, primar-
Prevention is a key concept as well. Inaction is ily physician groups, argue that many complica-
considered equally as culpable as performing the tions occur despite following best practice
wrong action. Many medical “errors” are due to guidelines (e.g., postoperative infections), and
not addressing foreseeable adverse events. Examples institutions and providers will be unfairly penal-
include not instituting fall precautions (e.g., raising ized, possibly leading to compromised patient
bedrails for patients at risk of falling out of bed), safety if healthcare organizations are denied vital
not washing hands properly (leading to transmis- resources.
sion of hospital-acquired infections), and not giv- Legal reform is also seen as an area for interven-
ing anticoagulant medicine to prevent blood clots tion. Healthcare providers are often hesitant to
in bed-bound patients. report errors due to the threat of legal liability.
Evidence-based medicine is the idea of integrat- U.S. Senators Hillary Rodham Clinton (D-NY)
ing available medical research into patient care. and Barack Obama (D-IL) jointly proposed the
Many clinical practice guidelines have been estab- National Medical Error Disclosure and
lished in recent years, which are consensus-based Compensation (MEDiC) Bill of 2005, which would
recommendations for physicians to apply to care create an Office of Patient Safety and Health Care
of patients. These guidelines can help create con- Quality to administer the MEDiC program. The
sistent care based on the most up-to-date scientific proposed program is designed to improve disclo-
data available. sure of medical errors, give physicians certain
To improve patient safety, medical errors need protections from liability, and help facilitate appro-
to be identified and studied to determine possible priate compensation for affected patients, with the
causes. Reporting of medical errors, including overall aim of improving patient safety. The bill
near-miss events, is paramount. A near-miss event was referred to the Senate in September 2005 and
is an unplanned event that did not result in injury, subsequently to the Committee on Health,
illness, or damage, but had the potential to do so. Education, Labor, and Pensions. Neither the
Reporting of near-miss events by observers is an MEDiC Bill nor any other recent legislation
established error reduction technique in other addressing medical malpractice reform has been
industries and has recently been applied to the passed by both houses of Congress, but this topic
healthcare sector. will likely resurface when a new administration
Patient Transfers 905
revisits the problems of healthcare costs and medi-

cal errors. Patient Transfers
Stacey Chamberlain Patient transfers can be defined by the various
methods (e.g., ground or air transport) and
See also Clinical Practice Guidelines; Evidence-Based
Medicine (EBM); Joint Commission; Leapfrog Group;
motives (e.g., transfer to another hospital because
Medical Errors; National Quality Forum; Pay-for- the patient does not have health insurance) for
Performance; Quality of Healthcare moving a patient from one location to another. A
major classification of patient transfers is whether
they are intrafacility or interfacility transfers.
Further Readings
Intrafacility transfers are patient transfers within
Agency for Healthcare Research and Quality. Patient a given healthcare facility, either between depart-
Safety Indicators, Version 2.1, Revision 1. Rockville, ments or between other organizations within the
MD: Agency for Healthcare Research and Quality, healthcare facility. In contrast, interfacility trans-
March 2004. fers are patient transfers from one healthcare
Clinton, Hillary Rodham, and Barack Obama. “Making facility to another facility. Examples of interfacil-
Patient Safety the Centerpiece of Medical Liability ity transfers include the following: (a) hospital-
Reform,” New England Journal of Medicine 354(21): to-hospital transfers, (b) clinic to hospital
2205–2208, May 25, 2006. transfers, (c) hospital to rehabilitation facility
Committee on Quality of Health Care in America, transfers, and (d) hospital to long-term care facil-
Institute of Medicine. Crossing the Quality Chasm: A ity transfers.
New Health System for the 21st Century. Challenges to the success of interfacility trans-
fers include the qualifications of those delivering
HealthGrades, Inc. HealthGrades Quality Study: Patient
the care, the ability to meet the clinical needs of the
Safety in American Hospitals. Golden, CO:
patient, and the aptitude to maintain continuity of
HealthGrades, 2004.
care. Due to the emergence of specialty medical
Kohn, Linda T., Janet M. Corrigan, and Molla S.
Donaldson, eds., Committee on Quality of Health
systems such as cardiac centers and stroke centers,
Care in America, Institute of Medicine. To Err Is
the ultimate destination of a patient is now often
Human: Building a Safer Health System. Washington, predicated on the patient’s specific medical condi-
DC: National Academies Press, 2000. tion rather than the proximity of the nearest medi-
Leape, Lucian L., Ann G. Lawthers, Troyen A. Brennan, cal facility. This practice has created the need for
et al. “Preventing Medical Injury,” Quality Review enhanced measurement and guidelines and the
Bulletin 19(5): 144–49, May 1993. evaluation of patient transfers to understand and
Zhan, Chunliu, and Marlene R. Miller. “Excess Length track the different circumstances under which
of Stay, Charges, and Mortality Attributable to transfers take place.
Medical Injuries During Hospitalization,” Journal of Because of this change, the number of stake-
the American Medical Association 290(14): 1868–74, holders involved in patient transfer protocols
October 8, 2003. and instrumentations has increased and diversi-
fied over the past few years. Stakeholders
Web Sites include physicians at both the receiving and
Agency for Healthcare Research and Quality (AHRQ): transferring facility, the medical staff of both
http://www.ahrq.gov institutions, the patient and the patient’s family
Anesthesia Patient Safety Foundation (APSF): and caregivers, the third-party insurance groups,
http://www.apsf.org the health administration and legal staff of both
Centers for Medicare and Medicaid Services (CMS): facilities, and the transferring bodies such as
http://www.cms.hhs.gov the ambulance staff. Additional stakeholders
Joint Commission: http://www.jointcommission.org include Emergency Medical Services (EMS)
Leapfrog Group: http://www.leapfroggroup.org organizations and the National Highway Traffic
National Quality Forum (NQF): http://www Safety Administration (NHTSA) who enter into
.qualityforum.org discussions to create EMS priority issues and
906 Patient Transfers
establish guidelines for the EMS organization’s Public Policy

critical-care transport. This level of transport
The federal Emergency Medical Treatment and
care is provided to patients whose indication
Active Labor Act (EMTALA) provides broad
requires an expert level of provider knowledge
guidelines regarding the transfer of patients after
and skills, a setting with necessary equipment,
they seek care in a hospital’s emergency depart-
and the ability to handle the challenge of the
ment. EMTALA, which was passed in 1986, was
transport.
designed to prevent patient dumping. It mandates
that hospitals that receive Medicare and Medicaid
funds provide medical screening examinations of
Reasons for Patient Transfers
all emergency department patients, regardless of a
The rationales for transferring patients include patient’s ability to pay. If critical medical condi-
facility capacity issues, facility or physician spe- tions are identified, EMTALA requires the hospi-
cialty and competency, and limitations in levels of tal to stabilize the patient before transferring
care offered. Hospitals are often plagued with him or her to another facility for care. The act
issues of overcapacity and inability to properly addresses concerns of patient safety and the ability
house and care for incoming patients. Some to receive medical care regardless of demographics
healthcare institutions such as clinics and nursing and socioeconomic status.
homes may accept only a few payment options,
thereby limiting the care they provide. Additionally,
many patients are transferred because the initial Future Implications
admitting facility is unable to support the needs of As the result of EMTALA, many of the nation’s
the patient. For example, some of the highest fre- hospitals are changing their patient transfer proto-
quencies of interfacility transfers occur among cols. They are increasingly implementing central-
obstetrics and gynecology (e.g., high-risk pregnan- ized transfer centers to improve overall patient
cies) and neurology (e.g., stroke) patients, who flows and to control incoming patients and facil-
require specialized training not available at many ity capacity. These centralized transfer centers
healthcare facilities. also promise to lower costs, save time, and protect
the facilities against lawsuits.
Issues Jillian R. O’Neill

Problems with interfacility patient transfers can See also Access to Healthcare; Emergency Medical
also be unrelated to medical care. Nonclinically Services (EMS); Emergency Medical Treatment and
related issues include redundant and unnecessary Active Labor Act (EMTALA); For-Profit Versus Not-
transports that create financial burdens in terms For-Profit Healthcare; Hospitals; Patient Dumping;
of both direct and indirect costs. Direct costs may Uninsured Individuals
include the expenses for transport and personnel,
while the indirect costs may include the expenses
related to increased patient morbidity, liability Further Readings
issues, and overcrowding in the emergency depart- Hanane, Tarik, Mark T. Keegan, Edward G. Seferian,
ment. Patient-related issues include the time et al. “The Association Between Nighttime Transfer
involved, the extent of morbidity and mortality From the Intensive Care Unit and Patient Outcome,”
associated with wait time, lack of care continuity Critical Care Medicine 36(8): 2232–37, August 2008.
and poor quality of care, patient privacy issues, Koval, Kenneth J., Chad W. Tingey, Kevin F. Spratt,
and patient dumping. Patient dumping occurs et al. “Are Patients Being Transferred to Level-1
when unexamined or unstable patients are trans- Trauma Centers for Reasons Other Than Medical
ferred to another facility because of nonclinical Necessity?” Journal of Bone and Joint Surgery
reasons, as when the patient does not have health 88(10): 2124–32, October 2006.
insurance and is likely not to be able to pay for his Spain, David A., Michael Bellino, Andrew Kopelman,
or her care. et al. “Requests for 692 Transfers to an Academic
Pauly, Mark V. 907
Level 1 Trauma Center: Implications of the practices on outcomes and costs. He also has stud-
Emergency Medical Treatment and Active Labor ied and proposed ways to reduce the number of
Act,” Journal of Trauma: Injury, Infection, and uninsured through the use of tax credits and ways
Critical Care 62(1): 63–8, January 2007. to redesign the Medicare program.
Pauly is a prolific researcher and author. He has
published many scholarly journal articles and
Web Sites books on various health economics topics. He is
the coeditor-in-chief of the International Journal
American Academy of Emergency Medicine (AAEM):
of Health Care Finance and Economics and the
http://www.aaem.org
associate editor of the Journal of Risk and
Uncertainty. He also serves on the editorial board
of Public Finance Quarterly.
Pauly has received many awards and honors
in recognition of his work. In 2007, he received
the Distinguished Investigator Award from
AcademyHealth and the John Eisenberg Excellence
Pauly, Mark V. in Mentorship Award from the federal Agency for
Healthcare Research and Quality (AHRQ). He is
Mark V. Pauly is one of America’s leading health an elected member of the National Academy of
economists. Although Pauly has conducted Sciences, Institute of Medicine (IOM). He also is
research in many areas of health economics, he is a member of the National Advisory Council for
perhaps best known for his work on moral haz- the AHRQ. He was the recipient of an investiga-
ard. His classic 1968 study of the economics of tor award in health policy research from the
moral hazard was the first to point out how health Robert Wood Johnson Foundation. And he previ-
insurance may affect the behavior of the insured ously served as a commissioner on the Physician
as well as those providing healthcare services to Payment Review Commission (PPRC), which
them. His work popularized the term. advised the U.S. Congress on Medicare physician
Pauly is currently the Bendheim Professor in the payment.
Department of Health Care Systems at the Wharton He has consulted for national public policy and
School of the University of Pennsylvania. He also research centers such as the American Enterprise
is professor of business and public policy and Institute for Public Policy Research (AEI),
insurance and risk management at the Wharton Mathematica Policy Research, and the Urban
School and professor of economics in the School of Institute; hospital associations, including the
Arts and Sciences at the University of Pennsylvania. Greater New York Hospital Association; and
Before joining the Wharton School in 1983, he pharmaceutical companies such as Amgen, Bayer,
taught at Northwestern University for 16 years. Glaxo, and Merck.
Born in 1941, Pauly earned a bachelor of arts Pauly’s current interests include the economic
degree in classical languages from Xavier analysis of healthcare reform, the understanding of
University in 1963, a master’s degree in econom- the conceptual foundations for cost-benefit analy-
ics from the University of Delaware in 1965, and sis of pharmaceutical drugs, and the economic
a doctorate in economics from the University of incentives in managed care. His work will continue
Virginia in 1967. to assist health services researchers and policymak-
Over his long career, Pauly has studied the ers to better understand the economics of health-
empirical and theoretical impact of health insur- care in America.
ance coverage on preventive care, ambulatory
care, and prescription drug use in managed care. Pritha Dasgupta
He has investigated the various influences that See also Health Economics; Health Insurance; Health
determine the availability of health insurance cov- Insurance Coverage; Medicare; Moral Hazard;
erage and, using cost-effectiveness analysis, deter- National Health Insurance; Public Policy; Uninsured
mined the influences of medical care and health Individuals
908 Pay-for-Performance
Further Readings to poor quality, including the structure of the pres-

Pauly, Mark V. “The Economics of Moral Hazard: ent healthcare payment system. The IOM noted
Comment,” American Economic Review 58(3 pt. 1): that, for certain types of clinical situations, health-
531–37, June 1968. care payment arrangements may actually produce
Pauly, Mark V. Health Benefits at Work: An Economic disincentives for quality care. For example, in gen-
and Political Analysis of Employment-Based Health eral, patients cared for under fee-for-service reim-
Insurance. Ann Arbor: University of Michigan Press, bursement systems receive more services that are
1998. under the discretion of the provider. The incentives
Pauly, Mark V. “Risk and Benefits in Health Care: The result in overuse of services without regard to effi-
View From Economics,” Health Affairs 26(3): ciency; services of high cost that are technically
653–62, May–June 2007. complex tend to be rewarded over those that are
Pauly, Mark V. Markets Without Magic: How labor and time intensive, such as counseling
Competition Might Save Medicine. Washington, DC: regarding self-care of diabetes or care coordination
AEI Press, 2008. among subspecialists. High-technology, -volume,
Pauly, Mark V., and Bradley Herring. Cutting Taxes for and -cost services are preferentially rewarded over
Insuring: Options and Effects of Tax Credits for low-technology, -volume, cost preventive health-
Health Insurance. Washington, DC: AEI Press, 2002. care services.
Pauly, Mark V., and Jose A Pagan. “Spillovers and Under fee-for-service, this imbalance in incen-
Vulnerability: The Case of Community Uninsurance,” tives for high-technology, -volume, -cost services is
Health Affairs 26(5): 1304–1314, September–October further compounded. When providers invest in
2007.
improving outcomes of chronic diseases (such as
diabetes), their income may eventually drop, as
patients with excellent control of their diabetes
Web Site require fewer office visits and hospital stays in the
University of Pennsylvania, Wharton School Faculty longer term, resulting in fewer opportunities to bill
Profile: http://www.wharton.upenn.edu/faculty/pauly for services.
.html Other payment methods do not reimburse for
services provided but pay healthcare providers
prospectively. These types of payment methods
may also provide disincentives for quality. For
example, capitation payment methods result in
Pay-for-Performance lower use of healthcare services overall and may
result in underuse of essential services. Furthermore,
The linkage of financial incentives to quality and while preventive care is more likely to be rewarded
performance is a relatively new concept in health- under capitation than it is under fee-for-service,
care. Pay-for-performance is a way to reward when patients switch healthcare plans, investments
healthcare providers for higher-quality healthcare. in preventive care are less likely to result in finan-
In most industries, lower costs are achieved through cial savings for the payer who provided and made
greater production efficiency, and financial rewards the up-front investments in such care.
accrue to firms that produce high-quality products In recognition of these issues, there are increas-
more efficiently. In contrast, most physicians and ing numbers of programs in the United Kingdom
hospitals are paid the same regardless of the qual- and the United States that link payment to perfor-
ity of the healthcare they provide, producing no mance. In 2004, the United Kingdom’s National
financial incentives for quality and, in some cases, Health Service (NHS) began a pay-for-performance
disincentives for quality. initiative. General practitioners agreed to partici-
In its 2001 report Cross the Quality Chasm: A pate in a performance program encompassing 146
New Health System for the 21st Century, the quality indicators reflecting clinical care for 10
National Academy of Sciences, Institute of Medicine chronic diseases, organization of care, and patient
(IOM) drew attention to the poor quality of the experience. In return, funding for primary care was
nation’s healthcare as well as factors contributing increased 20% over previous levels, permitting
Pay-for-Performance 909
practices to invest in technology and staff. A star- appropriate risk adjustments create incentives for
tling 90% of general practitioners now use elec- providers to avoid treating the sickest patients or
tronic prescribing, and general practitioners penalize healthcare providers who care for dispro-
increased their income by $40,000 through the portionate numbers of disadvantaged patients,
program. who may not be able to afford their medications or
In the United States, given the disincentives for comply with a treatment plan.
high quality healthcare that exist in current pay- Chronic medical conditions are the leading
ment methods such as fee-for-service and capita- cause of morbidity and mortality in the United
tion, the objectives of pay-for-performance include States, and treatment of patients with these condi-
rapid performance improvement to address ongo- tions consumes more than three fourths of all
ing quality deficits, innovation, structural changes healthcare expenditures. Yet despite the resources
in care delivery, and, ultimately, better outcomes devoted to the treatment of chronic conditions,
of care. A number of issues are critical to the suc- chronically ill patients receive only half of
cess of pay-for-performance programs in achieving the appropriate recommended care overall.
these objectives and improving the quality of Thus, many pay-for-performance programs have
healthcare. focused on increasing the provision of guideline-
recommended care.
The effect of common, chronic, coexisting (or
Measuring Quality
comorbid) conditions on measures of the quality
The methods used for defining and measuring of healthcare and patient ratings of their care is of
quality are the fundamental building blocks of concern to healthcare providers. Coexisting condi-
any pay-for-performance program and are critical tions complicate treatment plans and patient com-
to the success of a program in meeting its objec- pliance. Some studies show that patients with
tives. If measures of quality do not have a sound chronic diseases are less likely to receive treatment
theoretical and methodological foundation, health- for unrelated disorders or to undergo preventive
care providers are not being rewarded for the healthcare services, but others show that patients
behaviors that are desired and are even perhaps with coexisting conditions are more likely to
inadvertently being rewarded for behaviors that receive higher quality care. However, some studies
are undesirable. For example, if improving the have used a simple count of conditions as a crude
numbers of patients who quit using tobacco is the marker of complexity or accessed only a limited
desired outcome, but documentation of tobacco range of conditions, possibly obscuring important
cessation advice is the rewarded measure, health- relationships between types of conditions. For
care providers may merely document smoking example, in patients with diabetes, treatment of
cessation advice, without supplying any further hypertension is “concordant” with the goals of
tools to aid smokers in quitting. treatment for ischemic heart disease, whereas the
Significant limitations exist in current clinical treatment of arthritis is not, or, in other words, is
information systems in use by healthcare provid- “discordant.” Therefore, treatment of arthritis
ers, which are often not designed to collect data might reduce the time available during a visit to
valid for quality assessment. If the data sources for address care for diabetes, whereas treatment of
creating performance measures are not universally comorbid hypertension might not.
available, accurate, and reliable, healthcare pro- Healthcare providers are also concerned that
viders become suspicious that their performance is with the increasing numbers of comorbid condi-
not being accurately assessed. Furthermore, if the tions, patient ratings of their care may suffer. This is
cohort of patients eligible for the measures does because “high quality” care may come with a bur-
not reflect the actual panel of patients, healthcare den of large numbers of medications and healthcare
providers participating in a pay-for-performance use that lowers the satisfaction of patients overall.
program may be inadvertently penalized for care An evaluation of clinical practice guideline adher-
provided (or not provided) by others. ence found that a hypothetical older adult with five
Risk adjustment is also essential, where appro- common comorbidities would be prescribed at least
priate. Measures of quality that do not make 12 medications. Also, because evidenced-based
guidelines focus on single-disease processes and fail Effectiveness

to account for patients with multiple comorbidities,
Ideally, studies of pay-for-performance would be
the potential risks and benefits of such therapy, par-
multi-institutional, large-scale investigations of
ticularly in elderly patients, are unclear.
important and common medical conditions. Ideal
studies include concurrent control groups to ensure
Process Versus Outcome Measures of Quality that investigators can clearly infer associations
between pay-for-performance and changes in per-
In designing performance measures for incentive
formance. However, many pay-for-performance
programs, several issues should be noted. First,
projects are implemented in an uncontrolled fash-
the best process-of-care measures are those for
ion, making it unclear whether the benefits are
which there is evidence that better performance
truly due to the financial incentives. Concurrent
leads to better health outcomes. Second, it is
controls are essential to learn whether other tem-
important to note that process-of-care measures
poral changes in the healthcare environment are
may be more sensitive to quality differences than
resulting in improvements in the quality care,
are measures of health outcomes, because a poor
rather than a pay-for-performance program.
health outcome does not necessarily occur every
Quality-of-care measures should be based on
time there is a quality problem.
high-quality evidence and accepted guidelines, so
It could be argued that, other things being equal,
as to minimize dispute over the evidence base for
individual physician-level process-based incentives
rewarded measures. Outcomes of care should be
will create stronger incentives for improvement in
assessed. Unintended effects of the incentive pro-
processes over which the physician can exert direct
gram on performance measures that were not
control. In turn, such individual physician incen-
financially rewarded should also be assessed. To
tives may produce better health outcomes (assum-
ensure face validity, clinical data should be col-
ing that the processes receiving incentives are
lected consistently. However, empirical studies of
systematically related to improved health outcomes
the relationship between explicit financial incen-
over time). Therefore, combining outcome-based
tives designed to improve a measure of healthcare
(e.g., tobacco quit rates) with process-based incen-
quality and a quantitative measure of healthcare
tives (e.g., documentation of smoking cessation
quality are rare in the literature. Rigorous research
advice) may produce even greater quality improve-
designs and methodology are necessary to deter-
ment overall than process measures alone, by
mine whether performance-based payment
encouraging providers to balance process with
arrangements result in meaningful quality improve-
attention to results. This approach may avoid the
ments and are cost-effective. Studies meeting all
pitfalls of process-of-care measures alone that
the above criteria are surprisingly rare.
encourage gaming the system while avoiding the
Despite the limitations of the literature, the
disadvantage of basing incentives solely on out-
available studies in general show some significant
comes that may be relatively rare or difficult to
effects of pay-for-performance in improving the
achieve and somewhat beyond the control of the
quality of healthcare. In studies of preventive care,
provider. Thus, a combined approach capitalizes on
with rewards to individual physicians, investiga-
the advantages and complementary nature of both
tors have documented improvements in perfor-
types of quality-of-care measures. However, the
mance ranging from 8% to 19%. Rewards to
exact combination of process-based and outcome-
provider groups generally had effect sizes of less
based incentives that could be expected to produce
than 10%.
the highest quality of healthcare is unknown.
Careful attention to quality measurement issues
is important in averting healthcare provider oppo-
Design of Financial
sition to such programs. A scientifically sound
Incentive Reward Programs
approach to quality measurement may also allevi-
ate concerns that pay-for-performance is primar- Designing financial incentives is a complex pro-
ily a cost-cutting rather than a quality improvement cess involving decisions about whether providers
tool. should be in a “tournament” (competitive) style
Pay-for-Performance 911
program, whether the recipient of the incentive such as coexisting diabetes and chronic heart fail-
should consist of an individual healthcare pro- ure. Patients frequently interact with more than
vider or a group of healthcare providers (includ- one provider, and treatment requires consultation
ing clerical support staff, nurses, and pharmacists), with multiple subspecialists. Enhancing care coor-
the amount of the reward, how frequently the dination is essential to improving quality of care.
reward should be given, and whether the reward How to identify providers who act in a coordinat-
should include some sort of nonfinancial compo- ing role and then reward them for successfully
nent, such as audit and feedback or a public accomplishing this role is essential to improving
recognition program. Choices in any of these cat- care for patients with chronic, complex conditions.
egories have advantages and disadvantages. As The American College of Physicians (ACP) has
part of this decision-making process, policymak- proposed the concept of The Advanced Medical
ers should consider whether their goal is improv- Home as a patient-centered, physician-guided
ing performance at the lower end of the spectrum model of healthcare to address some of these com-
versus maintaining best performance, or both. munication and coordination issues.
Payment may be made according to relative Most programs to date have consisted of posi-
performance (i.e., the participant’s overall percen- tive rewards, rather than reduction in payments.
tile ranking) or absolute performance (i.e., strictly However, this is changing. In the United States, the
according to performance relative to the quality Centers for Medicare and Medicaid Services (CMS)
standard). Payment may also be made on what is has proposed eliminating payments for care that
termed a “Pay as You Perform” schedule, so that results in injury or death. As of October 2008,
each instance of the behavior is rewarded. payments would be reduced for “never events” as
Theoretical arguments for and against these designs defined by the National Quality Forum, such as
from the fields of economics, social psychology, hospital-acquired infections. And other healthcare
cognitive psychology, industrial/organizational payers are exploring similar plans.
psychology, and other behavioral disciplines can Apart from the structure of the payment plan,
be made. The approach that works best in health- the size of the bonus is almost certainly important.
care is an open question. Possible explanations for the lack of effect or small
One could anticipate that with group- or prac- effect in some previous studies may include the
tice-team-level incentives, individual physicians small size of the bonus. Similarly, when multiple
would not capture the full returns on their indi- insurers pay providers, the incentive may affect too
vidual effort to improve the quality of their care. few patients, effectively diluting the size of the
The potential for some physicians to “free-ride” incentive. On the other hand, a bonus that is per-
on the efforts of others may lead them to reduce ceived to be too large may produce negative feelings
their individual efforts. However, the problem regarding a pay-for-performance program. Some
with rewarding individuals, but not the organiza- critics have wondered whether pay-for-performance
tion or group, is that the provision of the required programs crowd out intrinsic motivation and nega-
institutional cooperation may not be present. tively affect professionalism. Larger bonuses are
Thus, theory suggests the potential for group-level more likely to contribute to these perceptions.
incentives to support organizational and team- The last design issue to consider is the “end-of-
based efforts to improve the quality of healthcare. year” compensation, which may not influence
Some evidence regarding teams and groups exists physician behavior as much as a concurrent fee or
from studies evaluating the chronic-care model. intermittent bonus. This is because lack of aware-
These suggest that multidisciplinary teams produce ness of the intervention and infrequent perfor-
better patient outcomes. Group- or system-level mance feedback appear to be significant potential
incentives may provide the impetus to create infra- barriers to the effectiveness of incentives.
structure changes or to promote cooperation that Regardless of the choices made, incentives
is absent from traditional practice. require very careful design and attention to possi-
Attributing care to a provider or a group of ble unintended consequences. A few studies have
providers can be challenging, particularly for shown that documentation, rather than actual use
patients who suffer from complex, chronic diseases, of the preventive service, was significantly improved
with a financial incentive. Obviously, the goal of concurrent control groups, is needed to guide
the pay-for-performance program is to improve implementation of explicit financial incentives
the quality of healthcare and not just documenta- for healthcare quality and to assess their cost-
tion alone. Measures more likely to show evidence effectiveness. Much more research is needed to
of unintended effects are those unrelated to reward ensure that the nation’s healthcare financing sys-
measures, such as screening for cancer or treat- tems are effectively designed to encourage and
ment of pneumonia. promote the highest possible quality of health-
care for the nation’s population.
Unanswered Questions Laura A. Petersen
Despite the wide adoption of pay-for-performance, See also Centers for Medicare and Medicaid Services
research evidence of the effectiveness of pay-for- (CMS); Medicare; National Quality Forum (NQF);
performance programs, particularly randomized Payment Mechanisms; Quality of Healthcare; United
trials, is very limited, and many questions remain Kingdom’s National Health Service (NHS)
unanswered. For example, what types of clinical
conditions or healthcare services should be the
target of financial incentives to improve quality— Further Readings
chronic diseases, acute care, and/or preventive
American College of Physicians. The Advanced Medical
care services? How effective (and cost-effective)
Home: A Patient-Centered, Physician-Guided Model
are financial incentives for quality? What are the
of Health Care. Philadelphia: American College of
optimum magnitude, frequency, and duration of
Physicians, 2006.
financial incentives for quality? Should insurers
Committee on Quality of Health Care in America,
reward achievement of an absolute threshold of Institute of Medicine. Crossing the Quality Chasm: A
performance, improvement over baseline perfor- New Health System for the 21st Century.
mance, or some combination of these? To whom Washington, DC: National Academies Press, 2001.
should such incentives be directed—the patient, McGlynn, Elizabeth, Steven M. Asch, John Adams, et al.
the healthcare provider, the provider group, or the “The Quality of Health Care Delivered to Adults in
hospital—or all of them? What types of quality the United States,” New England Journal of Medicine
measures should be rewarded—processes of care, 348(26): 2635–45, June 26, 2003.
health outcomes, or both? Are financial incentives Medicare Payment Advisory Commission. Report to the
for not providing inappropriate care (such as anti- Congress: Medicare Payment Policy. Washington, DC:
biotics for uncomplicated acute upper-respiratory Medicare Payment Advisory Commission, 2006.
illnesses) effective? What is the optimum “pack- National Committee for Quality Assurance. The State of
age” of nonfinancial interventions, if any, to Health Care: Industry Trends and Analysis.
include with financial incentives for quality—e.g., Washington, DC: National Committee for Quality
audit and feedback, recognition, clinical remind- Assurance, 2006.
ers, academic detailing, and/or information tech- Petersen, Laura A., LeChauncy D. Woodward, Tracy
nology support? Can insurers expect that the Urech, et al. “Does Pay-for-Performance Improve the
effect of financial incentives will persist after they Quality of Health Care?” Annals of Internal Medicine
are stopped? Because any effective intervention 145(4): 265–72, August 15, 2006.
will have some unanticipated effects, will impor-
tant patient care activities that are not rewarded
financially be neglected? Thus, despite the great Web Sites
enthusiasm about the potential for aligning finan- American College of Physicians (ACP):
cial incentives with high-quality healthcare, there http://www.acponline.org
are a number of fundamental unanswered ques- Centers for Medicare and Medicaid Services (CMS):
tions about their optimal design, effectiveness, http://www.cms.hhs.gov
and implementation. Joint Commission: http://www.jointcommission.org
Rigorous research, including randomized, National Academy of Sciences, Institute of Medicine
controlled trials and observational studies with (IOM): http://www.iom.edu
Payment Mechanisms 913
National Committee for Quality Assurance (NCQA): a predetermined fee schedule, providers can also
http://www.ncqa.org increase revenue by increasing their charges.
National Quality Forum (NQF):
http://www.qualityforum.org
Fee Schedules
Fee schedules are a particular type of fee-for-
service payment mechanism that establishes either
Payment Mechanisms a maximum amount or actual amount of reim-
bursement for a particular service. If the fee sched-
Payment mechanisms are the methods by which ule were used to establish maximum fees, the
healthcare providers are reimbursed for the goods provider would receive the lesser of the amount
and services they provide. Payment mechanisms charged and the predetermined amount in the fee
include those made by the patient, or first-party schedule. In practice, providers almost always
payments; health insurer, or third-party payments; charge more than the fee schedule amount to
and those payments that are assumed by the ensure receipt of the full amount established in the
healthcare provider, or second-party payments. fee schedule. Providers have the incentive to pro-
Each payment mechanism has inherent economic vide more services than necessary as a means of
incentives that affect utilization. increasing revenue, but they have no influence on
the amount reimbursed per service as long as their
fees are set above the fee schedule amount.
Third-Party Payment Mechanisms The most common fee schedule in the United
Third-party payers (i.e., insurance companies, States is the National Physician Fee Schedule
managed-care organizations, and the government) Relative Value System, which Medicare uses to
use a number of mechanisms to pay healthcare reimburse physicians for services provided to
providers for the cost of services delivered to their Medicare beneficiaries. The system is based on the
insured patients. Both public payers (e.g., Medicare Resource-Based Relative Value Scale (RBRVS),
and Medicaid) and private payers (e.g., Blue Cross which was developed by William Hsiao and his
and Blue Shield and other insurance plans) have associates at Harvard University. Specifically, this
similar types of payment mechanisms available. fee schedule establishes relative value units for
These payment mechanisms include fee-for-service, each Current Procedural Terminology (CPT) and
fee schedule, per diem, per stay, and capitation Healthcare Common Procedure Coding System
payments. Often, a payer uses multiple payment (HCPCS) code, and it then converts the relative
mechanisms within a particular insurance product. value units to a dollar amount of reimbursement
For example, physician outpatient care may be using a conversion factor that is revised annually.
reimbursed using a fee schedule and hospital inpa- Many third-party payers use this system as the
tient care may be reimbursed on a per-stay basis. basis for determining their physician fee schedules
by modifying the conversion factor that translates
relative value units to dollars of reimbursement.
Fee-for-Service
A fee-for-service payment mechanism reim-
Per Diem
burses healthcare providers on a per-unit basis or
for each service provided. The fee may be based on Per diem is a payment mechanism that reim-
the actual charges (i.e., the amount charged by the burses healthcare providers per day of stay and
provider) or based on a schedule that lists the dol- establishes a set fee per day. Per diem is most com-
lar amount to be reimbursed for each service. monly used by third-party payers for acute, long-
Under fee-for-service payment mechanisms, pro- term, skilled nursing and psychiatric hospital stays.
viders have the economic incentive to provide Providers have the incentive to keep patients in the
more services than necessary to increase revenue, facility longer than necessary to increase reim-
since they are paid per unit. When fee-for-service bursement, but they have no influence on the price
payments are based on actual charges rather than paid per day.
914 Payment Mechanisms
Per Stay First-Party Payment Mechanisms

Third-party payers may also use payment Healthcare providers also receive payments
mechanisms that make one payment for each epi- directly from patients. Self-pay is a first-party pay-
sode of care, such as a hospitalization stay. Per ment mechanism and includes situations in which
stay payments solve the incentive problem inher- the patient is the only payer and those in which
ent in per diem payments of treating patients for the patient is responsible for a portion of the pay-
longer durations of time than necessary, since a ment with a third party responsible for a balance
flat payment per episode is made. Providers do of the payment.
have an incentive, however, to increase the num-
ber of times a patient is admitted to increase
reimbursement. Self-Pay
Medicare’s prospective payment system (PPS) is
Self-pay is the patient’s out-of-pocket payment
a payment mechanism that reimburses services on
obligation. Self-pay as a payment mechanism
a fixed amount per episode of care for some types
includes two types of patients—those with no
of services, such as acute inpatient hospital stays
source of health insurance coverage who are respon-
and home health care, while it uses per diem pay-
sible for the entire fee (i.e., uninsured self-pay), and
ments for other services, such as skilled nursing
those with a third-party source of health insurance
care. Acute-care hospitals are reimbursed for each
coverage who must pay a portion of the fee out of
inpatient case based on the Diagnosis Related
pocket (i.e., insured self-pay). Payments for unin-
Group (DRG) assigned to the case, with one pay-
sured self-pay patients have historically been based
ment for each hospital stay. DRGs were developed
on hospital or provider charges with no negotiated
by John D. Thompson and Robert B. Fetter at Yale
price discounts. Many hospitals have been criticized
University. Specifically, the total payment includes
for charging patients with the least financial means
a base DRG payment component plus adjustments
the most for care, and many are revising their poli-
if the hospital has a high proportion of low-income
cies for uninsured self-pay patients.
patients or is a teaching hospital or if the case is an
Payments for insured self-pay patients are based
outlier in terms of being a high-cost case. Home
on the negotiated rates established between the
health care is reimbursed based on 60-day episodes
third-party payer and healthcare provider. Insured
of care, with a base payment plus adjustments for
self-pay payment mechanisms include three main
factors such as case-mix (i.e., severity of illness,
types of demand-side cost sharing, namely deduct-
clinical condition, and services required).
ibles, coinsurance, and copayments. A deductible
is the amount that an insured individual must pay
out of pocket before the insurer will start to reim-
Capitation
burse the providers for services, and the individual
Capitation is a payment mechanism that reim- usually must pay the deductible each year. From an
burses a physician, medical group practice, or insurance perspective, coinsurance is a general
hospital a fixed amount per patient for a fixed term that refers to the amount of a medical bill
period of time. Often capitation payments are paid that the insured individual is responsible for out of
for each insured member assigned to a provider for pocket, which could be stated as a percentage of
each month, or a per-member per-month (PMPM) the total amount billed or as a flat dollar amount.
capitation payment. Capitation payments cover a In healthcare, coinsurance is commonly used to
predetermined set of services provided within the refer specifically to the proportion of the negoti-
defined time period and may include primary and ated medical fees that the insured individual is
specialty-care physician services, other outpatient responsible for (e.g., 20% coinsurance), with the
services, diagnostic and laboratory tests, and hos- insurer paying the remaining proportion of the
pital stays. The provider assumes the risk of the fees. A copayment refers to the flat dollar amount
healthcare costs for the defined population of of the negotiated medical fees that the insured indi-
patients, and therefore, has the incentive to pro- vidual must pay (e.g., $20 copayment), with the
vide efficient care. insurer paying the remaining dollar amount of the
Payment Mechanisms 915
fees. The dollar amount paid out of pocket with same hospital often use different payment mecha-
coinsurance may vary for each visit, but the dollar nisms, or combination of payment mechanisms,
amount for a copayment remains constant. and pay different amounts for the same services.
These demand-side payment mechanisms may Even with healthcare reforms that would expand
work together in a single episode of care. For coverage to the currently uninsured population,
example, suppose an individual has health insur- the U.S. healthcare system is likely to continue
ance coverage with a $500 deductible and a 20% relying on multiple sources of coverage, which will
coinsurance once the deductible is met. At the further fuel the complex web of payment mecha-
beginning of the year, the individual receives an nisms. While nations with a single-payer system
MRI scan. This individual’s out-of-pocket expenses have inherently simplified payment mechanisms,
would be $540 ($500 deductible + $40 coinsur- many nations may consider an increase in the indi-
ance (20% × $200)), while the insurer’s portion vidual’s out-of-pocket responsibilities to control
would be $160 ($700 − $540). Instead, if the indi- their own spiraling healthcare costs.
vidual has a $500 deductible with a $20 copay- The largest change in the United States is likely
ment, the individual’s out-of-pocket expense would to occur with respect to the balance of payments
be $520, while the insurer would pay $180. made by the individual compared with the insurer.
Consumer-driven health plans are increasing the
Provider Internal Payment Mechanisms individual patient’s cost-sharing obligations as a
mechanism to control costs. This shift is likely to
Hospitals, physicians, and other healthcare provid- precipitate a change in how hospitals, physicians,
ers do not collect payments from all patients—either and other healthcare providers collect first-party
because of a decision to provide services as charity payments. While copayments for outpatient visits
care to a patient without the financial resources to are routinely collected at the time of service,
pay or because of a failure to collect payment from deductibles and coinsurance amounts for hospital-
the patient or third-party payer. Both charity care izations are more likely to be billed retrospectively.
and bad debt are classified as uncompensated care. These payments are often collected after treatment
because providers often cannot ex ante calculate
Charity Care the cost of treatment. As the size of first-party pay-
For patients without the income (or assets, in ments increases from hundreds to thousands of
some cases) to pay for needed services, healthcare dollars, providers will have a greater incentive to
providers may render the care as charity care. collect them up front to guarantee payment. At face
Charity care includes services that are provided value, this change seems relatively minute; however,
but for which the provider does not expect a pay- it could also lead to an increase in the number of
ment. The provider does not bill the patient or potential patients denied services until they can
insurer nor does the provider pursue collection of make payment, to prevent a surge in bad debt.
payment from an external source. Tricia J. Johnson and Michael Morgenstern
Bad Debt See also Capitation; Charity Care; Diagnosis Related

Groups (DRGs); Fee-for-Service; Healthcare Financial
Bad debt includes payments that are expected to Management; Prospective Payment; Resource-Based
be collected but are not collected from either the Relative Value Scale (RBRVS); Uncompensated
patient or a third-party payer. Providers attempt to Healthcare
collect these payments but are ultimately unsuc-
cessful. Bad debt is an expense to providers.
Further Readings
Baron, Richard J., and Christine K. Cassel. “21st-
Future Implications
Century Primary Care: New Physician Roles Need
Healthcare payment mechanisms have become New Payment Models,” Journal of the American
increasingly diverse and complex over time. Medical Association 299(13): 1595–97, April 2,
Patients undergoing the same procedure at the 2008.
916 Pew Charitable Trusts
Davis, Karen. “Making Payment Reform in the U.S. public opinion, and religion and public life.
Healthcare System Possible.” Medscape General Specifically in the health area, it funds a number of
Medicine 9(4): 63, 2007. centers and projects, including the Pennsylvania
Davis, Karen, and Stuart Guterman. “Rewarding Medicaid Policy Center, the Genetics and Public
Excellence and Efficiency in Medicare Payments,” Policy Center, and the Prescription Drug Project. In
Milbank Quarterly 85(3): 449–68, September 2007, the Trusts spent a total of $248 million on
2007. its multitude of centers and projects.
Newhouse, Joseph P. “Medicare’s Challenges in Paying
Providers,” Health Care Financing Review 27(2):
35–44, Winter 2005–2006. Changing Political Views
Joseph N. Pew’s political views were right of cen-
ter, as were those of his heirs. In the beginning, the
Web Sites
J. Howard Pew Freedom Trust felt that its goal
American Hospital Association (AHA): http://www.aha.org was educating the American people regarding the
American Medical Association (AMA): bureaucratic morass in Washington and how
http://www.ama-assn.org important the free market was for freedom. For
Centers for Medicare and Medicaid Services (CMS): instance, Pew thought that Roosevelt and his New
http://www.cms.hhs.gov Deal were nothing more than a hoax designed to
Healthcare Financial Management Association (HFMA): turn Americans into automatons doing exactly
http://www.hfma.org what Washington wanted. For many years, the
Medicare Payment Advisory Commission (MedPAC): Pew Charitable Trusts primarily funded conserva-
http://www.medpac.gov tive activities centered in Philadelphia. Initially,
the recipients comprised organizations such as
cancer research institutes, museums, and various
universities (especially those that were historically
Pew Charitable Trusts Black). The conservative leaning of the Trusts
changed when Thomas Langfitt, who was presi-
The Pew Charitable Trusts is the single recipient dent from 1987 to 1994, and his hand-picked
of seven charitable funds initiated by the children successor, Rebecca Rimel, shifted the Trusts’
of Joseph N. Pew, the creator of Sun Oil Company, emphasis to a more liberal stance. Both Langfitt
and his wife, Mary Anderson Pew. The four and Rimel thought that the views espoused by
founders of the Pew Charitable Trusts were Joseph Pew and his heirs were outdated and that, thus, a
N. Pew, Jr., J. Howard Pew, Mary Ethel Pew, and new direction was needed.
Mabel Pew Myrin. They established the Trusts in According to Rimel, one central theme undergird-
1948 as a means of honoring their parents. The ing the Pew Charitable Trusts is to help politicians
central aim of the Trusts is to donate to the public and policymakers in Washington make decisions
and add to its general health and welfare and that would lead to positive change for each American.
thereby strengthen the nation’s communities. Since As a result, the Trusts uses some of America’s great-
its establishment, the Pew Charitable Trusts has est scholars, scientists, and philosophers to envision
stayed robust, encompassing several national and initiate sensible solutions to urgent public prob-
organizations, while keeping its pledge to busi- lems. Even though the Trusts now has a more inter-
nesses and groups within the Philadelphia area. national focus, great emphasis is still placed on the
Based in Philadelphia, with an office in citizens and culture of Philadelphia.
Washington, D.C., the Pew Charitable Trusts pro-
vides organizations and citizens with fact-based
Pew Projects
research and practical solutions for changing issues.
It investigates a large number of topics, including In 1999, a new era for the Trusts began when the
arts and culture, children and youth, computers Pew Internet and American Life Project was cre-
and the Internet, education, environment, health, ated. This project scrutinizes the societal and com-
Hispanics in America, media and journalism, munity impact of the Internet. Other projects
Pharmaceutical Industry 917
include the Pew Research Center for the People regarding human health. Scholars are given finan-
and the Press (previously called the Times Mirror cial support (in the range of $240,000 for 48
Center for the People and the Press). The center months) and are encouraged to be commercial and
measures the changing opinions and mores of the original in their research endeavors.
American population. Each month, it conducts at
least one major national opinion poll. Cary Stacy Smith and Li-Ching Hung
Another Trusts program is the Pew Global See also Access to Healthcare; Health; Kaiser Family
Attitudes Project, which conducts a series of Foundation; Medicaid; Public Health; Public Policy;
worldwide opinion polls on a wide variety of top- State-Based Health Insurance Initiatives; Vulnerable
ics. Over the years, it has conducted more than Populations
150,000 interviews in 54 countries. In 2007, in
conjunction with the Kaiser Family Foundation it
conducted a global health survey that included 47 Further Readings
countries.
Pew Charitable Trusts. Sustaining the Legacy: A History
In 2001, the Trusts established the Pew Hispanic
of the Pew Charitable Trusts. Philadelphia: Pew
Center. Its primary goal focuses on the improve-
Charitable Trusts, 2001.
ment and awareness of the diverse U.S. Hispanic
Prescription Project. Report: Risk with No Benefit: The
populations. In addition, it seeks to record Latinos’
Marketing of Over-the-Counter Cough and Cold
increasing influence in the nation and to enlighten Medications for Children. Philadelphia: Pew
policy discussions regarding the nation’s largest Charitable Trusts, 2007.
minority population. Stateline.org. Report. State of the States, 2008.
The Pew Forum on Religion and Public Life Philadelphia: Pew Charitable Trusts, 2008.
sponsors an in-depth appreciation of questions at Trust for America’s Health and the Infectious Diseases
the junction of religious and public affairs. Its goal Society of America. Pandemic Influenza: The State of
is to offer appropriate, impartial information to the Science. Philadelphia: Pew Charitable Trusts, 2006.
government leaders, journalists, analysts, and vari-
ous national organizations. The forum never takes
sides regarding policy and/or legislation, priding Web Sites
itself on being a nonpartisan entity.
Since 1999, the Pew Charitable Trusts has sup- Pew Charitable Trusts: http://www.pewtrusts.org
Stateline.org: http://www.stateline.org/live
ported Stateline.org, an online news resource that
covers state politics and policy through original
reporting and by collecting news stories. Its goal is
to strengthen and enrich America’s political news
agencies by offering data about the daily political Pharmaceutical Industry
activities taking place in each of the 50 states.
Stateline.org considers itself to be an unbiased and The pharmaceutical or drug industry historically has
impartial news journal; thus, the information con- been one of the most innovative and profitable busi-
tained therein is apolitical. Each week, approxi- ness sectors in the United States. Recent develop-
mately 20,000 viewers peruse the Web site. Stateline. ments, however, portend major changes in the
org also publishes an annual State of the States nation’s pharmaceutical industry. Growing regula-
Report, and it sponsors professional development tory oversight, rising consumer distrust over adver-
conferences and workshops for the new media. tising claims, drug safety concerns, increased
The Pew Charitable Trusts also funds the Pew cost-containment initiatives by government and pri-
Research Center, which operates as a self-regulating, vate third-party payers, mandated health technology
apolitical organization. One activity of the center assessments to determine coverage and reimburse-
is to support the Pew Biomedical Scholars Program. ment policies, patent expirations of top-selling prod-
This program provides financial assistance to ucts, and the implementation of the Medicare Part
talented early- and mid-career scientists who D drug benefit have influenced changes in the indus-
are investigating fundamental and medical areas try’s practices and strategies. This entry describes the
918 Pharmaceutical Industry
global sales and market share of the pharmaceutical or “innovator” pharmaceutical industry. The
industry, the different classifications within the largest companies in this sector are often referred
industry, and the future outlook for the industry in to as “Big Pharma.” They are represented by the
light of the recent developments. trade association, Pharmaceutical Research and
Manufactures of America (PhRMA). This sector
focuses on the discovery, development, and pro-
Global Pharmaceutical Sales
duction of new chemical entities and new bio-
Global pharmaceutical sales grew by 7% in 2006, logic entities. These multibillion dollar
totaling more than $643 billion (all data reported corporations, however, are not limited solely to
in U.S. dollars) in sales, according to industry esti- drug products or vaccine sales. Many of these
mates by IMS Health. This marked the third corporations include other healthcare-related
straight year of single-digit revenue growth for the products, such as nutrition products, dietary
pharmaceutical industry, after 5 years of double- supplements, diagnostics, medical devices, and
digit increases from 1999 to 2003. The worldwide other consumer products.
pharmaceutical market is dominated by the United Relative rankings of the world’s top pharmaceu-
States, with 44% of the world’s market share, fol- tical companies change yearly due to sales, patent
lowed by Europe, with 28%, Japan, 10%, Asia expirations, mergers, acquisitions, and other prac-
Pacific, 7%, Latin America, 5%, the Middle East tices. Based on 2007 rankings (compiled from
and Africa, 3%, and Canada, 3%. The largest Fortune 500 lists), 12 pharmaceutical corporations
European markets are France, Germany, Italy, the accounted for 60% of the total global pharmaceuti-
United Kingdom, and Spain. The Asia Pacific cal sales. The leading companies—based on sales,
region includes fast-growing pharmaceutical com- headquarters country, revenue, and profit (as a
panies, located in India and China, which mainly percentage of revenues)—were (1) Johnson &
produce generic versions of drug products. Brazil Johnson (U.S.), $53.3 billion, 20.7%; (2) Pfizer
is the largest market in Latin America. (U.S.), $52.4 billion, 36.9%; (3) GlaxoSmithKline
(U.K.), $42.7 billion, 23.2%; (4) Novartis
(Switzerland), $37 billion, 19.4%; (5) Sanofi-Aventis
Classification of the Pharmaceutical Industry
(France), $37 billion, 13.6%; (6) Roche Group
The pharmaceutical industry, or pharma, includes (Switzerland), $34.7 billion, 18.1%; (7) AstraZeneca
three primary sectors: (1) the traditional research- (U.K.), $26.5 billion, 22.8%; (8) Merck & Co. (U.S.),
intensive pharmaceutical industry, (2) the research- $22.6 billion, 19.6%; (9) Abbott Laboratories (U.S.),
intensive biopharmaceutical industry, and (3) the $22.5 billion, 7.6%; (10) Wyeth (U.S.), $20.4 billion,
generic pharmaceutical industry. These sectors, 20.6%; (11) Bristol-Myers Squibb (U.S.), $17.9 billion,
however, are increasingly becoming blurred because 8.8%; and (12) Eli Lilly (U.S.), $15.7 billion, 17%.
of strategic company acquisitions, mergers, licens- Seven of the top pharmaceutical companies are
ing agreements, and other business practices. American-based, and the five other top companies
For example, most traditional research-intensive are headquartered in Europe. Depending on the
pharmaceutical companies manufacture or license year, other leading research-based pharmaceutical
generic versions of their original products. The companies include Bayer (Germany), Bochringer
traditional research-intensive industry is attempt- Ingelheim (Germany), Schering-Plough (U.S.),
ing to gain market share and position in the Baxter International (U.S.), Takeda Pharmaceuticals
biopharmaceutical industry. And the generic phar- (Japan), Procter & Gamble (U.S.), Astella Pharma
maceutical industry is lobbying for legislation to (Japan), and others.
facilitate the approval of biogenerics (i.e., similar The median profit margin for the leading phar-
versions of biotech pharmaceutical products). maceutical companies was 19.5%, which is well
above the median of 4% to 5% for most other
industries. Median profit margins for the pharma-
Traditional Pharmaceutical Industry
ceutical industry have been about 17% to 18% since
The traditional research-intensive pharmaceu- 2002 (with a slight dip to 14% in 2003). Industry
tical industry is also known as the “brand-name” profits increased in the United States due in part to
the passage of the Medicare Part D prescription drug “pharmaceutical biotechnology industry,” or “bio-
benefit, which the industry helped pass. pharma.” Its products are usually termed biotech
The pharmaceutical industry asserts that its pharmaceuticals or biological medicines. Biotech
profits are in line with those of other major indus- pharmaceuticals are medicines derived from living
tries in consideration of its need for a reasonable cells and proteins, the so-called large molecules. In
return on its investment and adequate revenue to comparison, the traditional research-based phar-
encourage risk and innovation in the business of maceutical industry discovers and produces drug
drug discovery. Critics counter that it is difficult to products based primarily on small-molecule chem-
consider such a routinely profitable industry as ical substances. Examples of biopharmaceuticals
being risky. include monoclonal antibodies, protein cell cul-
The research-based pharmaceutical industry tures, protein microbials, and bioengineered hor-
strongly supports innovative drug research, swift mones. Biopharmaceuticals are used to treat a
development and approval of drug products dem- variety of medical conditions, though most current
onstrated to be safe and effective, strong intellec- products are marketed as specialty medications
tual property and patent protection, and access to indicated for cancers, anemia, heart disease, rheu-
medicines in an open, competitive market. It also matoid arthritis, and less prevalent diseases such as
supports federal legislation that would limit liabil- ankylosing spondylitis and Crohn’s disease. A
ity (e.g., limits on punitive damages and on dam- large percentage of research and development
age awards) for drug manufacturers. On the other expenses (25–50% of revenue) is invested by the
hand, it opposes restrictive drug formularies, prior biopharma industry as compared with the tradi-
authorization policies for prescription drug cover- tional research-intensive pharmaceutical industry
age, limits on prescription reimbursement, price (which averages about 18% of revenue).
controls, and retail-level prescription drug impor- The U.S. market for biotech pharmaceuticals
tation from foreign sources. was $35 billion in 2006, a 17% increase in growth
The U.S. Food and Drug Administration (FDA) is from 2005, which was about two times the rate of
the federal agency that reviews drug products for the traditional research-intensive pharmaceutical
approval in America, while patents on drug products industry. Biotech pharmaceuticals accounted for
(and related chemical compounds, processes, and 12% of total prescription sales, though the high
other intellectual property) are granted by the U.S. costs for some of these products can make them
Patent and Trademark Office. Patents can be granted prohibitively expensive. For example, treatment
anywhere along the development lifeline of a drug with Genentech’s Avastin (bevacizumab)—
compound or product. Patents are granted for a indicated for certain types of lung cancer, advanced
period of 20 years from the date of filing, before pat- breast cancer, or metastatic colorectal cancer—can
ent term restoration activities and court challenges. cost $100,000 per patient per year.
The PhRMA states that due to lost patent time dur- The top 10 biopharmaceutical companies, based
ing the protracted drug approval process (estimated on reported 2006 revenues, were (1) Amgen ($14.3
at 11 to 12 years by the FDA and up to 15 years by billion), (2) Genentech ($7.6 billion), (3) Novo
the pharmaceutical industry), the effective patent life Nordisk ($6.5 billion), (4) Genzyme ($3.2 billion),
of prescription drugs in the United States is only (5) Gilead Sciences ($3 billion), (6) UCB Group
about 11 or 12 years, as compared with more than ($2.7 billion), (7) Biogen Idec ($2.7 billion), (8)
18 years for nondrug products. The FDA can grant Serono ($2.5 billion), (9) MedImmune ($1.2 bil-
exclusive marketing rights, or exclusivity, for certain lion), and (10) Millennium ($220 million). Eight of
time periods (ranging from 6 months to 7 years) to these companies are based in the United States.
help promote a balance between innovation in new The exceptions are Novo Nordisk (Denmark) and
chemical entities and generic competition. UCB Group (Belgium).
Financial positions, relative rankings, and own-
ership can change quickly, especially in the more
Biopharmaceutical Industry
volatile biopharmaceutical sector. For example,
The research-based biopharmaceutical industry Amgen’s profits of almost $3 billion dropped by
is the newest sector and is also referred to as the 19.7% from the levels achieved in 2005. Gilead
920 Pharmaceutical Industry
Sciences and Genzyme also experienced substan- The biopharmaceutical industry generally
tial profit decreases during a 1-year period. The espouses similar position statements as the tradi-
eighth-ranked biopharmaceutical company— tional research-intensive pharmaceutical compa-
Serono—was acquired by Merck KGaA in 2006 nies with respect to support of market-based
and is now Merck Serono (known as EMD Serono, pricing for medicines, support of tax incentives to
Inc., in the United States and Canada because encourage investment in biotech-derived medi-
Germany-based Merck KGaA is a different com- cines, opposition to price controls for biotech
pany from the U.S.-based Merck & Co., which has drugs, and opposition to restrictive reimbursement
the rights to the name in North America). Similarly, programs. Similar to Big Pharma, the biotech
AstraZeneca purchased MedImmune in 2007. pharmaceutical industry is using late life-cycle
The biopharmaceutical industry has a similar strategies to expand its product line and to extend
product approval process to that of other pharma- the market life of its products, such as the second-
ceutical products. However, the approval time for generation anemia drug, EPO Aranesp (darbepoe-
a biopharmaceutical ranges between 7 and 12 tin alfa), which is manufactured by Amgen. One
years from development to approval. The develop- area where the position of the biopharmaceutical
ment and manufacture of biologic medicines is industry differs from those of the traditional
more complex and expensive than production of research-intensive pharmacy companies is with
small-molecule chemical entities, which is one of respect to policies on separate reimbursement
the reasons for their high costs. Because biologics mechanisms for drugs and biologicals.
are produced in living cells, it would be very diffi-
cult for other manufacturers to duplicate the pro-
Generic Pharmaceutical Industry
cess exactly in attempts to make generic versions
of biopharmaceuticals. Thus, biosimilars may be A generic drug product is defined as a product
therapeutically equivalent, rather than chemically that is bioequivalent to a referenced innovator
equivalent with original products. The FDA is in (brand name) drug product and is identical in
the early stages of creating regulatory procedures active chemical ingredient, strength, dosage form,
for the review and approval of biogenerics or bio- route of administration, quality, performance char-
similars, which are “generic” (or, more aptly acteristics, safety, and treatment indication.
named “similar”) versions of the innovator bio- Multisource generics are available for about three-
tech pharmaceuticals. However, it is likely to be quarters of drug products approved by the FDA.
years before that process is completed. The generic pharmaceutical industry experienced a
The major biotechnology trade association is 22% growth in sales from 2005 to 2006. Nationally,
the Biotechnology Industry Organization (BIO), 63% of prescriptions dispensed in the United States
and its multidisciplinary membership includes in 2006 were generic products, though generics
more than 1,100 biotech companies, universities, accounted for only 20% of prescription drug sales.
research organizations, and affiliates. In addition Over the past 20 years, the sustained growth in use
to biotech pharmaceutical firms, an increasing of generic drug products has been promoted as a
number of PhRMA companies are branching into cost-saving measure by managed-care organiza-
pharmaceutical biotechnology because of the rapid tions, private health insurance companies, state
growth of the industry and the lack of current pro- Medicaid and other government programs, phar-
cesses to enable generic competition. From 2005 to macy benefit management companies, and others.
2007, Big Pharma companies spent $76 billion to The pharmaceutical industry differentiates
acquire biotech companies. For example, Novartis, between unbranded generics and branded generics.
Wyeth, Abbot, and Eli Lilly have invested hun- Following approval of an abbreviated new drug
dreds of millions of dollars each in the formation application (ANDA) by the FDA, unbranded gener-
of in-house units for the development and manu- ics are manufactured by pharmaceutical companies
facture of biotech pharmaceuticals and the build- unaffiliated (for that product) with the innovator
ing of new manufacturing facilities. Other Big company. The ANDA (and equivalent) process does
Pharma companies have acquired smaller biotech not require the applicant firm to repeat the expen-
firms to expand their pipelines. sive preclinical and clinical research for the drug
ingredients and dosage forms that were approved rights (for 180 days) without competition by any
by the FDA for the application of the innovator product other than the original brand label. It also
company. Rather, the generic product must demon- opposes foreign importation of drug products at the
strate bioequivalence. The median ANDA approval retail level.
time in 2006 was 16.6 months. Branded generics
(called “authorized generics” by the industry) are
Future Implications
generic versions of the innovator product that are
manufactured by the innovator pharmaceutical Mergers, acquisitions, and other consolidations
industry sponsor and/or otherwise produced and among the major pharmaceutical companies are
distributed by one of its licensed partners. Branded anticipated to continue, and the nature of the phar-
generics are not required to undergo an abbreviated maceutical industry is changing. Fewer blockbuster
FDA approval process because the innovator com- drug products (i.e., products with annual global
pany is selling the same product previously approved sales of at least $1 billion) have been approved in
under a brand name. In 2006, the top pharmaceuti- recent years, with drugs in the research pipelines
cal companies for unbranded generic drug products appearing less promising for the traditional
(accounting for 54% of prescription dispensed and research-based pharmaceutical industry than for
10% of U.S. sales) were Teva Pharmaceuticals, the growing biotech pharmaceutical sector.
Novartis (Sandoz division), Mylan Laboratories, It has been estimated that Big Pharma lost $14
Watson Pharmaceuticals, Pfizer (Greenstone divi- billion in sales as the result of patent expirations
sion), Apotex Corporation, Par Pharmaceuticals, and increased generic competition in 2006. In the
Mallinckrodt, Barr Labs, Boehringer Ingelheim, future, while the companies will remain profitable,
Actavis US, Qualitest Products, and Hospira, Inc. revenues are likely to decline because many of their
The main generic pharmaceutical industry trade drug products are coming off patent between 2008
association is the Generic Pharmaceutical Association and 2012 (e.g., Fosamax, Valtrix, Advair, Lipitor,
(GPhA). The association states that the generic Plavix, and Crestor).
manufacturers provide consumers with safe, effec- In light of these patent expirations, more limited
tive, quality drug products at lower costs. Generic pipeline resources, and declining sales, many major
drugs are estimated to save U.S. customers $8 to pharma companies are reorganizing. In recent
$10 billion yearly at the retail level, with more sav- years, many companies have attempted to have
ings realized when including other pharmacy distri- leaner operations by laying off employees and
bution outlets such as hospitals and nursing homes. streamlining programs.
The generic pharmaceutical industry supports Predicted trends for the pharmaceutical industry
efforts to promote free market forces and supports include the increased use of outsourcing and global
the development of an abbreviated regulatory licensing because of reduced regulatory monitoring
approval process for biogenerics or biosimilars. The and decreased costs. The U.S. pharmaceutical
generic pharmaceutical industry wants faster FDA industry (research and generic) already outsources
review times for ANDAs. It is strongly opposed to much of its production to offshore territories (e.g.,
brand-name (research-intensive) drug industry Puerto Rico) and overseas countries, especially the
efforts to extend patents and other tactics to delay emerging markets of India, China, and Eastern
market introduction of generic drug products, such Europe. While the FDA inspects these facilities (for
as patent extensions for minor changes in formula- drug products legitimately sold in the United
tions or processes and unsubstantiated citizen peti- States), the oversight is less stringent than the rou-
tions to block FDA approval of generic applications. tine inspections in U.S.-based corporations.
The unbranded generic industry has challenged the Last, the future outlooks of the pharmaceutical
FDA’s regulatory policies in approving authorized industry will include increasing regulatory consid-
generics. The generic pharmaceutical industry eration of biosimilars. The European Commission
claims that by merely changing their label, the granted Sandoz approval to market a biosimilar
brand-name companies compete with the first version of epoetin alfa, or EPO (indicated for treat-
generic drug company at a period in which the first ment of anemia) in 2007, becoming the first bioge-
generic sponsor should have exclusive marketing neric product approved in the European EPO
922 Pharmacoeconomics
market. While predicted to be a potential block- U.S. Government Accountability Office. New Drug
buster, the ultimate impact of this regulatory Development: Science, Business, Regulatory, and
action is unknown. Sandoz’s Omnitrope (somatro- Intellectual Property Issues Cited As Hampering
pin, rDNA origin), a biosimilar version of Pfizer’s Drug Development Efforts. Report No. GAO-07–49.
human growth hormone Genotropin, was mar- Washington, DC: U.S. Government Accountability
keted under special rules in the United States and Office, November 2006.
Europe in 2006. Its sales, however, represent less
than 1% of the market. Perhaps its low market Web Sites
share was due to the drug’s relatively high price
Biotechnology Industry Organization (BIO):
and physician concerns about its bioequivalence.
http://www.bio.org
In 2007, legislation was introduced in the U.S.
Generic Pharmaceutical Association (GphA):
Congress (H.R. 1038 and S. 623, Access to Life- http://www.gphaonline.org
Saving Medicine Act) to provide for the licensing IMS Health: http://www.imshealth.com
of therapeutically equivalent biological medicines, Pharmaceutical Research and Manufacturers of America
which would mandate the FDA to create an abbre- (PhRMA): http://www.phrma.org
viated approval process for biological products. U.S. Food and Drug Administration (FDA):
However, Congress took no action. http://www.fda.gov
Stephanie Y. Crawford
See also Cost of Healthcare; Direct-to-Consumer

Advertising (DTCA); Medicare Part D Prescription Pharmacoeconomics
Drug Benefit; Pharmacy; Pharmacoeconomics;
Prescription and Generic Drug Use; U.S. Food and Pharmacoeconomics can be defined as the descrip-
Drug Administration (FDA) tion and analysis of the costs and consequences of
pharmaceutical products and services and their
impact on individuals, the healthcare system, and
Further Readings society at large. Pharmacoeconomics as a field of
research arose in the late 1970s in response to rising
Angell, Marcia. The Truth About the Drug Companies:
expenditures on prescriptions and growing concerns
How They Deceive Us and What to Do About It.
regarding cost containment of drug budgets. The
New York: Random House, 2004.
underlying purpose of pharmacoeconomic analysis
“By the Numbers. Top 20 Pharmaceutical Companies
is to promote the efficient use of healthcare resources
Ranked by U.S. Sales, October 2006 to September
2007,” Modern Healthcare 38(1): 31, January 7, 2008.
by informing treatment choices and related policy.
Engelhardt, H. Tristram, and Jeremy R. Garrett, eds.
Innovation and the Pharmaceutical Industry: Critical Background
Reflections on the Virtues of Profit. Salem, MA: M
and M Scrivener Press, 2008. Pharmacoeconomics has ties to both economic
Evans, Ronald P. Drug and Biological Development: evaluation and health outcomes research. Many
From Molecule to Product and Beyond. New York: of the theoretical methods have roots in social
Springer, 2007. welfare and cost-benefit analysis that are found in
Fulda, Thomas R., and Albert I. Wertheimer, eds. public finance and environmental economics. The
Handbook of Pharmaceutical Public Policy. New field is also related to decision analysis and corpo-
York: Pharmaceutical Products Press, 2007. rate finance principles often used in evaluating
Shayne, Gad. Pharmaceutical Manufacturing Handbook: corporate business decisions.
Production and Processes. Hoboken, NJ: Wiley, 2008.
Sloan, Frank A., and Chee-Ruey Hsieh, eds.
Categories of Study Methods
Pharmaceutical Innovation: Incentives, Competition,
and Cost-Benefit Analysis in International Within pharmacoeconomics, there are four gen-
Perspective. New York: Cambridge University Press, eral subcategories of study methods: (1) cost-
2007. minimization analysis (CMA), (2) cost-effectiveness
Pharmacoeconomics 923
analysis (CEA), (3) cost-utility analysis (CUA), administering treatment, the cost of treating side
and (4) cost-benefit analysis (CBA). These four effects, the costs associated with healthcare utili-
subcategories are differentiated according to how zation (e.g., physician office visits or hospitaliza-
health outcomes are measured: CMA requires tions), or the cost of patient time that is spent
that the health effects of the alternatives in ques- during treatment, to name a few. Finally, the costs
tion are equal. CEA measures health outcomes in of pain and suffering from a treatment or disease
some natural unit (e.g., life years). CUA is very can be considered. Note, that a central element of
similar to CEA except that the unit of health is a pharmacoeconomic analysis is the choice of the
quality-adjusted life years (QALYs). These units study perspective, where a societal perspective is
are formed by assigning health status (e.g., mild generally felt to be the most relevant in terms of
angina) a preference-based utility score, typically informing national policy (other perspectives
between 0 and 1, where 1 represents perfect include the payer perspective, the provider per-
health and 0 represents death, and then multiply- spective, and the employer perspective). The study
ing life years in a particular health state by the perspective fundamentally determines what costs
preference score of that health state (e.g., 10 years are included in the analysis, which is a reason that
in a health state with a utility score of 0.7 results studies that take a broad perspective, such as a
in 7 QALYs). The scores themselves come from societal perspective, are considered to be of greater
survey-based methods, and there are various importance. However, data availability and avail-
methodologies for obtaining the utility scores. able budgets for research may limit the perspective
Finally, CBA measures health effects in dollars, that research can cover. More important, it is the
which often involves some means of translating research question (or decision to be made) that
health gains into a dollar value. All four subcate- dictates the appropriate perspective.
gories consider costs measured in dollars.
Decision Making
Data Sources
In terms of how the results inform decisions,
There are numerous potential sources of data for CMA identifies the lowest-cost treatment among
quantifying costs and outcomes for use in a phar- two or more with the same effect. CEA and CUA
macoeconomics analysis, ranging from prospective identify treatments that cost more and provide
data collection to analyses of administrative data- equal or lower amounts of a health outcome, a
bases to information based on surveys of experts. choice that is never favorable. CEA and CUA also
In addition, information from randomized clinical measure the additional spending that is required
trials or from pharmacoepidemiologic studies can per gain in additional units of health outcome in
be examined in combination with cost informa- making a treatment switch to a higher-cost, high-
tion. Any pharmacoeconomic study is limited by er-effect treatment (or visa versa). By identifying
the availability of data related to what treatments the cost of increasing health in particular treat-
it sets out to compare. In addition, data are typi- ment options, CEA and CUA promote efficient
cally available from a particular patient popula- treatment choices. Currently, treatment adoptions
tion, a particular time period, and a particular with cost-to-QALYs ratios lower than $100,000
setting. Consequently, studies often involve the use are generally considered favorable. Cost-benefit
of models to project results across patient popula- analysis typically provides a direct calculation of
tions, and to project costs and outcomes into time the net benefit of making a treatment change,
horizons beyond the research of existing data. defined as the change in benefits minus the change
in costs. When the change in treatment is deemed
to have a positive net benefit, then that change is
Determining Costs
recommended.
A key aspect of pharmacoeconomics is consider- Currently, CUA with a societal perspective is
ation of costs beyond just the simple cost of the considered the gold standard strategy among
drug. Examples of other costs that can be included pharmacoeconomic analysts, though this is not
are the personnel, equipment, or facilities used in without controversy. While many feel that QALYs
924 Pharmacy
are the best available measure of general health Rychlik, Reinhard. Strategies in Pharmacoeconomics and
outcomes, many also feel that the measurement Outcomes Research. Binghamton, NY: Haworth
techniques to acquire QALYs are flawed and that Press, 2002.
there are too many underlying assumptions that Schweitzer, Stuart O. Pharmaceutical Economics and
go into aggregating QALYs (e.g., that an added Policy. 2d ed. New York: Oxford University Press,
QALY for an elderly person is the same as for a 2007.
younger person) for them to adequately inform
actual policy decisions. Suffice to say that devel-
opment of appropriate measures of health out- Web Sites
comes and notions of how to best apply aggregated International Society for Pharmacoeconomics and
results to inform policy toward health treatments Outcome Research (ISPOR): http://www.ispor.org
is an ongoing process. Society for Medical Decision Making (SMDM):
http://www.smdm.org
Future Implications
Pharmacoeconomics continues to grow, as mea-
sured by the number of published articles and
Pharmacy
books, the number of researchers, as well as the
number of dollars spent on research in the field. For the general public, pharmacists are often the
Many nations require pharmacoeconomic analy- most accessible health professionals for patients to
ses as part of the drug approval process. Although obtain information and advice. Currently, there
the U.S. Food and Drug Administration (FDA) are about 245,000 licensed pharmacists employed
does not currently require pharmacoeconomic in the United States, which ranks pharmacy as the
analyses in its approval process, a growing num- nation’s third-largest health profession. There are
ber of healthcare organizations are including also about 285,000 employed pharmacy techni-
pharmacoeconomic evidence in their decision- cians. Pharmacists help ensure the rational and
making processes. In addition, many of the nation’s safe use of drug therapies by working to achieve
pharmacy schools require pharmacoeconomics in positive therapeutic outcomes, improve the qual-
the curriculum of their students, and there are a ity of life for patients, reduce healthcare costs, and
number of graduate programs available that minimize patient risk from drug-related morbidity
include concentrations in pharmacoeconomics. and mortality.
Pharmacists are increasingly expanding their
Surrey M. Walton roles in healthcare. Specifically, they are advising
physicians, nurses, and other health professionals
See also Cost-Benefit and Cost-Effectiveness Analysis; on medication selection, dosages, use, interac-
Cost of Healthcare; Health Economics; Outcomes tions, and side effects; dispensing medications and
Movement; Pharmaceutical Industry; Pharmacy; Public monitoring patients for expected outcomes and
Policy; Quality-Adjusted Life Years (QALYs)
adverse effects; and educating and counseling
patients on prescription and nonprescription
drugs, dietary supplements, self-care, and other
Further Readings healthcare topics.
Bonk, Robert J. Pharmacoeconomics in Perspective: A As recognized medication-use experts, pharma-
Primer on Research, Techniques, and Information. cists are well educated on the composition and
Binghamton, NY: Haworth Press, 1999. characteristics of pharmaceuticals (e.g., chemical,
Drummond, Michael F., Mark J. Sculpher, George W. pharmacological, and physical properties), their
Torrance, et al. Methods for the Economic manufacture and/or preparation, and use.
Evaluation of Health Care Programmes. 3d ed. New Pharmacists strive to verify the quality of drugs
York: Oxford University Press, 2005. and related ingredients in the supply chain to help
Rascati, Karen L. Essentials of Pharmacoeconomics. ensure drug purity, strength, and proper labeling
Baltimore: Lippincott Williams and Wilkins, 2009. for improved patient safety.
Pharmacy 925
History of American Pharmacy unscrupulous. Many physicians continued to dis-

pense their own medicines, and a widening rift
The existence of pharmacists was rare in Colonial developed between pharmacy and clinical medicine.
America. Drugs and “patent medicines” (i.e., By the early 1900s, federal legislation and regu-
cheap and supposedly curative tonics, pills, and lations helped improve safety and quality of the
other concoctions, which often contained large drug supply to some extent. Medical education,
proportions of alcohol, opium, or laxatives) were training, and practice underwent substantial
readily available and hawked for sale without a change. Most physicians stopped or limited their
prescription at general stores and by traveling dispensing of medicines, and druggists compro-
salesmen. In the late 1700s, physicians com- mised by limiting their diagnosing to minor ill-
pounded drugs they prescribed (i.e., prepared nesses. During the Prohibition Era (1920–1933),
specially customized medicines), or their appren- drugstores were popular hangouts because drug-
tices prepared the drugs under their supervision. gists could dispense alcohol for medicinal pur-
Apothecary shops were generally owned by physi- poses. Regulatory change of certain drug products
cians and were located in large cities. The local to prescription-only status in the early 1900s
drug clerk was a shop employee whose role was eliminated the discretionary latitude of pharma-
more akin to a wholesaler than retailer; the drug cists in dispensing certain medications over the
clerk primarily compounded, stocked, and distrib- counter. Mass manufacturing of drug products by
uted medicines for physicians. The job of the drug the pharmaceutical industry began around the
clerk was viewed as a trade occupation, which same time, which greatly reduced compounding
was best learned by daily application of repetitive activities by pharmacists. By the 1960s, pharmacy
practices. The apprentice drug clerks eventually practice started to evolve from the product-
developed more expertise in pharmaceuticals, far oriented distributive focus to include more patient-
beyond the knowledge of most physicians, and oriented clinical roles.
they enjoyed a close working relationship with Laws and regulations, professional standards,
physicians, since they usually operated the shops and a professional code of ethics underpin contem-
on behalf of them. porary pharmacist roles. Leaders in the profession
Over time, the physician-owners of the shops embraced the clinical pharmacy movement in the
moved away and/or sold their businesses to their 1970s to the 1990s, when the concept of pharma-
former drug clerks, which began the establishment ceutical care was conceptualized. Today, pharma-
of the independent retail drugstore trade. In the ceutical care is defined as assuming responsibility
early to mid-1800s, independent apothecary shops for providing drug therapy intended to produce
and drugstores proliferated, and the businesses outcomes that improve the patient’s quality of life.
became increasingly profitable. As proprietors, the The changing healthcare marketplace, societal
former drug clerks adopted the titled of apothecar- need, shifting of some drugs from prescription to
ies or druggists (and a few called themselves phar- nonprescription status, advent of computerization
macists). The first college of pharmacy was and other automated systems, and educational
established in Philadelphia in 1821, and a small reforms help shape pharmacy practice.
number of other pharmacy colleges were founded,
though most druggist-practitioners lacked formal
training. From the mid-1800s through the early Education
1900s, the country lacked laws and regulations Throughout the 20th century, inconsistent phar-
governing foods, drugs, and healthcare practice. macy educational requirements resulted in dis-
The sale of inefficacious, possibly poisonous, and jointed perceptions of pharmacists and fragmented
mislabeled patent medicines were sold by self- philosophies of practice. More formalized phar-
designated apothecaries and other merchants. Some macy education programs were established by the
19th-century druggists diagnosed patients and dis- early 1900s, including 2-year diploma programs
pensed medicines, which conflicted with medical and a few 3-year and 4-year programs. The mini-
practice. Physicians widely criticized the appren- mum educational requirement for pharmacy
tice-trained employees as unknowledgeable and increased to 3 years in 1925 and increased to a
926 Pharmacy
4-year bachelor of science degree in 1932. By the products, pharmaceutics, pharmacokinetics, and
1950s, many pharmacy schools had expanded the physiology), the social, behavioral, and administra-
degree program requirements to a 5-year bache- tive sciences (e.g., communications, health systems
lor’s degree, which became the minimum standard analysis and services delivery, pharmacoeconomics,
in 1960. and management), and pharmacotherapeutics (e.g.,
Most of the nation’s pharmacy degree programs clinical pharmacy). Early experiential education is
in the 1960s and 1970s were heavily science based, included throughout the curriculum, and advanced
with curriculums focused on chemistry and other pharmacy practice experiential education (i.e.,
physical sciences. Clinical therapeutics courses clerkships) is offered during the final year of study.
were added to the curricula at most pharmacy pro- Graduate programs (leading to master’s and doc-
grams by the 1970s. A number of pharmacy toral degrees) are also available in specific areas of
schools converted their programs to a 6-year doc- the pharmaceutical sciences, but these research-
tor of pharmacy (PharmD) degree by the 1980s, based graduate degree programs do not generally
though the majority of colleges continued to offer require a background in pharmacy as a prerequisite
the 5-year bachelor’s degree as the entry-level for admission. More than 100 accredited pharmacy
degree in pharmacy. At that time, the doctor of schools exist in the United States, and these pro-
pharmacy degree was typically available as an grams graduate approximately 9,000 pharmacists
advanced postbaccalaureate degree. annually.
A protracted debate ensued among members of Optional postgraduate training opportunities
the profession, major pharmacy providers, and the exist in pharmacy. More than 1,500 pharmacists
academic community as to whether there was the complete a residency each year. A pharmacy resi-
need for the advanced clinical degree for all phar- dency is an organized, postgraduate training pro-
macists. A dual system of pharmacy education gram in professional practice and management
(bachelor’s degree and doctor of pharmacy) per- activities. Pharmacy residency programs are mainly
sisted for decades in a contentious atmosphere of located in the hospitals or ambulatory-care set-
strong support for and opposition to the all-doctor tings but also include home care and long-term
of pharmacy standard for professional education. care facilities, managed-care facilities, community
The debate ended in 1992, when the accrediting pharmacies, and other settings. The American
body (now the Accreditation Council for Pharmacy Society of Health-System Pharmacists (ASHP)
Education [ACPE]) announced its intent to recog- accredits more than 800 residency programs, and
nize only the doctor of pharmacy as the first the training programs cover diverse practice areas,
professional degree. Since 2004, the doctor of such as ambulatory care, cardiology, critical care,
pharmacy has been the only professional phar- informatics, psychiatric pharmacy, and transplan-
macy degree program accredited by ACPE. tation. Residency programs usually last 1 year
The doctor of pharmacy (PharmD) is designed (though a few are 2 years in duration), and some
to take a minimum of 6 academic years, including pharmacists complete a second, specialized resi-
2 years of prepharmacy requirements and 4 years dency after 1 year of general pharmacy residency
of pharmacy school. Admission to pharmacy school training. A pharmacy fellowship, typically lasting
is highly competitive. Applicants must have high 2 years, is a highly individualized postgraduate
academic achievement in courses such as biology, training program to develop research skills for
chemistry, physics, and calculus. More pharmacy pharmacists. The pharmacy fellow is under the
schools are also requiring students to take various direction of an experienced researcher-preceptor,
liberal arts courses such as communication and usually in the academic or the pharmaceutical
economics to have a broader education. Most phar- industry sector.
macy schools require Pharmacy College Admission
Test (PCAT) scores and interviews before appli-
Licensure and Credentialing
cants are considered for admission. The pharmacy
school curriculum includes strong foundations in Graduates of accredited pharmacy programs in
the basic pharmacy sciences (e.g., medicinal chem- the United States must pass state board examina-
istry, pharmacology, pharmacognosy, or natural tions to earn a license to practice pharmacy. Initial
Pharmacy 927
state licensure as a registered pharmacist is gained drug-therapy-related tests, administer medications,

by passing the North American Pharmacist and order and monitor drug regimens.
Licensure Examination (NAPLEX), the appropri-
ate sections of the Multistate Pharmacy Juris
Pharmacy Technicians
prudence Examination, both of which are
administered by the National Association of Pharmacists often are assisted by pharmacy tech-
Boards of Pharmacy (NABP), and/or other state nicians who provide technical support. Depending
requirements. Mechanisms exist to transfer on individual state practice acts and regulations,
NAPLEX scores (during initial licensing) and to pharmacy technicians may enter medication
transfer existing licenses (reciprocity) to gain orders, prepare medications and supplies for dis-
licensure in more than one state or jurisdiction. A pensing (e.g., counting and labeling), stock and
certification process is established by NABP and transport medications, purchase drugs, manage
individual state boards to allow foreign pharmacy narcotics inventories, answer telephone inquires,
graduates (who pass the Foreign Pharmacy and conduct other administrative duties. Roles of
Graduate Equivalency Examination and provide pharmacy technicians are determined by their
documentation of sufficient foreign pharmacy employer, and their work must be supervised
education) to become eligible to take the NAPLEX. under the direction of a registered pharmacist.
Pharmacists are expected to maintain professional There are no uniform qualifications for pharmacy
competence, legal requirements, ethical standards, technicians, and requirements vary across states
and continuing professional education to main- and practice settings. Most, though not all, states
tain their licensure. require that pharmacy technicians be high school
At the highest recognized level of specialization, graduates or equivalent. Pharmacy technicians
pharmacists in certain fields may become board may be trained informally or formally on the job,
certified through programs administered by the in vocational programs, community colleges, or
Board of Pharmaceutical Specialties (BPS). Board the U.S. military; training program lengths range
certification does not grant the recipient any legal from 1 day to 2 years. Increasingly, employers and
authority. However, certification offers advantages some states are requiring that pharmacy techni-
in knowledge gained, competitive job advantages, cians obtain certification, primarily by the
and recognized expertise for third-party payers. Pharmacy Technician Certification Board (PTCB)
BPS-specialties exist in nuclear pharmacy, nutri- or by the Institute for the Certification of Pharmacy
tion support pharmacy, oncology pharmacy, phar- Technicians (ICPT).
macotherapy (including added qualifications for
subspecialists in cardiology and infectious dis-
Pharmacist Associations
eases), and psychiatric pharmacy. Nearly 7,000
pharmacists (about 3% of the workforce) were Hundreds of pharmacist associations exist to
board certified in 2007. In addition to BPS certifi- serve member needs, including government rela-
cation, pharmacists can develop specialized areas tions, public relations, continuing education, pro-
of practice through residency or fellowship train- fessional standards development, meetings, products
ing, certificate programs in disease state manage- and services, and other professional activities. The
ment and other areas of practice, or extensive three largest pharmacist associations are (1) the
work experience. American Pharmacists Association (APhA), (2)
The role of pharmacists continues to expand, the American Society of Health-System Pharmacists
partly due to increasing numbers of pharmacists (ASHP), and (3) the National Community
specializing in practice areas and participating in Pharmacists Association (NCPA).
disease state management. Certain states have Founded in 1852, the APhA (formerly the
enacted legislation to enable collaborative practice American Pharmaceutical Association), which is
between pharmacists and physicians based on set located in Washington, D.C., is the oldest profes-
protocols. Through such collaborative drug ther- sional pharmacist society. The APhA has a mem-
apy management agreements, qualified pharma- bership of approximately 60,000 pharmacists,
cists may perform patient assessments, order pharmacy students, and pharmacy technicians.
928 Pharmacy
The ASHP (formerly the American Society of increasing demand for pharmacists, their salaries
Hospital Pharmacists), which is located in continue to rise each year.
Bethesda, Maryland, has the largest annual bud- The future employment outlook for pharma-
get of any pharmacist association, at approxi- cists is very promising. Pharmacists are in increas-
mately $40 million. Its membership consists of ing demand because of the greater use of
about 30,000 pharmacists whose practice settings prescription drugs, demographic trends such as the
include hospitals, health maintenance organiza- aging of the population, and the increasing inci-
tions (HMOs), patients’ homes, and long-term dence of chronic diseases. It is anticipated that
care facilities. there will be a national shortage of 112,000 to
The NCPA, which was founded in 1898 as the 157,000 pharmacists by 2020. It is also estimated
National Association of Retail Druggists, is head- that about 91,000 additional pharmacy techni-
quartered in Alexandria, Virginia. It represents cians will be needed by 2016. Future workforce
approximately 23,000 members who practice in projections will be influenced by the attrition rate
independent community pharmacies. of older pharmacists, shifts in full-time-equivalent
Other major pharmacist associations represent positions (currently 85% of practitioners) versus
managed-care practitioners (Academy of Managed the growing part-time employment in pharmacy
Care Pharmacists), clinical specialists in pharmacy practice, the continued expansion of existing and
practice and research (American College of Clinical new pharmacy school degree programs, and effec-
Pharmacy), compounding pharmacists (Interna tive use of support personnel and automation.
tional Academy of Compounding Pharmacists),
and minority pharmacists (National Pharmaceutical Stephanie Y. Crawford and Ketsya M. Amboise
Association).
See also Direct-to-Consumer Advertising (DTCA);
Affiliate member status is available for phar- Medicare Part D Prescription Drug Benefit; Patient
macy technicians in most of the major pharmacist Safety; Pharmaceutical Industry; Pharmacoeconomics;
associations, but the primary group representing Prescription and Generic Drug Use; U.S. Food and
them is the American Association of Pharmacy Drug Administration (FDA)
Technicians (AAPT).
Other important related associations are the
National Association of Chain Drug Stores Further Readings
(NACDS) and the Pharmaceutical Care Management
Association, which represent chain drugstores and Chisolm, Stephanie. The Health Professions: Trends and
pharmacy benefit managers, respectively. Opportunities in U.S. Health Care. Sudbury, MA:
Jones and Bartlett, 2007.
Kelly, William N. Pharmacy: What It Is and How It
Future Implications Works. 2d ed. Boca Raton, FL: CRC Press, 2007.
Knapp, Katherine K., and James M. Cultice. “New
Currently, about 60% of pharmacists work in
Pharmacist Supply Projections: Lower Separation
community pharmacies (e.g., independently owned
Rates and Increased Graduates Boost Supply
pharmacies, chain drugstores, mass merchandis-
Estimates,” Journal of the American Pharmacists
ers, and supermarket pharmacies). About 20% of Association 47(4): 463–70, July–August 2007.
pharmacists work in healthcare institutions (e.g., Manasse, Henri R., and Marilyn K. Speedie.
hospitals, nursing homes, and health clinics). The “Pharmacists, Pharmaceuticals, and Policy Issues
remaining pharmacists work in various areas such Shaping the Work Force in Pharmacy,” American
as the federal government, academia, the pharma- Journal of Pharmaceutical Education 71(5): 82–3,
ceutical industry, managed-care organizations, October 15, 2007.
professional associations, and public health agen- McCarthy, Robert L., and Kenneth W. Schafermeyer, eds.
cies, among others. Introduction to Health Care Delivery: A Primer for
Although salary ranges vary widely across geo- Pharmacists. 4th ed. Sudbury, MA: Jones and Bartlett,
graphic regions and practice settings, the median 2007.
annual pharmacist salaries ranged between about Poirier, Therese. “A New Vision for Pharmacy
$83,000 and $108,000 in 2006. And because of the Education: It Is Time to Shift the Old Paradigm and
Physician Assistants 929
Move Forward,” American Journal of Pharmaceutical duties, such as ordering supplies and equipment
Education 71(5): 103–104, October 15, 2007. and supervising others.
Smith, Michael I., Albert I. Wertheimer, and Jack E.
Fincham, eds. Pharmacy and the U.S. Health Care
System. 3d ed. New York: Pharmaceutical Products Background
Press, 2005. During the 1960s, the United States had a short-
age of physicians. During the Vietnam War, many
medical corpsmen returned from their tour of
Web Sites duty looking for suitable employment in which to
Accreditation Council for Pharmacy Education (ACPE): apply the skills they learned while in military ser-
http://www.acpe-accredit.org vice. The physician assistant vocation was viewed
American Association of Pharmacy Technicians (AAPT): as a measure to aid the delivery of primary care,
http://www.pharmacytechnician.com while extending the practice of physicians.
American Pharmacists Association (APhA): The first program in the nation to train physi-
http://www.pharmacist.com cian assistants was established at Duke University
American Society of Health-System Pharmacists (ASHP): in 1967. The program’s goal was to make health-
http://www.ashp.org care available to all people, especially those living
National Association of Boards of Pharmacy (NABP): in underserved areas. Federal grants allowed the
http://www.nabp.net expansion of physician assistant programs, and
National Association of Chain Drug Stores (NACDS): between 1970 and 1980 the number of programs
http://www.nacds.org grew from 12 to 56.
National Community Pharmacists Association (NCPA):
http://www.ncpanet.org
Pharmaceutical Care Management Association (PCMA): Education Programs
http://www.pcmanet.org
Today, about 12,000 students are enrolled in 141
Pharmacy Technician Certification Board (PTCB):
accredited physician assistant educational pro-
http://www.ptcb.org
grams in the nation. Most programs (121) offer
students the opportunity of earning a master’s
degree. The other programs allow students to earn
either a bachelor’s degree or an associate degree.
Physician Assistants Each program has its own admission require-
ments, but all require at least 4 years of college and
Physician assistants play an important role in some healthcare experience prior to admission.
America’s healthcare system, working in areas Like medical students, physician assistant stu-
often not directly served by physicians. In 2008, dents take a variety of science courses, such as
there were about 68,000 physician assistants biology, chemistry, and mathematics. They also
delivering healthcare in the nation. Physician take courses in various subspecialties, including
assistants are trained to diagnose health condi- pharmacology, human growth and development,
tions and administer therapy under the direction and human physiology. The students receive their
of a supervising physician. They are an integral clinical training in various medical specialties, such
part of healthcare teams. They often take patients’ as obstetrics-gynecology, general surgery, and oto-
medical histories, examine and treat patients laryngology. Depending on the program, some
within their respective range of knowledge, and students have the option of serving on more than
order and interpret laboratory tests and X rays, as one clinical rotation.
well as make specific diagnoses. They may per- Physician assistants are not bound to one spe-
form simple medical procedures such as stitching cialty. That is, if a physician assistant wants addi-
cuts and splinting and casting broken limbs. tional education to gain new skills, he or she has
Physician assistants are allowed to prescribe med- the option of doing so. For example, it is common
ications in 48 states and the District of Columbia; for physician assistants to receive additional
they may also be responsible for managerial instruction in specialties such as pediatrics or
930 Physician Assistants
emergency medicine. To meet common healthcare neurology, internal medicine, and surgery.
challenges found in underserved areas, many phy- Physician assistants with specialties in surgery pro-
sician assistants enroll in postgraduate educational vide both preoperative and postoperative treat-
programs that emphasize disciplines critical to ment and are often the physician’s primary
rural and/or inner-city communities. assistants if major surgery is required. The physi-
cian assistant’s work setting depends on his or her
supervising physician. For example, some work
Licensure mainly in an office, whereas others assist with sur-
geries. Physician assistants working in hospitals
To gain licensure, each state requires a physician
usually have a variety of schedules and are often
assistant to complete an accredited, recognized
on call. On the other hand, physician assistants
curriculum of study as well as pass a qualifying
employed in physicians’ clinics usually work 40
examination. Physician assistant programs typi-
hours per week.
cally last 2 years and require full-time attendance.
Some courses in the curricula are given in univer-
sity health clinics, medical schools, and traditional Future Implications
colleges and universities, while others are given at
community colleges, in military establishments, or The demand for physician assistants is expected
in hospitals. to continue to grow in the future much faster
Each state and the District of Columbia have than the average job growth for all occupations
laws specifying the requirements and qualifications in the nation. The U.S. Bureau of Labor Statistics
needed to become a physician assistant. All require projects rapid job growth for physician assistants
physician assistants to successfully pass the Physician because of the general expansion of healthcare
Assistant National Certifying Examination (PANCE), and an emphasis on cost containment, which will
which is given by the National Commission on result in the increasing use of physician assistants
Certification of Physician Assistants (NCCPA). The by healthcare organizations. Job opportunities
examination is available only to graduates of will likely be in rural and inner-city clinics
accredited physician assistant education programs. because these settings have difficulty attracting
To retain certification, physician assistants need to physicians.
take 100 hours of continuing medical education
Cary Stacy Smith and Li-Ching Hung
every 24 months. Every 72 months, they must take
a recertification examination. See also Access to Healthcare; Nurse Practitioners (NPs);
Nurses; Physicians; Physician Workforce Issues;
Primary Care; Public Health
Scope of Work
All professional medical services provided by phy-
sician assistants are under the guidance of a physi- Further Readings
cian. However, in many rural areas where there Ballweg, Ruth, Sherry Stolber, and Edward M. Sullivan,
are few physicians, the physician assistants are eds. Physician Assistant: A Guide to Clinical Practice.
often the primary medical-care providers. In sce- 4th ed. Philadelphia: Saunders-Elsevier, 2008.
narios such as this, the physician assistants discuss Cassidy, Barry A., and J. Dennis Blessing, eds. Ethics and
each case with the overseeing physician, as man- Professionalism: A Guide for the Physician Assistant.
dated by statutory law. Unlike many physicians, Philadelphia: F. A. Davis, 2008.
physician assistants visit patients in their home, Hooker, Roderick S., and James F. Cawley. Physician
travel to various hospitals and nursing homes to Assistants in American Medicine. 2d ed. St. Louis,
see how patients are progressing, and then report MO: Churchill Livingstone, 2003.
everything back to the physician. Keir, Lucille, Barbara A. Wise, and Connie Krebs.
Like physicians, physician assistants often spe- Medical Assisting: Administrative and Clinical
cialize in areas such as general practice, cardiol- Competencies. 6th ed. Clifton Park, NY: Thomson
ogy, and psychiatry. Other specialty areas include Delmar Learning, 2008.
Physicians 931
Web Sites a standardized licensing examination to physi-

American Academy of Physician Assistants (AAPA) cians, the United States Medical Licensing
http://www.aapa.org Examination (USMLE).
Bureau of Health Professions (BHPr): http://bhpr.hrsa.gov
Bureau of Labor Statistics (BLS): http://www.bls.gov Entrance Into Medical School
Duke University, Physician Assistant History Center
(PAHx): http://www.pahx.org Motivations to enter the field of medicine, while
unique to the individual who pursues this path,
generally include factors such as the desire to
help others in a healing capacity, service in the
context of science, technology, and research, and
Physicians preference for an autonomous profession.
Medical school admission requirements include
Physicians are medical practitioners who focus successful completion of the Medical College
on improving human health through the study, Admissions Test (MCAT), a standardized test
diagnosis, and treatment of disease and injury. comprising three sections of physical sciences,
Physicians are able to apply their knowledge and biological sciences, and verbal reasoning, scored
the science of medicine after much training and from 1 to 15 points, as well as two writing sam-
specialized studies. Physicians play a vital role in ples. An application is typically submitted through
the nation’s healthcare system, and they may the American Medical College Application
work directly with patients in a clinical setting or Service (AMCAS), which processes applications
conduct medical research. Although physicians for the majority of allopathic medical schools, or
make up less than 10% of the nation’s total med- through the American Association of Osteopathic
ical workforce, they command enormous resources, Medicine (AACOM) for osteopathic medical
and the entire healthcare industry is usually sub- schools.
ordinate to their professional authority in clinical This highly selective and competitive process
matters and research. draws serious and motivated students. Applicant
data are collected annually and shows that most
accepted applicants earned an average of 10 to 15
Overview
points on each section of the MCAT. Moreover,
Modern medicine in the United States dates back they have an undergraduate cumulative grade
to the latter half of the 18th century when the first point average in science of 3.75 on a 4.0 scale.
medical school was founded at the University of Recently, there have been an increasing number of
Pennsylvania. Quickly thereafter, there was a push female applicants to medical schools, and approxi-
to standardize the practice of medicine. In 1847, mately 60% of students are female. Most appli-
the American Medical Association (AMA) was cants are White. Blacks, Native Americans, Mexican
established; with this came the initiation of licens- Americans, and mainland Puerto Ricans comprise
ing laws and accreditation standards for medical about 12% of all medical students, while these
schools. The strength of the AMA was illustrated groups together comprise about 20% of the
with the publication of the landmark report nation’s overall population.
Medical Education in the United States and On graduating from medical school, physicians
Canada, more commonly known as the Flexner enter medical residency programs to continue their
Report, in 1910, which subsequently led to the training. These programs run from 3 to 8 years in
closure of a number of medical schools that did length, and, generally, osteopathic physicians must
not meet the AMA’s criteria. Another consequence complete a 12-month rotation prior to entry. After
of the Flexner Report was the curtailment of the residency, physicians obtain a state license to prac-
supply of physicians. Standardization of medicine tice medicine. Licensing laws are set by state
continued in many ways, including the establish- boards of medicine that require graduation from
ment of the National Board of Medical Examiners an accredited medical school and passing the three
(NBME) in 1915, whose function was to administer steps of the USMLE to obtain a license. Furthermore,
932 Physicians
these boards set certain standards for physicians, from medical schools in countries outside the
such as qualifications for a license and standards United States, including Puerto Rico and Canada.
of practice, and they have authority over disciplin- The Educational Commission for Foreign Medical
ary action. Graduates (ECFMG) must certify IMGs prior to
their entrance into U.S. graduate medical educa-
tion programs. To receive certification, IMGs must
Allopathic and Osteopathic Physicians
pass both the Test of English as a Foreign Language
and International Medical Graduates
(TOEFL) and the USMLE. In addition, as of 1988,
All physicians, including allopathic physicians IMGs must also pass the Clinical Skills Assessment
(MDs) and osteopathic physicians (DOs) have (CSA) examination. Many influential organiza-
the role of evaluating, diagnosing, and treating tions, including the AMA, the national Institute of
patients. However, these medical providers accom- Medicine (IOM), and the Pew Health Professions
plish their goals in distinct roles, as most MDs are Commission have called for a reduction in the
specialists whereas most DOs are primarily gen- number of IMGs in residency programs citing
eral practitioners. the fact that they are not helping the problem of the
Allopathic medicine is generally regarded as the maldistribution of physicians in the nation. Despite
traditional (Western) practice of medicine and its the fact that most IMGs train in underserved areas,
study leads to the doctor of medicine degree (MD) most practice in nonunderserved areas.
in any of the 126 accredited schools of medicine
in the nation. These schools are accredited by the
Need for Physicians
AAMC and graduate about 14,500 students per
year. The federal government plays an important but
Osteopathic medicine, however, has a history indirect role in the number of physicians in the
distinct from the allopathic school of thought. In United States by funding both medical school edu-
1892, Andrew T. Still, the father of osteopathic cation and medical residency programs. Moreover,
medicine, founded the American School of the government also influences the number of
Osteopathy, which has since changed it name to physicians practicing in specialties or primary care
the Kirksville College of Osteopathic Medicine, in by regulating the amount of funds for training in
Kirksville, Missouri. The school was founded on these areas. Importantly, some believe that access
the core beliefs of osteopathy that stress holistic to healthcare itself can be managed by exercising
medicine, manipulative therapies, and the impor- control over the supply of physicians.
tance of the neuromusculoskeletal system. These
beliefs still prevail today and are taught in con-
Supply of Physicians
junction with academic courses similar to those
offered in allopathic schools of medicine. At the In the early 1960s, the ratio of physicians to the
completion of their four-year education in one of population was 140 physicians per 100,000 peo-
the 19 U.S. osteopathic schools of medicine, osteo- ple in the nation. Many felt this ratio was too low
pathic students earn a DO (or doctor of osteopa- and that there was a national physician shortage.
thy or doctor of osteopathic medicine) degree, and To overcome the shortage, the U.S. Congress
they can then enter into either osteopathic or allo- enacted the Higher Education Facilities Act (PL
pathic residency programs. About 2,500 students 88–204) in 1963, and efforts were made to both
graduate from osteopathic schools of medicine increase the enrollment of students in existing
annually, and about two thirds of DOs go through medical schools and create new schools across the
allopathic medical residencies. Ultimately, most nation. Eventually, 40 new medical schools were
DOs are in general practice, and they account for created, and many more physicians graduated
about 6% of all active physicians in the nation. from medical school. By 1980, the ratio of physi-
International Medical Graduates (IMGs) com- cians to the population rose to 202 physicians per
prise about 25% of all residency positions and 100,000 people. The federal Civil Rights Act of
account for about a quarter of all active physicians 1964 (PL 88–352) also increased the national sup-
in the nation. These individuals have graduated ply of physicians, particularly of Blacks and
Physicians 933
women. In fact, between 1965 and 1999, the entirely accurate picture of access to care, as there
number of women graduates from the nation’s are significant problems with the maldistribution
medical schools increased from 7% to 43%. of providers. In particular, physicians are not
Similarly, there was an increase in the total num- evenly distributed across geography or by spe-
ber of women physicians in active practice from cialty, which has resulted in shortages in rural
7% in 1970 to 21% in 1999. areas and in primary care. The geographic maldis-
The Graduate Medical Education National tribution of physicians generally means that some
Advisory Committee (GMENAC), which consisted areas lack adequate numbers of physicians whereas
of a panel of prominent experts, was established in others have a sufficient number or even an over-
1976 to assess the success of the effort to overcome supply. There are severe shortages of healthcare
the national physician shortage problem. Com services in many rural areas, particularly in areas
missioned by the U.S. Department of Health and with populations of less than 5,000 individuals.
Human Services (HHS), GMENAC was given the People who reside in these areas must rely on only
task of determining the following: (a) the number of 5 physicians per 10,000 residents. Approximately
physicians required to meet the healthcare needs of 20% of the nation’s population lives in these areas,
the nation, (b) the most appropriate specialty distri- which only have about 9% of the nation’s physi-
bution of these physicians, (c) the most favorable cians. Furthermore, although cities generally report
geographic distribution of physicians, (d) appropri- an adequate number of practicing physicians, in
ate ways to finance the graduate medical education many instances, they are not distributed equally
of physicians, and (e) the strategies that can achieve within the cities. As a result, there are local com-
the recommendations formulated by the committee. munities that need more physicians. In fact, some
GMENAC published its findings in 1980 and con- urban areas have physician to population ratios as
cluded that there was no longer a national shortage low as 10 physicians per 100,000 people.
of physicians. Rather, it predicted, there would be Some steps have been taken to compensate for
an excess number of physicians by the 1990s. Also, these shortages of physicians. In 1970, the federal
the committee noted concerns related to geographic National Health Service Corps (NHSC) was estab-
and primary-care shortages, specifically in the areas lished with the mission of recruiting and retaining
of general medicine and child psychiatry, and fail- physicians and other health professionals in short-
ure to meet its suggested ratio of between 145 and age areas. To entice people to join the NHSC,
185 physicians per 100,000 people. The trend of scholarships and loan repayments are offered, pro-
training more physicians continued, with the num- viding that the minimum 2 years of service are
ber of physicians in the nation increasing by 173% completed. This program has placed more than
between 1950 and 1990. Consequently, the Pew 20,000 health professionals since its inception.
Commission published data in the mid-1990s pre- Additionally, guidelines were developed for the
dicting that there would be a surplus of physicians designation of Medically Underserved Areas
and called for the closing of 20% of medical schools (MUAs) in 1973. MUA status was determined by
and for a 25% reduction in the number of medical using a four part Index of Medical Underservice
residency positions. Along with the increasing num- that looked at the percentage of the population
ber of physicians there were also rising costs associ- below the federal poverty level, the percentage of
ated with their training. To curtail this, the federal the population 65 years of age or older, the infant
Balanced Budget Act of 1997 capped the total num- mortality rate, and the physician to population
ber of medical residents funded by the Medicare ratio. In 1976, similar guidelines were set for the
program and also reduced payments to residency designation of Health Manpower Shortage Areas
programs. (HMSAs) under the Health Professionals Education
Assistance Act. These guidelines outlined three
different types of primary-care HMSAs: (1) geo-
Demand for Physicians
graphic areas, (2) population groups, and (3)
The demand for physicians is a function of access medical facilities. Another effort to combat the
to healthcare. The total number of physicians and geographic shortage of physicians was the devel-
the physician to population ratio do not present an opment of Community and Migrant Health Centers
934 Physicians
(C/MHCs), which have been important in provid- 13% to 12% in pediatrics. However, it is difficult
ing services to patients in rural areas. For example, to predict the numbers of medical residents who
in 2000, about 53% of all C/MHCs were located will actually practice in primary care, since many of
in rural areas and served more than 9 million them enter fellowship programs and subspecialize.
people. The enactment of the federal Rural Health This dichotomy has grown larger over time, such
Clinics Act in 1977 instituted a successful reim- that two thirds of physicians are specialists.
bursement strategy to help deal with the lack of
physicians in rural areas. This legislation allowed
Impact of Managed Care
physician assistants, nurse practitioners, and certi-
fied nurse midwives associated with rural clinics to Managed care has greatly influenced the practice
practice without the supervision of a physician. of medicine. Managed-care organizations such as
Also, this act gave rural health clinics eligibility for health maintenance organizations (HMOs) and
reimbursement from Medicaid at a higher rate, preferred provider organizations (PPOs) were the
matching that provided by Medicare. preferred choice of employers and the government
Medical schools have also taken steps toward in the 1980s as a means to contain the costs of
overcoming the physician shortages in rural areas. healthcare. Managed-care organizations either
Schools such as Philadelphia’s Thomas Jefferson contract with physicians or directly employ them.
School of Medicine and the University of Illinois They use three principal types of payments: (1)
College of Medicine have implemented programs payments to preferred providers with discounted
to deal with geographic shortages. A 2001 study of fee schedules, (2) capitation payments, and (3)
the Physician Shortage Area Program of the salaries. The consequence is that these organiza-
Thomas Jefferson School of Medicine found that it tions exercise control over physicians by way of
was successful in contributing to the supply of constraints on payments, and they tend to use a
physicians practicing in rural and underserved capitation or discounted rate payment scheme.
areas. The study noted that the program’s selection This approach results in disincentives for physi-
criteria, which almost exclusively favor admission cians to refer patients to specialists and to limit
for students from rural areas, coupled with its inpatient hospital stays. The use of primary-care
emphasis on primary care during training were the physicians as gatekeepers to specialty care has also
key reasons for its success. jeopardized patient care by imposing barriers to
The imbalance between specialists and primary- specialty care. On the other hand, the managed-
care physicians is another obstacle limiting access care organizations offer incentives to physicians
to healthcare. Reasons for specialty maldistribu- depending on their productivity. Despite this, the
tion include medical technology, reimbursement objective of cost containment has not been real-
methods, and specialty-oriented medical education. ized since the wide-scale implementation of man-
Medical technology is expanding at a rapid pace, aged care. And healthcare costs continue to rise.
and it may appeal to medical students who are
further attracted into specialties because their train-
Future Implications
ing is organized around it. Moreover, reimburse-
ment and remuneration of specialists is higher In 2009, there will be about 890,000 active physi-
compared to primary-care physicians, which may cians in the United States, or approximately 295
deflect interest in pursing a career in primary care. per 100,000 people. Future projections, however,
These factors have been linked to fluctuations in indicate that there will be a growing national
the number of medical students who match resi- shortage of physicians. According to several
dencies in internal medicine, pediatrics, and family reports, although the total number of physicians
care. These fields were most popular in 1998 and will increase, the demand for their services will
had a match rate of 53%, but interest has dropped, outpace supply. Factors such as the accelerating
and in 2002 only 44% of students matched in these rate of retirements of older physicians, the aging of
areas of practice. Specifically, rates between 1998 the nation’s population, with associated chronic
and 2002 decreased from 24% to 22% in internal medical conditions, and restrictions on the number
medicine, 16% to 10% in family medicine, and of hours medical residents work will contribute to
Physicians, Osteopathic 935
the physician shortages. To prevent the shortage, Blumenthal, David. “New Steam From an Old
there is a push to increase the enrollment of stu- Cauldron: Physician-Supply Debate,” New England
dents in medical schools across the nation. While Journal of Medicine 350(17): 1780–87, April 22,
this is a feasible solution, its effects will not be 2004.
realized in the short term, because it takes 12 to 15 Bujak, Joseph S. Inside the Physician Mind: Finding
years to train a physician. Also, financial factors Common Ground with Doctors. Chicago: Health
complicate this issue and influence the number of Administration Press, 2008.
students who apply to medical school. It is prob- Cooper, Richard A., “Weighing the Evidence for
Expanding Physician Supply,” Annals of Internal
lematic that the costs of education have consis-
Medicine 141(9): 705–714, November 2, 2004.
tently risen against a background of decreasing
Ginzberg, Eli, and Panos Minogiannis. U.S. Health Care
physician reimbursement. With an average of
and the Future Supply of Physicians. New Brunswick,
about $200,000 in educational costs incurred
NJ: Transaction Publishers, 2004.
postgraduation, coupled with less return on the Mitka, Mike. “Looming Shortage of Physicians Raises
investment today as compared with the past, inter- Concern about Access to Care,” Journal of the
est in medicine has declined and so have the num- American Medical Association 297(10): 1045–1046,
ber of applicants to medical schools. A more March 14, 2007.
immediate solution to the shortage of physicians More, Ellen S., Elizabeth Fee, and Manon Parry, eds.
may be achieved by having a greater number of Women Physicians and the Culture of Medicine.
IMGs enter residency programs. Another possibil- Baltimore: Johns Hopkins University Press, 2008.
ity is the greater use of nonphysician practitioners Rabinowitz, Howard K., James J. Diamond, Fred W.
(NPPs), who represent a large portion of health- Markham, et al. “Critical Factors for Designing
care providers. Specifically, nurse practitioners Programs to Increase the Supply and Retention of
(NPs) and physician assistants (PAs) are popular Rural Primary Care Physicians,” Journal of the
medical careers that can be helpful in combating American Medical Association 286(9): 1041–1048,
the need for care in underserved areas at a lower September 5, 2001.
cost, typically 40% less than the cost of a physi- Whelan, Gerald P., Nancy E. Gary, John Kostis, et al.,
cian. NPs, who complete registered nursing degrees “The Changing Pool of International Medical
in addition to extended study, are able to write Graduates Seeking Certification Training in U.S.
prescriptions in most states. PAs practice under the Graduate Medical Education Programs, “ Journal of
supervision of a physician and also tend to practice the American Medical Association 288(9): 1079–
in primary-care fields. Pooling resources from 1084, September 4, 2007.
multiple areas, including more domestic medical
graduates and IMGs, along with the greater use
of NPPs, will help to equilibrate the imbalance Web Sites
between physician supply and demand and also American Association of Colleges of Osteopathic
promises to help with the problem of geographic Medicine (AACOM): http://www.aacom.org
and specialty maldistribution. American Medical Association (AMA):
Kristen Friscia Association of American Medical Colleges (AAMC):
See also American Medical Association (AMA); American http://www.aamc.org
Osteopathic Association (AOA); General Practice; Bureau of Health Professions (BHPr): http://bhpr.hrsa.gov
Managed Care; Medical Group Practice; Physicians,
Osteopathic; Physician Workforce Issues; Primary
Care Physicians
Physicians, Osteopathic
Further Readings There are currently about 61,000 osteopathic phy-
American Medical Association. Physician Characteristics sicians in the United States; they constitute about
and Distribution in the U.S. Chicago: American 7% of the nation’s practicing physician workforce.
Medical Association, 2008. But osteopathic physicians are responsible for
936 Physicians, Osteopathic
16% of patient visits in small communities with ability to heal itself. He stressed preventive care,
populations of fewer than 2,500 individuals. In eating properly, and keeping fit. In 1892, Still
addition, 22% of all osteopathic physicians prac- founded the American School of Osteopathy, now
tice in rural and medically underserved areas. known as the Kirksville College of Osteopathic
The osteopathic medical philosophy emphasizes Medicine of the A. T. Still University of Health
preventive care and focuses on the unity of all Sciences, in Kirksville, Missouri.
body parts. Instead of just treating specific symp-
toms or illnesses, osteopathic physicians regard the
body as an integrated whole, and they help patients Osteopathic Medical Education
develop attitudes and lifestyles that help prevent
Currently, there are 26 osteopathic medical schools
illness. Like allopathic physicians, osteopathic
in the United States. Students in these programs
physicians are fully licensed to prescribe medica-
take courses in anatomy, physiology, microbiol-
tions and practice in all medical specialty areas,
ogy, histology, osteopathic principles and prac-
including surgery.
tices, including osteopathic manipulative medicine,
Osteopathic physicians also receive extra medi-
pharmacology, clinical skills, physician–patient
cal training in the musculoskeletal system, the
communications, and systems courses that focus
body’s interconnected system of nerves, muscles,
on each major system of the body, such as the
and bones that make up two thirds of its body
cardiac and respiratory systems.
mass. This training provides osteopathic physi-
Many osteopathic medical schools have stu-
cians with a better understanding of the ways that
dents assigned to work with physicians beginning
an injury or illness in one part of the body can
early in their 1st year of study. This process con-
affect another.
tinues throughout the 2nd year in conjunction
Furthermore, osteopathic physicians incorpo-
with the necessary science courses. In the 3rd and
rate osteopathic manipulative treatment into their
4th years, osteopathic medical students spend
medical care. With this treatment, osteopathic
time learning about and exploring the major spe-
physicians use their hands to diagnose injury and
cialties in medicine through clinical rotations.
illness and to encourage the body’s natural ten-
One unique aspect of the osteopathic medical
dency toward good health.
student’s education is how these rotations are
conducted in community hospitals and physi-
Background cians’ offices across the nation. Because few
osteopathic medical colleges have their own hos-
Andrew Taylor Still (1828–1917) was the father of
pitals, the schools partner with community hos-
osteopathic medicine as well as the founder of the
pitals to deliver the final years of curriculum as
first college of osteopathic medicine. Born in a log
well as internship and residency training. This
cabin in Jonesville, Virginia, Still decided at an early
model of medical education developed by the
age to follow in his father’s footsteps and become a
osteopathic medical profession has been touted
physician. As an apprentice physician to his father,
as the new model for all medical education.
he learned both from being at his father’s side as
Current pilot studies are being developed on a
well as from the course of study. Still later served in
national level to evaluate this model of medical
the Civil War as a surgeon in the Union Army.
education.
It was not until the early 1870s that Still sepa-
rated himself from his allopathic counterparts by
his pervasive criticism of the misuse of drugs com-
Medical Licensure
mon in that day. Believing that medicine should
offer the patient more, he supported a philosophy Licensing boards in each state provide osteopathic
of medicine different from the practice of his day, physicians with licensure to practice medicine.
and in its place he advocated the use of osteopathic Requirements vary by state, but there are gener-
manipulative treatment. ally three ways an osteopathic physician can
Still identified the musculoskeletal system as a become licensed. First, osteopathic physicians
key element of health and recognized the body’s must successfully complete a medical licensing
Physician Workforce Issues 937
examination administered by the state licensing Stone, Caroline. Science in the Art of Osteopathy:
board. State boards may prepare their own exam- Osteopathic Principles and Models. Cheltenham, UK:
ination or administer an examination that has Nelson Thornes, 2000.
been prepared and purchased from a specialized
agency. Today, the United States Medical Licensing
Examination (USMLE) and the Comprehensive Web Sites
Osteopathic Medical Licensing Examination
(COMLEX-USA) are the most widely used tests. American Association of Colleges of Osteopathic
The osteopathic physician can also accept the cer- Medicine (AACOM): http://www.aacom.org
tificate issued by the National Board of Osteopathic American Osteopathic Association (AOA):
http://www.osteopathic.org
Medical Examiners (NBOME), awarded after an
Bureau of Health Professions (BHPr): http://bhpr.hrsa.gov
applicant has satisfied the requirements, including
Bureau of Labor Statistics (BLS): http://www.bls.gov
the successful passage of a rigorous series of tests.
Finally, licensure can be granted through reciproc-
ity or endorsement of a license previously received
from another state. This typically has to be issued
on the basis of a written examination. Physician Workforce Issues
The rate of change throughout the healthcare
Future Implications industry has had profound effects on the composi-
Osteopathic physicians are one of the fastest tion of the physician workforce. Yet while many
growing segments of healthcare professionals in health services researchers study issues involving
the nation. By the year 2020, an estimated the physician, including healthcare insurance and
100,000 osteopathic physicians will be in active managed care, quality of care and outcomes, and
medical practice. Approximately 60% of all prac- malpractice and tort reform, direct evidence of
ticing osteopathic physicians specialize in the pri- changes in the physician workforce is relatively
mary-care areas of family practice, internal scant. Researchers, however, are able to use infor-
medicine, obstetrics and gynecology, and pediat- mation from the studies that do exist to help
rics. Many of these physicians will continue to fill develop efficient and effective healthcare manage-
a critical need by practicing in rural and medically ment and policy.
underserved areas of the nation.
American Osteopathic Association Nature and Function of
See also Access to Healthcare; American Osteopathic
the Physician Workforce
Association (AOA); Health Professional Shortage Areas More than 15 centuries ago, the Greek physician
(HPSAs); Health Workforce; Physician Workforce Hippocrates advocated that all physicians pay
Issues; Physicians; Preventive Care; Primary Care attention to the individual patient. In this rebel-
lion against the Cnidian convention that favored
diagnosis and classification of diseases, Hippocrates
Further Readings modernized the practice of medicine. While the
Gevitz, Norman. The DOs: Osteopathic Medicine in physician has historically trained as an apprentice
America. 2d ed. Baltimore: Johns Hopkins University and basic responsibilities have remained the same
Press, 2004. over time, the physician is no longer simply some-
Still, Andrew T. Autobiography of Andrew T. Still: With one who is a skilled healer. Today’s physician is a
a History of the Discovery and Development of the healer who is formally trained—and legally
Science of Osteopathy. Whitefish, MT: Kessinger, qualified—to practice medicine. More stringent
2007. standards have existed only since the early 20th
Still, Andrew T. Philosophy of Osteopathy. New York: century, when Abraham Flexner’s report on the
Ams Press, 2008. status of medical education in North America
938 Physician Workforce Issues
largely resulted in the advent of scientifically within-specialty gender distribution. Medical stu-
based university medical schools and teaching dents also have expressed that receiving early
hospitals similar to those that had been estab- exposure to positive role models and opportunities
lished in Europe. in a certain specialty is likely to influence their
The physician workforce is presently composed career pursuits in that specialty.
of individuals educated and trained in primary At the same time, lifestyle issues are increasingly
care and various specialties. A primary-care physi- and conclusively central to career choice decisions
cian is a Medical Doctor (MD) or Doctor of of medical school students. Measuring the deter-
Osteopathic Medicine (DO) who, as a generalist, minants of specialty choice and overall satisfaction
serves as the patient’s first entry point into the among generalists and specialists in different types
healthcare system; a specialist physician is one of workplaces and organizations also requires the
who is qualified to diagnose and care for specific consideration of various factors, including possible
ailments or injuries. Physicians also may choose to postponement of family plans. And as the physi-
practice in surgical specialties, which include the cian workforce experiences the introduction of
branches of medicine that treat injury or disease by younger professionals and the development of new
operative procedures, or medical specialties, which opportunities for older ones, there is an increased
include the branches of medicine that deal with need to consider the availability of role models
nonsurgical techniques. and mentors, gender demographics, assurance in
Various specialty boards, recognized by the expressing emotions at work, development of per-
American Board of Medical Specialties (ABMS) sonal relationships, parenthood during residency,
and the American Medical Association (AMA), family plans, and geographic location—all of
individually certify physicians as specialists based which act as important factors in choices made by
on specific requirements, such as training, examina- physicians throughout their careers. That is, the
tion, and continuing education. Recognized special- manner in which physicians view quality of life,
ties include the following: Allergy and Immunology, both at work and at home, is of increasing impor-
Anesthesiology, Colon and Rectal Surgery, Derma tance when considering issues in and of the physi-
tology, Emergency Medicine, Family Practice, cian workforce.
Internal Medicine, Medical Genetics, Neurological
Surgery, Nuclear Medicine, Obstetrics and
Work Conditions
Gynecology, Ophthalmology, Orthopedic Surgery,
Otolaryngology, Pathology, Pediatrics, Physical Although the majority of physicians continue to
Medicine and Rehabilitation, Plastic Surgery, work in private offices or clinics, typically assisted
Preventive Medicine, Psychiatry and Neurology, by a small staff of nurses and administrative per-
Radiology, Surgery, Thoracic Surgery, and Urology. sonnel, the professional lives of American physi-
A majority of the specialties also acknowledge cians are increasingly—and almost entirely—being
various subspecialties. defined by group practice relationships and
Many factors influence the choice of specializa- health maintenance organizations (HMOs). The
tion as well as the choice to pursue a career in HMO model, originated by Kaiser Permanente,
medicine. These factors become more defined as is vertically integrated to link financial concerns
the individual’s career, status, and function change with healthcare delivery and horizontally inte-
over time. Among these factors are career oppor- grated to connect healthcare services, with the
tunities; academic opportunities; practical experi- intent of providing continuity of care to patients
ence during medical school; role models or mentors who are members. This healthcare delivery struc-
in the specialty; length of training required; life- ture is also designed to reduce scheduling and
style and work hours, especially during residency; administrative by using a team approach to
likelihood of obtaining a residency position; con- coordinating patient care. The model does, by
cern about loans and debt; call schedules; post- definition, however, decrease the amount of
training lifestyle, work hours, and financial independence solo practitioners experience by
rewards; intellectual challenges; interactions with increasingly centralizing power within the orga-
patients; potential patient demographics; and nizational hierarchy.
Such organizational structures have had a sig- schedules and the like. But physicians have also cited
nificant impact on physician working conditions. decreased control over medical decisions, decreased
Where excessive workloads, professional- and control over referral processes, the proliferation of
personal-time demands, and interpersonal com- malpractice lawsuits, ethical concerns due to
munication hassles have long contributed to physi- managed-care arrangements, federal Health
cian dissatisfaction at work, there are strong Insurance Portability and Accountability Act
indications that HMO and other managed-care (HIPAA) compliance requirements, and reduced
physicians base work satisfaction on a combina- income as reasons for diminished satisfaction at
tion of professional expectations and characteris- work. Where these effects of managed care may be
tics of the workplace as well as whether they are interpreted or overinterpreted by any human being
working for one managed-care organization or as an affront to personal self-image, they may have
more. As with physicians in other practice types, a consequent effect on how physicians view their
these physicians’ satisfaction is based on the extent work environments and how they perform in them.
of autonomy, administrative issues, resources,
work-related relationships, and the amount of
Time and Money
time allotted to visit with patients. In keeping with
Max Weber’s early-20th-century analyses of Irrespective of the type of organization or envi-
bureaucratic organizations as fundamentally ronment in which a physician practices medicine,
impersonal and constraining of individuals’ behav- the amount of time a physician spends at work
iors, managed-care physicians increasingly report may exceed an average of 60 hours per week, espe-
less job satisfaction as compared with nonman- cially during medical residency. Physicians who are
aged-care physicians. The enjoyment that they on call also have to contend with patients’ con-
individually sense in their daily work or career, cerns over the telephone and have to prepare to
however, is contingent on whether the physicians make emergency hospital visits; the emergence of
can accept the differences between work in the e-mail as a physician–patient communication chan-
context of managed care and prior to its arrival. nel has also had an impact on physicians’ time
considerations. These considerations have emerged
on top of the expansion of managed care, which
Adaptation to the Work Milieu
has arguably had an adverse effect on the quantity
Federal and state governments have taken inter- and quality of time physicians can dedicate to
est in regulating the number of medical resident patient care.
work hours, in response to growing public con- The requisite time commitments provide chal-
cerns over medical errors and the national Institute lenges in scheduling individually desired work
of Medicine’s (IOM) seminal report, To Err Is shifts. In instances where physicians negotiate new
Human. Although there is no conclusive evidence and more flexible schedules, coworker resentment
of a significant relationship between medical errors can emerge. Thus, physicians and the organiza-
and the number of hours worked, the reduction in tions for which they work are discovering that they
medical resident work hours has affected educa- have to amicably determine some form of compen-
tional, practical, and patient care experiences. sation when desired schedules cannot be realized.
There is also a focus in government institutions One potential trade-off to the amount of time
and public and private organizations on modern- spent in professional activities is the income gener-
izing information technology systems used by ated by most physicians. The latest reports on
healthcare providers in ways that align with the physician distribution from the American Medical
implementation of service-outcome and quality Association (AMA) and the U.S. Department of
improvement programs. Labor (DOL) indicate that almost 900,000 active
To further understand physicians’ motivation to physicians in the United States practice profes-
act on issues in the work environment, there must be sional activities in hospital-based, office-based,
an account of concerns over capitation-based income, and academic medical settings. The number of
negotiability of other work incentives, and whether physicians spread across these diverse practice set-
physicians have autonomy when arranging work tings, combined with an increasingly consumerist
940 Physician Workforce Issues
healthcare system, are a cursory signal of the mar- has been contrarily refuted by scores of plaintiff
ket forces that facilitate physician income streams. attorneys and like-minded advocacy groups.
With incomes generally holding across the six- Increases in malpractice insurance premiums have
figure range, medicine remains one of the highest nevertheless reached a point where many physi-
paid professions in the nation. cians have considered practicing without malprac-
Yet physicians report that their service commit- tice insurance coverage, while others have difficulty
ment is disproportionate to the financial reward. obtaining insurance—in some cases despite having
Physicians are seeing more patients, or have simply never faced a claim. Coverage from many insurers
had to increase the price of their services, in an has now become cost-prohibitive. The existing
effort to keep pace with rising operational costs and malpractice conundrum has thrown professional
the rate of inflation. This development runs in line practices into a state of confusion.
with a public perception that physicians seek a “tar- Physicians generally function on the basis that a
get income” that is accomplished through their majority of the litigious claims are erroneous alle-
increasing the volume of services. Plus, the relative gations made by patients whose medical cases
disparity in income between specialists and primary- resulted in negative outcomes. To whatever extent
care physicians and the variability of income across this belief is true, malpractice claims seem to be in
the profession, combined with the implications of large part contingent on the physician–patient
managed care, government reform, and the econ- relationship and how actively engaged the patient
omy in general, have conceivably led many physi- judges the physician to be when communicating
cians to seek alternative sources of remuneration. during office, clinic, or hospital visits. Although
effective communication between the physician
and the patient is an obvious means toward reduc-
Malpractice and Tort Reform
ing liability, the sheer number, financial and repu-
Among the healthcare issues that further affect tation costs, and jury awards associated with
physician income is the current condition of medi- malpractice suits brought against physicians have
cal malpractice litigation in the nation. The origi- also significantly contributed to a shift in the way
nal intent of medical malpractice litigation, which physicians practice medicine.
first materialized in the nation during the 19th In an attempt to avoid litigation, some physi-
century, was to safeguard patients against sham or cians are said to be practicing defensive medicine,
hazardous medical practices and to equitably com- whereby patient care decisions are predicated
pensate patients injured by such practices. Over more on reducing the physician’s liability risk than
time, and despite the medical profession having by what treatments may be considered accurately
become more regulated, the per-person cost of in the best interest of the patient. For example,
malpractice litigation in the United States is pro- physicians may feel compelled to order excessive
portionately more than that in any other country tests, treatments, and services and may even avoid
in the world. The considerable number of plaintiffs certain high-risk procedures and entire specializa-
in medical malpractice cases who have received tions altogether for fear of being sued for mal-
multimillion-dollar monetary awards has led to a practice. As physicians increasingly diminish the
widespread assertion that there is a national mal- types of procedures they are willing to perform
practice crisis. This crisis has in turn caused a great and find their incomes being reduced by rising
number of professionals in the healthcare field to malpractice fees, a palpable cascade effect affects
share the belief that malpractice litigation has sur- the delivery of care to patients. The decrease in
passed reasonable levels and that some correction income and decision-making opportunities may
is overdue. The concomitant fallout has pro- further help explain why physicians have been
foundly affected the medical profession. seeking out and clinging onto the vestiges of their
Physicians have recently experienced enormous autonomy and self-esteem.
changes with regard to professional liability insur- Also striking is the finding that younger physi-
ance. These circumstances have been attributed to cians are likely to seek a job as opposed to want-
a systemwide failure to adopt tort reform that ing to establish a practice. This trend may be due
includes caps on noneconomic damages. This view to a movement away from the less-satisfying,
productivity-based compensation of private prac- to voice their opinions and make high-level deci-
tice, which has long been a risky but lucrative sions. And practicing medicine has provided a
system for medical professionals. Even though respectable level of affluence for most of them
production-based compensation leads to increased because of less-stringent economic constraints on
productivity among physicians, physicians have medicine during the early and middle years of their
reported being satisfied when an emphasis is careers. But younger physicians have entered the
placed on quality of care and dissatisfied when field during a time when medical-practice manage-
productivity is emphasized in their work. This ment has been increasingly enveloped by the
finding echoes earlier conclusions that time pres- bureaucratic systems of managed care.
sure may lead to suboptimal work performance Another change is that women now account for
and overall satisfaction levels, which lead to about half of all medical school applicants; 35
potential compromises in patient care. In today’s years ago, they comprised less than 1/10 of the
healthcare system, the amount of time a physician applicant pool. While this shift may well alter the
spends with a patient or on a given task is regu- physical image of the physician in the popular
lated to an extent by the size and structure of the imagination, the increasing number of women in
organization in which the physician works. the workforce has already changed things. Chief
among the changes has been the growth in the
number of women who join the physician work-
Demographic Changes
force and who also continue to involve themselves
A number of economic factors have clearly influ- in traditional roles at home, which has been the
enced change throughout healthcare. Yet the cen- motive behind flexible work schedules. Female
tral management concern in healthcare lies in two physicians born between the early 1960s and as
significant social transformations that have late as 1980 were among the first physicians to
occurred with a minimum of attention: The older demand flexibility and variety in their schedules.
generation of physicians assert different expecta- When these requests were accommodated by
tions about their work as compared with the administrators, male physicians of the same gen-
younger generation; and the physician workforce eration requested similar elasticity in their sched-
in the United States, which before the last quarter ules, and then so, too, did more senior physicians.
or third of the 20th century had been male domi- Information about physicians’ attitudes toward
nated, is now becoming female dominated. work and home life is becoming more focused on
Many of the age-based changes may be seen in illuminating physician-specific healthcare-related
the contrasts between baby boomers, born between trends and could be integrated into plans to
1946 and 1964, and Generation X-ers, born improve individual and organizational perfor-
between 1965 and 1981. Within the medical pro- mance abilities and functions.
fession, baby boomers and the first half of
Generation X comprise upward of 60% of the
Physician Supply
physician workforce, while the latter half of
Generation X accounts for slightly less than 20% There are now indications that the United States
of the total. Physicians of the baby boomer genera- will face a shortage of physicians in the coming
tion experienced enormous practice management decades. Reasons for this supply shortage include
changes throughout their careers. They most likely the following: (a) the overall growth of the nation’s
began and spent most of their careers in private population, (b) an increased demand for physi-
practice as solo practitioners or in small groups but cians’ services due to economic expansion, (c) an
are now likely to be employed by or associated increased demand for more medical care by aging
with a large healthcare organization. Yet they may baby boomers, (d) an increase in performance of
assert a sense of confidence about their work and physicians’ services by nonphysician clinicians who
are often accused of caring more about their work will need to be supervised, (e) an increase in mal-
than their lives outside work. They convey satisfac- practice insurance premiums and concomitant legal
tion in their jobs because they are often at a point issues, (f) insurance carriers that dictate practice
in their careers where they are given opportunities methods and income, (g) salaries that lag behind
942 Preferred Provider Organizations (PPOs)
the rising rate of inflation, (h) the retirement of Cooper, Richard A., Thomas E. Getzen, Heather J.
practicing physicians, (i) a decline in physician McKee, et al. “Economic and Demographic Trends
work effort, (j) the suddenly low number of appli- Signal an Impending Physician Shortage,” Health
cations to medical schools, and (k) geographically Affairs 21(1): 140–54, January–February 2002.
dependent lifestyle effects. As the composition of Linzer, Mark, Thomas R. Konrad, Jeffrey Douglas, et al.
the physician workforce continues to change, and “Managed Care, Time Pressure, and Physician Job
with it ideas about the length and meaning of Satisfaction: Results From the Physician Worklife
work, questions abound as to how positions will be Study,” Journal of General Internal Medicine 15(7):
441–50, July 2000.
filled throughout the workplace.
Murray, Alison, Jana E. Montgomery, Hong Chang,
et al. “Doctor Discontent: A Comparison of Physician
Future Implications Satisfaction in Different Delivery System Settings,
1986 and 1997,” Journal of General Internal
Contemporary healthcare facility and medical Medicine 16(7): 452–59, July 2001.
school administrators must contend with chal- Williams, Eric S., Mark Linzer, Donald E. Pathman,
lenges related to physician recruitment and reten- et al. “What Do Physicians Want in Their Ideal Job?”
tion, especially as the U.S. population consumes Journal of Medical Practice Management 18(4):
more healthcare as it moves through midlife and 179–83, January–February 2003.
into old age. But complex social, economic, polit-
ical, organizational, and individual factors have
influenced the creation of new institutions through- Web Sites
out healthcare. To understand and capably man-
age the new aims, physicians and their employers, American Board of Medical Specialties (ABMS):
patients and their advocates, politicians, and the http://www.abms.org
press will have to examine all facets of the physi- American Medical Association (AMA):
cian at work. It is physicians who on a daily basis http://www.ama-assn.org
participate in healthcare more than any other Association of American Medical Colleges (AAMC):
stakeholder, which means that they are a valid http://www.aamc.org
Council on Graduate Medical Education (COGME):
point from which to assess the thoughts and
http://www.cogme.gov
behaviors of the people, organizations, and sys-
tems that have an impact on healthcare.
Lee H. Igel
See also American Medical Association (AMA); Preferred Provider

Association of American Medical Colleges (AAMC); Organizations (PPOs)
General Practice; Malpractice; Medical Group
Practice; Physicians; Primary-Care Physicians
A preferred provider organization (PPO) is a
healthcare delivery system where providers con-
Further Readings tract with the PPO at various reimbursement lev-
els in return for patient steerage into their practices
American Medical Association. Physician Characteristics and/or timely payment. PPOs differ from other
and Distribution in the U.S. Chicago: American healthcare delivery systems in the way they are
Medical Association, 2008. financed as well as by providing more choice, ben-
Arnold, Mark W., Anna F. Patterson, and A. S. Li Tang.
efit flexibility, and enrollee access to providers and
“Has Implementation of the 80-Hour Work Week
medical services both in and out of network.
Made a Career in Surgery More Appealing to Medical
Students?” American Journal of Surgery 189(2):
129–33, February 2005. History
Bureau of Labor Statistics. Occupational Outlook
Handbook, 2008–09 Edition. Washington, DC: While PPOs have been in existence in some form
Bureau of Labor Statistics, 2008. or another for decades, the development of modern
Preferred Provider Organizations (PPOs) 943
PPOs was the result of key legislative actions at the 1990s—encouraged the expansion of a limited
the state and national level. In the 1970s and number of national PPOs. The growth in PPO plan
1980s, many states passed enabling legislation to enrollment at the expense of traditional indemnity
specifically allow for the development of PPOs. insurance and point of service plans is shown in
In 1974, the U.S. Congress enacted the Employee Figure 1.
Retirement Income Security Act (ERISA). A very Today PPOs are tremendously popular. Over
small portion of this law gave Taft-Harley Funds the past few years, there has been a consolidation
and other organizations the right to self-insure of the PPOs marketplace resulting in fewer regional
their healthcare benefits. Under the new law, PPOs and larger national plans as regional plans
organizations that self-insured would not be sub- merge or are bought by larger national plans.
ject to various state coverage mandates or to In 2007, more than 158 million individuals
state premium taxes; instead, they were now free were enrolled in a PPO program, which represents
to develop employee healthcare benefit pro- 64% of all Americans with healthcare coverage.
grams. Recognizing the unique opportunity, One reason for this strong market share is that
third-party administrators began providing some PPOs have delivered what the public has called for:
or all of the services required by the self-insuring choice, flexibility, and a balance between delivery
companies. of appropriate care and cost control.
As a rule, however, these third-party adminis-
trators did not develop their own delivery net-
Characteristics and Types of PPOs
works and instead looked to another fledgling
group of companies—preferred provider organiza- There are two basic types of PPOs: a nonrisk PPO
tions—to credential and supply networks of physi- and a risk PPO. A nonrisk PPO’s primary focus is
cians and healthcare institutions. Insured products to contract with providers in a geographical area
grew and employers and other purchasers came to to form an interconnected network of providers
see PPOs as the middle ground between health and services. The nonrisk PPO network leases
maintenance organizations (HMOs) (traditionally and/or “rents” its network for a fee to insurance
lower cost but more restrictive) and indemnity companies, self-insured employers, union trusts,
insurance plans (permissive but more expensive). third-party administrators, business coalitions,
This fueled the development of local PPO organi- and associations. In contrast, a risk PPO assumes
zations in the 1970s and 1980s and—beginning in the financial risk for an enrollee’s healthcare costs.
1993 48% 27% 7% 19%
1995 29% 29% 14% 27%
1997 15% 35% 20% 30%
1999 11% 43% 16% 30%
2001 7% 46% 14% 33%
2003 5% 54% 14% 27%
2005 3% 61% 10% 25% 1%
2006 3% 81% 9% 24% 3%
Traditional Indemnity PPO POS HMO CCHP
Figure 1 A Comparison of Medical Plan Enrollment, 1993 to 2006

Source: Association of Preferred Provider Organizations (2007).
944 Prescription and Generic Drug Use
Traditionally, insurance companies offer a risk See also American Association of Preferred Provider
PPO that includes a benefit plan and network ser- Organizations (AAPPO); Employee Retirement Income
vices either provided by the risk PPO or leased Security Act (ERISA); Healthcare Financial
from a nonrisk PPO. Management; Health Insurance; Hospitals; Managed
Care; Physicians
Insurance companies own most PPOs. They are
also owned by hospitals, hospital consortiums, indi-
vidual entrepreneurs, and private equity groups.
Further Readings
Enrollees in PPOs typically have benefit plans
that provide both in-network and out-of-network Association of Preferred Provider Organizations. PPO
coverage. Enrollees who seek care from providers Outlook: 2007 Market and Industry Trend Report.
within the PPO network receive in-network cover- Louisville, KY: Association of Preferred Provider
age, generally at a greater benefit level or lower Organizations, 2007.
coinsurance or copayment. Enrollees may still seek Greenrose, Karen, J. Stephen Ashley, American
care outside the PPO network, but the benefit level Association of Preferred Provider Organizations,
is usually lower, and the enrollee may incur addi- American Accreditation HealthCare Commission/
tional costs due to balance billing from the nonnet- URAC. Rise to Prominence: The PPO Story. Arlington,
work provider. Enrollees can choose, each time they VA: American Association of Preferred Provider
seek care, to use an in-network or out-of-network Organizations; Washington, DC: URAC, 2000.
provider. PPOs benefit enrollees by supporting their Joint Commission. Accreditation Manual for Preferred
Provider Organizations. 3d ed. Oakbrook Terrace, IL:
need to take a more active role in their healthcare.
Joint Commission, 2004.
PPOs also benefit providers. The financial con-
National Committee for Quality Assurance. Standards
siderations of the PPO healthcare delivery model
and Guidelines for the Accreditation of PPO Plans.
do not override patient care decisions but rather
Washington, DC: National Committee for Quality
work in conjunction with PPO providers in deliv- Assurance, 2004.
ering patient care. U.S. Congressional Budget Office. CBO’s Analysis of
Claims from providers are usually handled in Regional Preferred Provider Organizations Under the
several ways. The PPO can give access to its fee Medicare Modernization Act. Washington, DC: U.S.
schedule to the claims-paying entity. This is often Congressional Budget Office, 2004.
done by providing a computerized record of the
payment amount. If the PPO does not share its fee
schedule with the payer, the PPO usually reprices Web Sites
the claims and then sends them to the payer, which
American Association of Preferred Provider
pays the bill. Claims from hospitals and profes-
Organizations (AAPPO): http://www.aappo.org
sional providers are sent to the PPO. The PPO
adds information to each claim about the fees that
http://www.ahip.org
should be used to process the claim. The fee infor-
mation includes the PPO’s negotiated and contrac- National Committee on Quality Assurance (NCQA):
tual rate. The claims are then sent to the paying http://www.ncqa.org
entity (HMO, insurance company, third-party
administrator) for processing. Of course, some
PPOs pay claims for all providers as well.
In addition to comprehensive network PPOs,
some PPOs are dedicated to specialty networks.
Prescription and
Specialty network PPOs facilitate and support the Generic Drug Use
delivery of specialized healthcare services, such as
dental, vision, chiropractic, radiology, behavioral The pharmaceutical industry in the United States
health, and other areas. Often, these types of provid- represents a multibillion dollar a year enterprise
ers have unique reimbursement and benefit issues. that has helped fuel increasing healthcare costs. In
2006, America’s spending alone on drugs increased
Lynn Huls to over $250 billion, accounting for more than
Prescription and Generic Drug Use 945
41% of worldwide expenditures. New foreign This entry presents an overview of the 12-step
markets, primarily in Asia, have seen more drastic FDA approval process and discusses orphan and
annual expenditure increases than the United generic drugs. Then, this entry discusses the fac-
States, however. Reasons cited for the increase in tors associated with those who use prescription
drug expenditures include the introduction of drugs. Next, the prescription drugs’ cost dilemma
new, more expensive drugs to the marketplace, a is addressed; and last, future implications are
population that is aging and requiring more phar- considered.
maceuticals for disease management, increasing
prices on the manufacture of existing drugs, and
The FDA Approval Process
the use of drugs as a substitute for other forms of
healthcare services. Once a pharmaceutical company has developed a
Historically, the pharmaceutical industry has new drug, the company must apply to the FDA for
grown with the development of new drugs, new approval to market and sell the drug. The FDA
drug therapies, and the expansion of medical process involves 12 steps, beginning with animal
knowledge and practice. This expansion has testing. This is designed to increase the size of
required an increased focus on new drug efficacy clinical studies until the drug has been proven to
and safety. Tighter government scrutiny and con- have the desired effect while being safe.
trol have been realized through the Prescription Animal testing, referred to as preclinical testing,
Drug Marketing Act of 1987 and the U.S. Federal involves establishing the efficacy of the drug before
Drug Administration (FDA) approval process. it is given to humans. Many new drugs are stopped
Many, especially within the pharmaceutical indus- at Stage 1 because the FDA has not deemed the
try, view the FDA’s approval process as prohibi- drugs reasonably safe for human usage because of
tive; others view it as necessary to ensure public their side effects or their lack of desired effect on
safety. The length of the approval process delays a the animals tested.
drug’s entry into the marketplace and quite possi- If the drug shows promise and is considered safe
bly drives the developmental costs upward. It is for further testing, a protocol for human testing is
estimated that the total development costs for a developed and must be approved by a local institu-
new drug in the United States, including losses to tional review board (IRB) and the FDA in Stage 2.
nonapproval of previous drugs, is around $1 bil- The IRB is composed of scientists and researchers
lion each year. The accepted estimate is around who must determine whether human subjects are
$860 million per new medication developed, adequately protected from possible negative out-
although some recent estimates put development comes. It also determines whether the study is sci-
costs at somewhere between $500 million and $2 entifically acceptable. This stage represents the
billion per new drug. Companies try to recoup company’s proposal for clinical trials, involving
these costs as quickly as possible, which leads to human subjects, of the new drug.
higher prices when the drugs arrive on the market- Once the protocol is established and approved
place for use by the public. by the IRB, the company may move on to Stage 3
Although pharmaceutical companies typically of the process. Stage 3 includes what is generally
receive a 20-year patent on the new drugs they referred to as Phase 1 clinical trials. Phase 1 studies
develop, the FDA approval process may take as involve testing the drug on a small group of human
long as 12 years in and of itself. This lengthy subjects. The size of the group is generally between
period considerably reduces the effective income- 20 and 80 healthy volunteers. The observance and
producing potential of any new drug produced. notation of negative or frequent side effects of the
Because of the shortened brand name shelf life for drug is particularly important during Phase 1. If
a drug, the companies must make profits within a significant side effects are not detected, Phase 2
relatively short amount of time. When the patent clinical trials may begin. Occasionally, alternative
expires, other companies may produce the drug in uses for a drug may be uncovered at this stage.
its generic form. Generic drugs represent a cheaper That is, it is possible that a side effect may have a
alternative to the branded versions of the drug significant impact on another medical condition.
when released by the companies. An example of such unintended uses of a drug is
the case of AZT. AZT was originally developed as In Stage 10 of the FDA approval process, the
an anticancer drug in the 1960s, but its trial results focus is on the review of the proposed labeling of
were disappointing. Twenty years later, AZT was the drug. The FDA ensures that the patient instruc-
discovered to be a viable treatment for HIV/AIDS. tions are clear and understandable. Its review team
Phase 2 studies, Stage 4 in the FDA approval also visits the pharmaceutical company’s produc-
process, increase the size of the subject panels from tion facilities and evaluates its processes to ensure
several dozen to a few hundred participants. The quality control in Stage 11.
focus of Phase 2 clinical trials shifts from the safety Finally, in Stage 12 of the process, the FDA
focus of Phase 1 trials to a focus on effectiveness. reviews all submitted evidence and documentation.
Safety is continually monitored, though. Rather The agency arrives at a final decision of “approv-
than testing on healthy individuals, Phase 2 trials able” or “not approvable.” Assuming that the data
use volunteers with the condition that the drug indicate an acceptable risk and demonstrable ben-
attempts to alleviate. These studies often involve the efit, the drug is ready for manufacture and sale.
use of cohorts comparing the effectiveness of the The length of time between drug development
drug to a placebo. A cohort study represents a type and sale is obviously long. For drugs that can
of epidemiological approach to investigating the potentially save patients with immediate and life-
incidence and prevalence of disease across a fixed threatening conditions where no drug currently
population group over time. Investigators compare exists, the FDA may allow the company to engage
outcomes between a group of individuals who have in an accelerated approval process. This more
a risk factor believed to be associated with the out- expedient process involves using “surrogate end-
come to a group without that factor. Cohort studies points” or alternative data to establish the drug’s
can be conducted prospectively or retrospectively, efficacy. In some cases, the larger Phase 3 clinical
but the concept of control is extremely important to trials may be waived based on the promise of data
determining a drug’s efficacy. from the smaller Phase 2 trials. Accelerated
Should the evidence from the Phase 2 clinical approval, however, is relatively rare. It tends to be
trials point to the drug’s safety and effectiveness, used on drugs developed to treat diseases with very
the pharmaceutical company moves its application poor projected outcomes where other treatments
to Stage 5 of the approval process. In Stage 5, have been shown to be ineffective. Most recently,
Phase 3 clinical trials include a larger number of drugs used to treat HIV/AIDS have been approved
participants, usually up to a few thousand sub- through an accelerated process because the benefits
jects, and they continue to scrutinize the safety and of the drug to patients are deemed to outweigh the
effectiveness of the drug. On successful completion risks when the disease is terminal.
of these drug trials, the process moves to Stage 6. The entire FDA drug approval process is
Stage 6 is sometimes referred to as the pre–New designed to ensure the public’s safety and its confi-
Drug Application, or pre-NDA, stage. At this dence that these drugs achieve the results that the
point in the approval process, drug company rep- pharmaceutical companies maintain. It is long,
resentatives meet with FDA representatives to arduous, and expensive to the developers of new
review the proposed product. If it is determined pharmaceuticals. Even then, however, it is still pos-
safe and effective, the pharmaceutical company sible that long-term negative effects may surface at
moves to the next stage of the process. a later date, necessitating a change in the FDA’s
Stage 7 involves the submission of the New initial ruling. Therefore, even after a drug has
Drug Application (NDA) to the FDA. The NDA obtained FDA approval, it is continuously moni-
represents a formal request from the pharmaceuti- tored for safety. This postapproval safety monitor-
cal company for the FDA’s approval of the drug. ing may cost the pharmaceutical industry an
The FDA has 60 days to decide whether to consider additional $50 million annually.
approval. The agency’s decision itself is considered
Stage 8 of the overall process. A positive decision
Orphan Drugs
leads the FDA to file the application as Stage 9. It
also assigns a team to evaluate the evidence col- Although the FDA approval process is clearly
lected from the three phases of the clinical trials. intended to protect the public’s interest and
Prescription and Generic Drug Use 947
guarantee their safety, it can become cost- Prescription Drugs Users

prohibitive for pharmaceutical companies to use
As previously mentioned, age is an important fac-
their resources to develop drugs for conditions
tor in who uses prescription drugs. The National
that affect a relatively small number of patients.
Center for Health Statistics (NCHS) reports that
Relatively rare diseases are sometimes referred to
nearly 85% of all Americans over the age of 65
as orphan diseases. Similarly, drugs developed
had at least one prescription in the previous
to treat such diseases are called orphan drugs.
month and nearly 52% had three or more pre-
Orphan drugs have received special federal regu-
scriptions. The percentage of those using prescrip-
lations that allow for a 7-year monopoly on the
tion drugs increases steadily with age.
production of the drugs as well as tax reduc-
Gender also plays a significant role in prescrip-
tions. The orphan drug rules are in effect for
tion drug use. The data reported by NCHS indi-
diseases that affect fewer than 200,000 people in
cate that a higher percentage of women use
the United States.
prescription drugs than do men across every age
group except those under 18. Women are more
Generic Drugs likely than men to use prescription drugs across
racial/ethnic groups as well.
A generic drug is a prescription drug that is pro-
Whites, for both men and women, are the most
duced and sold without a brand name. Once the
likely to use prescription drugs, followed by
patent for a drug expires, companies may make
African Americans and Hispanics, respectively.
generic versions for sale to the public. Generic
Because access to prescription drugs is restricted,
drugs are generally less expensive than their
disparities in their use are similar to disparities in
branded counterparts, primarily because they are
healthcare resulting from different levels of access
not advertised and because of increased competi-
to physician services and medical care.
tion among pharmaceutical companies. Many
health insurance companies encourage their ben-
eficiaries to use generic equivalents whenever pos-
Prescription Drug Cost Dilemma
sible because they provide significant cost savings.
The Congressional Budget Office (CBO) estimates The widespread use of generic drugs represents one
that generic drugs save consumers between $8 and way in which consumer costs can be reduced.
$10 billion annually. Generic drugs are lower in price because they do
If a pharmaceutical company wishes to sell a not incur a number of the high costs associated
drug as a generic, it must file an abbreviated new with brand name drugs. First, there are no new
drug application with the FDA prior to introduc- research and development costs. Once a patent
ing it in the marketplace. The company must dem- expires on a brand name drug, pharmaceutical
onstrate that the generic version of the drug is companies can make generic equivalents through a
identical to the brand version in order to obtain reverse engineering process. Second, they do not
FDA approval to sell the drug. Not only must the have marketing costs. Generic equivalents tend to
generic version be chemically identical, but the benefit from previously marketed brand drugs. In
same strict manufacturing procedures previously addition, companies tend not to provide free sam-
adhered to for the brand version must also be used ples of generic drugs to physicians. Third, generic
to make the generic version of the drug. drugs do not have the costs associated with the
Some health insurance companies require the 12-stage FDA approval process; rather, they only
substitution of a generic equivalent to be covered. have to demonstrate the biochemical equivalence
Patients who request not to receive a generic drug of the brand version. Finally, because multiple drug
may have to pay the additional cost out of pocket. companies can sell generic equivalents after the
Not all drugs have generic counterparts, however. patent expires, there is greater competition, which
Presently, only around 50% of brand name drugs results in lower costs to the consumer.
have generic equivalents. Patients desiring a generic The elderly have been especially affected by spi-
equivalent may ask their physician if an equivalent raling drug costs because they often live on a
exists and whether a substitution is appropriate. lower, fixed income than younger cohorts, and
older adults use prescription drugs more fre- See also Cost of Healthcare; Inflation in Healthcare;
quently. In 2003, the federal government enacted Medicare Part D; Pharmaceutical Industry;
the Medicare Prescription Drug, Improvement, Pharmacoeconomics; Pharmacy; Randomized
and Modernization Act, which is generally referred Controlled Trials (RCT); U.S. Food and Drug
Administration (FDA)
to as Medicare Part D, to assist the elderly in
accessing necessary prescription drugs in a more
cost-effective manner. Medicare Part D was imple-
Further Readings
mented in 2006 and allowed eligible elderly and
disabled Medicare patients to select enrollment Adams, Christopher P., and Van V. Brantner. “Estimating
into one of a set of government-approved private the Cost of New Drug Development: Is It Really $802
prescription plans. Million?” Health Affairs 25(2): 420–28, March–April
Different approved prescription drug plans tend 2006.
to cover different drugs. An early complaint from Gooi, Malcolm, and Chaim M. Bell. “Differences in
Medicare recipients about the selection process Generic Drug Prices Between the U.S. and Canada,”
was that it was too complicated. The enrollee is Applied Health Economics and Health Policy 6(1):
expected to make a plan choice by matching a list 19–26, 2008.
of the prescriptions they receive against the lists of Grabowski, Henry G., and Y. Richard Wang. “The
approved drugs and their prices to arrive at the Quantity and Quality of Worldwide New Drug
most cost-effective choice given their personal situ- Introductions, 1982–2003,” Health Affairs 25(2):
452–60, March–April 2006.
ation. After initial problems, however, the process
Griffith, H. Winter, and Stephen Moore. Complete
has gone considerably more smoothly. Revenues
Guide to Prescription and Nonprescription Drugs.
from Medicare Part D premiums are expected to
New York: Perigee Group, 2007.
be nearly $750 million by the year 2015.
Sloan, Frank A., and Chee-Ruey Hsieh, eds.
Pharmaceutical Innovation: Incentives, Competition,
and Cost-Benefit Analysis in International
Future Implications
Perspective. New York: Cambridge University Press,
The use, and the expense associated with that use, 2007.
of prescription drugs has spiraled upward in the Stagnitti, Marie N. Trends in Brand Name and Generic
past and is likely to increase even more in the Prescribed Medicine Utilization and Expenditures,
future. As this happens, efforts to make drugs 1999 and 2003. Statistical Brief No. 144. Rockville,
more accessible will escalate. In some cases, this MD: Agency for Healthcare Research and Quality,
may mean that some prescription drugs may be October 2005.
made available over the counter if they have dem- Voet, Martin A. The Generic Challenge: Understanding
onstrated very long-term efficacy and safety. This Patents, FDA, and Pharmaceutical Life-Cycle
practice allows greater exposure and availability Management. 2d ed. Boca Raton, FL: Brown Walker
Press, 2008.
of the drug to a wider public consumer audience.
It also typically reduces the unit cost because of
higher expected sales.
Web Sites
The percentage of the population, adjusted for
age, that has received at least one prescription has AARP: http://www.aarp.org
increased from 38% in the early 1990s to over Agency for Healthcare Research and Quality (AHRQ):
45% in the early 21st century. For the elderly, the http://www.ahrq.gov
increase is even more dramatic. Pharmaceutical Henry J. Kaiser Family Foundation (KFF):
companies strive to bring more and better drugs to http://www.kff.org
the marketplace as part of their financial strategic National Center for Health Statistics (NCHS):
plans. The net effect on the consumer and the phy- http://www.cdc.gov/nchs
sician is a wider selection of drugs that can be used Pharmaceutical Research and Manufacturers of America
to treat a wider array of conditions. (PhRMA): http://www.phrma.org
U.S. Food and Drug Administration (FDA):
Ralph Bell http://www.fda.gov
Preventive Care 949
quality review groups. Its work has established

Preventive Care the importance of including prevention in primary
care and prompted insurance coverage for effec-
Preventive care is a set of measures taken before tive preventive services.
symptoms begin to prevent illness or injury. While
the number of preventive services has expanded in
recent years, particularly in the areas of cancer
Types of Prevention
and ischemic heart disease, preventive care is still Preventive care can be categorized into three levels:
best exemplified by routine physical examinations (1) primary, (2) secondary, and (3) tertiary preven-
and immunizations. The emphasis remains to pre- tion. Primary prevention services avert disease
vent disease before it occurs. Physicians, nurses, development and include population-based health
and public health officials perform preventive ser- promotion activities such as vaccination and safe
vices in various settings, including physicians’ water supplies. Secondary prevention services tar-
offices, clinics, health departments, and hospitals. get early detection of asymptomatic disease with
Public and private health insurance plans gener- the goal of preventing the progression of disease
ally pay for preventive services, and the literature (exemplified by the pap smear to detect precancer-
and expert consensus agree that healthcare sys- ous cervical changes). Secondary prevention ser-
tems focused on preventive care are more cost- vices may also include prophylaxis to reduce the
effective. A number of barriers to preventive care chance of disease recurrence (e.g., aspirin, blood
exist, and medicine, public health, and policymak- pressure control, and lipid-lowering medications
ers must work to eliminate them. for the secondary prevention of ischemic heart dis-
ease following an initial myocardial infarction, or
heart attack). Tertiary prevention services reduce
Background
the impact of already established disease. Preventive
While traditional preventive strategies of medicine care encompasses both therapeutic interventions,
and public health, such as routine physical exami- such as immunizations or antibody prophylaxis
nations and immunizations, have been around for and diagnostic examinations that screen for early
many years, the science of preventive care was asymptomatic disease. Screening examinations
first formalized with the establishment of the U.S. often detect early disease at a point where interven-
Preventive Services Task Force (USPSTF) in 1984. tions improve health outcomes.
The task force, first convened by the U.S. Public
Health Service (PHS) and since 1998 sponsored
by the Agency for Healthcare Research and
Preventive-Care Services
Quality (AHRQ), is the leading independent panel The historical foundation of preventive care rests
of private-sector experts in prevention and pri- on routine medical history taking, physical exam-
mary care. The task force ensures that the clinical ination, and healthy lifestyle counseling, but rapid
guidelines for providing preventive care are evi- advances in medical technology provide new
dence based. Specifically, the task force conducts devices and laboratory tests to screen for disease.
rigorous, impartial assessments of the scientific Amid the rapid growth of preventive-care services,
evidence for the effectiveness of clinical preventive clinicians must decipher the evidence of each ser-
services, including health screening, counseling, vice. The USPSTF offers the most rigorous evalu-
and preventive medications. Its recommendations ation of preventive services and provides guidance
are considered the gold standard for clinical pre- for clinicians to make evidence-based decisions.
ventive services. The task force is made up of pri- The task force’s Guide to Clinical Preventive
mary-care clinicians along with nurses. The task Services, 2007 provides recommendations on 58
force evaluates the benefits of individual services services made from 2001 to 2006. These services
based on age, gender, and risk factors for disease are grouped into clinical categories, including can-
and offers recommendations that have formed the cer; heart and vascular diseases; infectious dis-
basis of the clinical standards for many profes- eases; injury and violence; mental health conditions
sional societies, health organizations, and medical and substance abuse; metabolic, nutritional, and
950 Preventive Care
endocrine conditions; musculoskeletal disorders; lipid disorder screening (for men 35 years of age or
obstetric and gynecological conditions; pediatric older and women 45 years of age or older, and for
disorders; and vision and hearing disorders. younger adults with other risk factors for coronary
The task force recommends that clinicians dis- disease); obesity screening (including intensive
cuss the 58 preventive services, based on their counseling and behavioral interventions to promote
strength of evidence, with their eligible patients. sustained weight loss for obese adults); osteoporo-
The services include the following: abdominal aor- sis screening (for women 65 years of age and older
tic aneurysm screening (one-time screening by and women 60 years of age or older who are at
ultrasonography in men 65 to 75 years of age who increased risk for osteoporotic fractures); Rh(D)
have ever smoked); alcohol misuse and behavioral incompatibility screening (including blood typing
counseling interventions (for men, women, and and antibody testing at the first pregnancy-related
especially pregnant women); aspirin for the pri- visit); syphilis infection screening (for persons at
mary prevention of cardiovascular events (for men risk and all pregnant women); tobacco use and
and women at increased risk for coronary artery tobacco-caused disease counseling (including cessa-
disease); asymptomatic bacteriuria screening (for tion interventions for those who use tobacco); and
pregnant women); breast cancer (mammography visual impairment screening (for children younger
every 1–2 years for women 40 years of age and than 5 years of age to detect amblyopia, strabis-
older and discussion of chemoprevention in high- mus, and defects in visual acuity).
risk populations); breast and ovarian cancer It should be noted that the task force did not
susceptibility (genetic testing and counseling); pro- make recommendations for newborn screening,
motion of breastfeeding (structured education and which aims to identify treatable genetic, endocri-
behavior counseling for pregnant women); cervical nologic, metabolic, and hematologic diseases. It
cancer screening (for women over 18 who are sexu- also did not address immunizations.
ally active); chlamydial infection screening (for
women 25 and younger and other asymptomatic
Immunizations
women at risk of infection); colorectal cancer
screening (for men and women 50 years of age and Immunization is the process in which the body
older); dental caries prevention (oral fluoride sup- develops a defense against foreign agents (e.g.,
plementation to preschool children in areas where bacteria, viruses, and fungi). Exposure to these
water sources are deficient in fluoride); depression foreign molecules prompts the immune response
screening (for men and women within established to protect the body. A hallmark of the immune
clinical systems); diabetes mellitus (Type 2) screen- system is its memory. After first exposure to most
ing in adults (for men and women with hyperten- agents, the human body develops immunological
sion or hyperlipidemia); diet counseling (for adult memory, such that later exposure to the same
men and women with hyperlipidemia and other agent will result in quick, efficient, and successful
known risk factors for cardiovascular and diet- protection from the agent. A common example is
related chronic disease); gonorrhea screening (for the lifetime protection conferred to most people
all sexually active women at increased risk for after infection with Varicella (chickenpox). It is
infection, including pregnant women); prophylactic this feature of the immune system that provides
gonorrhea treatment (including ocular topical med- the basis for successful vaccines, which have
ications for all newborns); hepatitis B virus infec- become a cornerstone of public health and preven-
tion screening (for pregnant women at first prenatal tive care. Under typical conditions, immunizations
visit); high blood pressure screening (for adult men expose the body to nonvirulent doses of foreign
and women at all visits); HIV screening (for all agents, enabling it to develop immunological
adolescents and adults at risk for HIV infection and memory, which confers lifetime protection to the
all pregnant women); iron deficiency anemia pre- specific agent. Since the original work of Edward
vention (including routine iron supplementation for Jenner in the early 19th century, biomedical
asymptomatic children 6–12 months of age who research has developed many successful vaccines,
are at risk for iron deficiency); iron deficiency ane- of which many are given routinely to children and
mia screening (for asymptomatic pregnant women); are considered compulsory for attending school.
Preventive Care 951
Immunizations have led to worldwide eradication to healthcare and draws on several core competen-
of smallpox and the dramatic decline in mortality cies, including biostatistics and epidemiology, man-
and morbidity from diseases such as polio, mea- agement and administration, clinical preventive
sles, diphtheria, whooping cough, hepatitis B, and medicine, and occupational and environmental
bacterial meningitis. health. Board-certified physicians in preventive
The Advisory Committee on Immunization medicine can hold many positions within a variety
Practices (ACIP), a branch of the Centers for of healthcare settings, yet a common undercurrent
Disease Control and Prevention (CDC), provides of their work in all venues involves an approach to
evaluation of the literature and offers evidence- health that seeks systemic and population-based
based recommendations for immunization sched- interventions to improve the health of individuals.
ules for adults, infants, and toddlers, preteens and Preventive medicine residencies are offered at
adolescents, college students and young adults, more than 75 institutions in the nation and include
parents, pregnant women, healthcare workers, a general medicine internship, a year of classwork
people with specific diseases/conditions, racial and to attain a master of public health (MPH) degree,
ethnic populations, and travelers. The ACIP is and a year of practicum work, which is often tai-
composed of 15 experts who are selected by the lored to an individual’s career interests and aspira-
Secretary of the U.S. Department of Health and tions. The three specialty areas within preventive
Human Services (HHS). This committee provides medicine residencies are (1) public health/general
advice and guidance to the Secretary, the Assistant preventive medicine, (2) occupational medicine,
Secretary for Health, and the CDC on the control and (3) aerospace medicine.
of vaccine-preventable diseases. The committee Another venue for potential preventive care that
develops written recommendations for routine has received much attention is the school—more
administration of vaccines with the goal of reduc- specifically, the role of school nurses in obesity
ing the incidence of vaccine-preventable diseases in prevention. Schools present a critical setting for
the nation and ensuring safe use of vaccines. Under addressing the significant and increasing public
this guidance, immunizations remain one of the health problem of childhood obesity. School nurses
most valuable services of preventive care. are uniquely positioned to address obesity and
offer preventive services such as height, weight,
and body mass index (BMI) measurements along
Providers
with healthy diet and lifestyle counseling.
Primary-care physicians (i.e., internal medicine,
pediatrics, family medicine, and obstetrics and
Reimbursement
gynecology), nurses, physician assistants, and nurse
practitioners represent the majority of the clini- The USPSTF’s rigorous evaluation of the literature
cians who provide preventive-care services on a offers authority to clinicians’ utilization of many
daily basis. They provide these services in various preventive services. The consensus among clini-
settings, including physicians’ offices, outpatient cians, researchers, and public health officials
clinics, public health departments, and hospitals. regarding the value of routine preventive services,
Importantly, these professions have incorporated as recommended by the USPSTF and described
preventive care into their missions of providing above, has prompted their reimbursement by both
care and ensuring health among their patients. public and private health insurance plans.
While primary-care physicians provide the bulk The nation’s Medicare program, for example,
of preventive services, as recommended by the offers its beneficiaries many preventive services,
USPSTF, the profession of medicine further formal- including screening tests for heart disease; mam-
izes and emphasizes preventive care through desig- mograms, pap smears, and pelvic examinations;
nated training in the specialty of preventive medicine. bone mass measurements; colon cancer screen-
Preventive medicine is one of 24 medical specialties ing; prostrate screening; diabetes testing; diabetes
recognized by the American Board of Medical self-management training; foot care and supplies;
Specialties (ABMS). The specialty encompasses flu shots; pneumonia vaccine; hepatitis B vaccine;
multiple population-based and clinical approaches and glaucoma screening. Despite these services,
952 Preventive Care
however, Medicare falls short of providing com- Although much more research is needed, it
prehensive preventive care for its beneficiaries. appears that the potential impact of preventive care
One deficiency is that Medicare only covers one both economically and with respect to improved
routine preventive physical examination that health outcomes may be highly significant. For
must be received within 6 months of initial example, it has been estimated that about 800,000
enrollment in the program. deaths in the nation (40% of the total annual mor-
All the nation’s state Medicaid programs pro- tality) in 2000 were from preventable causes, such
vide inclusive preventive care for eligible recipi- as tobacco use, poor diet, physical inactivity, and
ents, who are mostly children and pregnant alcohol misuse. It also has been shown that preven-
women, groups that benefit significantly from tive measures, such as tobacco cessation programs
preventive services. The Early and Periodic and screening for colorectal cancer, can reduce
Screening, Diagnostic, and Treatment (EPSDT) mortality at low cost or even at cost savings. It
service is Medicaid’s comprehensive and preven- seems logical that if preventive services were more
tive child health program for individuals under 21 widely used they would lower mortality and likely
years of age. Defined by law in 1989, the EPSDT lower the total cost of healthcare.
includes periodic screening, vision, dental, and
hearing services. EPSDT guarantees that physi-
cians will provide initial and periodic evaluations Barriers
of children and assures that health problems are Individuals face a number of barriers to receiving
diagnosed and treated early, preventing complica- preventive care. One important barrier is lack of
tions, and improving health outcomes. health insurance coverage. It is clear that individu-
Although private health insurance coverage var- als without health insurance often delay needed
ies with respect to the preventive services covered, healthcare and many times entirely forgo preventive
most private insurance policies provide compre- care. However, even individuals with health insurance
hensive preventive care, especially for children and coverage face significant barriers to receiving preven-
pregnant women. tive care. Many characteristics of the physician–
patient interaction have been found to hinder the
Cost-Effectiveness delivery of preventive care, including the following:
the physician’s attitudes toward prevention, unfa-
Intuitively, it is easy to accept the notion that pre- miliarity with the USPSTF’s recommendations,
vention is more cost-effective than treatment. belief that some healthcare services do not fall
However, with respect to medicine and public under the physician’s scope of care; hurried office
health, this notion needs to be verified with evi- visits and lack of time to address prevention; lack of
dence. While an emerging body of literature sup- financial incentives to provide preventive care; and
ports specific preventive-care interventions, no patients’ attitude toward preventive care. Another
studies of the overall cost-effectiveness of preven- important dynamic of the physician–patient rela-
tive services have been conducted. tionship that affects preventive services is continu-
Recent literature tends to show that the cost- ity of care. Several studies confirm that identifying
effectiveness of specific preventive services depends a regular site of care is associated with increased
greatly on the particular intervention and its target access to preventive services, particularly for women
population. For instance, a recent systematic review and children. The medical literature supports the
of the cost-effectiveness of preventive interventions value of both site and provider continuity in pre-
for Type 2 diabetes mellitus suggests that primary ventive care. Despite the growing rhetoric among
prevention of that disease is highly cost-effective. policymakers and politicians about the importance
Other interventions, such as strict blood pressure of preventive care, the day-to-day infrastructure of
control, have also been shown to be overwhelm- healthcare delivery does not support this ideal. And
ingly cost-effective. However, other individual a concerted effort must be made to overcome the
interventions aimed at lowering weight, average many barriers to preventive care.
blood glucose, and cholesterol levels varied signifi-
cantly in their cost-effectiveness. Benedict S. Dillon
Primary Care 953
See also Child Care; Diabetes; Disease; Health; Obesity; sound and socially acceptable” way; it is “univer-
Primary Care; Public Health; Tobacco Use sally accessible” to all in the community who seek
it; it is affordable; and it is geared toward “self-
reliance and self-determination.” Primary care
Further Readings includes basic, routine, and preventive care that is
often provided in an office or clinic by a provider
Cohen, Joshua T., Peter J. Neumann, and Milton C.
who coordinates all aspects of a patient’s health-
Weinstein. “Does Preventive Care Save Money?
Health Economics and the Presidential Candidates,”
care needs. It is often the patient’s first contact
New England Journal of Medicine 358(7): 661–63, with the healthcare system for a given health
February 14, 2008. problem. Physicians, nurses, or other healthcare
Institute for Clinical Systems Improvement. Health Care professionals can provide primary care. Primary-
Guideline: Preventive Services for Adults. 13th ed. care physicians are generally considered to include
Bloomington, MN: Institute for Clinical Systems those trained in family medicine or general prac-
Improvement, 2007. tice, general pediatrics, and general internal medi-
Institute for Clinical Systems Improvement. Health Care cine. Sometimes physicians in obstetrics and
Guideline: Preventive Services for Children and gynecology are also considered primary-care phy-
Adolescents. 13th ed. Bloomington, MN: Institute for sicians. After briefly discussing problems with the
Clinical Systems Improvement, 2007. U.S. health services system, this entry summarizes
Ross, Joseph S., Susannah M. Bernheim, Elizabeth H. primary care’s role in health services and how
Bradley, et al. “Use of Preventive Care by the health policies can foster the provision of quality
Working Poor in the United States,” Preventive primary care to patients.
Medicine 44(3): 254–59, March 2007.
Starfield, Barbara. “U.S. Child Health: What’s Amiss,
and What Should Be Done About It?” Health Affairs Background
23(5): 165–70, September–October 2004. Every complex organization, whether biological
Woolf, Steven H., Steven Jonas, and Evonne Kaplan- or social, requires a framework to support and
Liss, eds. Health Promotion and Disease Prevention coordinate its different functions. Healthcare sys-
in Clinical Practice. 2d ed. Philadelphia: Wolters tems rank among the various social systems that
Kluwer/Lippincott Williams and Wilkins, 2008.
require a unified framework for appropriate func-
tioning. Among industrialized nations, the United
States is an anomaly because it lacks such a uni-
Web Sites
fied framework. A highly developed nation with
Advisory Committee on Immunization Practices (ACIP): well-developed and long-standing systems in many
http://www.cdc.gov/vaccines/recs/ACIP/default.htm areas, such as education, it lacks any semblance of
American College of Preventive Medicine (ACPM): a health services delivery system with a structural
http://www.acpm.org framework. Historically, health services developed
Institute for Clinical Systems Improvement (ICSI): without any planning or regulation of their sup-
http://www.icsi.org porting structures and rules of conduct.
Office of Disease Prevention and Health Promotion As a result, the United States stands alone
(ODPHP): http://odphp.osophs.dhhs.gov among industrialized nations in its inability to
U.S. Preventive Services Task Force (USPSTF): respond to new imperatives and new challenges to
http://www.ahrq.gov/clinic/uspstfix.htm public health. At the mercy of unaccountable mar-
ket forces, the healthcare system reacts unpredict-
ably, or sometimes not at all, to changing needs of
the population for services of various kinds.
Primary Care Market-oriented organizations, including private
universities and hospitals, medical-device manu-
Primary health care, as defined by the World facturers, pharmaceutical companies, professional
Health Organization (WHO), is “essential health- organizations, and disease-oriented consumer
care” that is delivered in a “practical, scientifically advocacy groups, can set agendas for the operation
954 Primary Care
of health services according to the likelihood of to primary-care interventions, such as asthma,

these services furthering the interests of the group heart and cerebrovascular diseases, and pneumo-
in particular ways of defining health needs. They nia. These results remain consistent after control-
can create unwarranted health demands, particu- ling for other important influences on health,
larly among population groups whose care con- including differences in age structure of the popu-
tributes to high rates of profit for the industry. lation, income per capita, gross domestic product
Some in the health services research field believe (GDP) per capita, and behavioral factors such as
that the federal and state governments have abdi- smoking and alcohol consumption.
cated responsibility or accountability. This current The evidence of the benefits of primary care is
system has resulted in continuing escalation of not limited to studies of the supply of primary-care
costs, proliferation of unnecessary and potentially physicians. There are demonstrated benefits from
harmful technology, and declining population improving access to and use of primary-care prac-
health as measured by the United States’ relative titioners as people’s regular source of care, as well
position in the world. as from better experiences with the four cardinal
features of primary care, which are detailed below.
The greater the reported use of primary-care physi-
Importance of Primary Care
cians as the regular source of care, the better the
Numerous research studies in the United States 5-year survival rates of patients, even after control-
have found that a greater primary-care physician ling for a variety of sociodemographic characteris-
supply is associated with a variety of positive tics and initial health status: the better the
health outcomes, including fewer instances of all- experiences with the receipt of primary-care ser-
cause mortality; cancer, heart disease, stroke, and vices, the better the self-reported health.
infant mortality; low birth weight; increased life
expectancy; and higher self-rated health. These
Beneficial Impact on Health and Costs
results were consistent across study years and geo-
graphic areas. Pooled results for all-cause mortal- Primary-care services are the supporting spine
ity indicate that an increase of one primary-care of healthcare systems by virtue of four cardinal
physician per 10,000 people is associated with an features: (1) They are generally the first contact
average mortality reduction of 5.3%, or 49 fewer point of access and use, (2) they are person-focused
deaths per 100,000 deaths per year. Mortality care over time instead of being disease focused, (3)
rate reductions for the Black population were they are comprehensive in the sense of taking care
higher than those for the White population, indi- of all health-related needs except those too uncom-
cating improved equity and effectiveness. At a mon to maintain competence, and (4) they coordi-
national level, a 5.3% reduction in all-cause mor- nate and integrate care that is more appropriately
tality in the year 2000 would have translated into provided elsewhere.
about 130,000 averted deaths. In comparison, a In combination, these four functions constitute
decline in the number of deaths of about 2,000 is primary care. Their achievement makes it possible
considered sufficient to justify a national focus on for care to be patient focused, family oriented, and
screening the entire adult population for colorec- relevant to the needs of the community in which
tal cancer. An increase of one primary-care physi- people live and work. Primary care, when orga-
cian per 10,000 people would require a 12.6% nized to carry out these functions, makes it possi-
overall increase in the primary-care physician sup- ble to achieve more appropriate, safer, and less
ply, or an absolute one-time increase of 28,726 costly care. It helps people navigate the healthcare
primary-care physicians, based on the supply in system so that they avoid the unnecessary or dupli-
the year 2000. cated interventions that increase the risk of adverse
These results are consistent with international effects and that are becoming common in the expe-
comparisons of nations differing in the strength of riences of people.
primary care. Nations with strong primary-care Evidence for the beneficial impact of each of the
infrastructures have lower mortality rates, with the four cardinal features of primary care is strong.
greatest reductions for causes particularly sensitive That is, the filtering of patients by primary care,
Primary Care 955
the first-contact feature, is effective in reducing mortality (total deaths, deaths from heart disease,
unnecessary visits to specialists that both increase cancer, and stroke, and infant deaths), 28 of the
costs and increase the risk of overuse and adverse studies found that the greater the primary-care phy-
effects. Moreover, the person focus of primary- sician supply, the lower the mortality. And in 25 of
care practitioners leads to better overall improve- the studies, it was found that the higher the specialist
ment in health. The third feature of primary care, to population ratio was, the higher the mortality.
comprehensiveness, is an important contributor to
the beneficial impact of primary care. The breadth
Primary Care’s Growing Importance
of problems that are dealt with in primary care as
opposed to being provided by specialists is the Four major challenges to health services deliv-
most consistent distinction between nations that ery in the nation will make the role of primary care
have strong primary care and nations with weak increasingly important in the future. First, the
primary care. Both national studies and interna- morbidity burden of the population will increase
tional comparisons show that the greater the num- as a result of increased survival from individual
ber of physicians involved in caring for an individual diseases. Most people, particularly as they age,
patient, the worse the outcome. And last, the coor- accumulate a higher burden of morbidity—that is,
dinating feature of primary care is responsible for comorbidity. Coexisting illnesses cause the focus of
reducing duplication of medical tests and adverse medical attention and quality assessments on par-
effects of interventions. These four features, which ticular diseases to be inadequate. Clinical practice
in combination may be referred to as “primary- guidelines are based, at best, on randomized con-
care practice,” are associated with increased access trolled trials (RCTs) that attempt to exclude indi-
to care for relatively deprived population groups, viduals with coexisting disease, even though they
improved quality of care overall, better preventive may constitute the majority of people otherwise
services overall, better early interventions for eligible to participate in the trial. Consequently,
health problems, fewer hospitalizations, and reduc- the results of the trial are not applicable to most
tions in referrals to specialists, with resulting better people with the disease for which the guidelines
population health at considerably lower costs. are implemented. A major, largely unrecognized
A focus on achieving the combination of these defect in the application of results of the trials is
four features explains why studies of people’s expe- the assumption that their findings apply to all
riences with primary care are even more consistent populations even though it is known that the prop-
in showing benefits than are studies that seek to erties of tests and interventions differ according to
correlate the supply of primary-care physicians to the characteristics of the target population: general
health outcomes. The mere presence of such clini- communities, patients in primary-care settings, or
cians does not assure that good primary care is patients in specialty settings. When applied in a
being provided; some population subgroups may general community, in the example of fecal blood
lack access to existing primary-care resources, and screening for colon cancer, the proportion of false-
some purported primary-care practices may not be positive tests is much greater than would be the
adequate in their provision of first-contact, person- case if the intervention were applied in primary-
focused, comprehensive, and coordinated care. care settings or specialty-care settings; intervention
Moreover, an excess of directly accessible special- applied to the whole population will lead to many
ists may detract from the benefits of existing pri- more unnecessary interventions, with a much
mary-care resources by discouraging coordination greater likelihood of adverse effects and greatly
and person-focused care, as well as by leading to decreased cost-effectiveness. For most medical
unnecessary and excessive interventions in the con- interventions directed at individuals in the popula-
text of the patient’s needs. Studies in the United tion, it is much more effective and efficient to focus
States have shown that a greater supply of special- on their application to patients in primary-care set-
ists available to the population does not improve tings than in community-based settings, with refer-
the outcomes of care and, in fact, often worsens ral to specialists from primary care as needed.
it. In 35 research studies dealing with differences Second, an increase in the morbidity burden of
between various geographic areas and rates of the population exists because of growing rates of
956 Primary Care
diagnosis of existing and new health problems. In United States. To have it incorporated into medical
the past two decades, the prevalence of diagnosed practice will require considerable leadership from
disease has increased markedly, largely due to low- professional and policy-making bodies.
ered thresholds for diagnosis of individual diseases Finally, the imperative to reduce disparities in
or inclusion of one or more risk factors as a proxy health resulting from avoidable differences in out-
for a diagnosed disease. The increase has greatly comes across different population subgroups
expanded the market for use of medications, many remains a challenge to the healthcare system. In
of which have subsequently been shown to be dan- contrast to specialty services, which are distributed
gerous. Primary care bears the burden, from inequitably in most nations, primary-care services
increasing workloads to the challenges of dealing are generally equitably distributed. The exception
with adverse effects. is in the United States, however. The equity-facili-
A third challenge is presented by an increase in tating influence of primary care is well documented,
the frequency of occurrence of adverse effects in both from studies in the nation and elsewhere. The
medical interventions. These negative effects are benefits of a greater supply of primary-care physi-
estimated to precipitate more than 200,000 deaths cians are even greater for the Black population in
annually in the nation. Between 4% and 18% of this nation than for the majority White population
patient visits are also associated with adverse and are greater in socially deprived areas than in
effects. more advantaged areas. Populations receiving their
The rate of withdrawal of drugs from the mar- care from Federally Qualified Health Centers
ket due to lack of safety has greatly increased since (FQHCs), which are required to maintain stan-
1992, when the Food and Drug Administration dards for primary-care practice, have fewer dis-
(FDA) drug approval process was relaxed. Rates of parities in health outcomes between Black and
nonindicated prescriptions have also increased. White populations; studies in other industrialized
For example, the rate of prescribing medications nations such as the United Kingdom and in devel-
for the common cold is 50% higher than the oping nations have had similar results. Thus, the
national desirable target, and the percentage of the move toward primary care can be considered a
elderly receiving a prescription for 1 of the 11 move toward equity in health.
always-contraindicated drugs remains unchanged
at about 3% per year. Deaths associated with
Public Policy Directions
medication errors increased markedly, by more
than 65% in the nation just between 1990 and The supply of primary-care physicians in the
1993. Only 40% of coronary angiographies are nation is declining at a rapid rate, as is evident from
done competently; one fourth of those are errone- the 45% reduction from 1997 to 2003 in the num-
ously read as showing severe disease; 6% of ber of medical school students intending to enter a
patients are informed that the test was normal primary-care specialty. Chronic underfunding of
although it was not; and one third of those indi- primary-care services as compared with specialists
viduals with misread tests have had surgery that has contributed to this decline in the attractiveness
was of uncertain benefit. The more physicians a of primary-care practice, as the level of reimburse-
patient sees, the greater the likelihood of adverse ment for fee-for-services payment is set by reference
effects. Primary-care physicians, as the locus of to historical levels of relative reimbursement rather
responsibility for the ongoing care of patients, are than to the difficulty and time requirements of
in the best position to identify and deal with these practice. As a result of media focus on the techno-
adverse effects. Electronic health records, portable logic and pharmacologic aspects of health services,
across a variety of settings, provide a way to the public has come to believe that specialty care is
facilitate identification of adverse effects and con- superior to primary care; hence, population groups
duct research to establish more effective ways of with rich insurance coverage and the ability to pay
dealing with these effects. However, to do this, a out of pocket have set the standard of seeking out
system of coding patients’ problems, in the form of specialty care directly. Research on the quality of
symptoms and signs, will have to become routine. care, however, is consistent in showing that primary
Such a system exists but is not widely used in the care is superior to specialty care when the outcomes
Primary Care 957
are broad rather than focused on diseases. Recent care and specialty care have important roles to
literature reviews indicate that even outcomes for play in the care of the population, and researchers
specific common diseases are at least as good if not can help policymakers make rational, evidence-
better when care is provided by based decisions about the relative functions and
primary-care physicians, appropriately buttressed appropriate contributions of each.
by care from specialists. Early studies purporting to
demonstrate the superiority of care from specialists Barbara Starfield
were fraught with methodological inadequacies, See also Equity, Efficiency, and Effectiveness in Healthcare;
especially with regard to controlling for overall Physician Workforce Issues; Physicians; Preventive Care;
morbidity burden. Even the extensive focus on Primary Care Case Management (PCCM); Primary
evidence-based quality of care fails to give sufficient Care Physicians; Public Health; Public Policy.
attention to the special benefits of primary care in
relation to person- and population-focused out-
comes rather than disease outcomes. This failure is Further Readings
due to the inappropriateness of guidelines for “all-
or-nothing” performance measures. American College of Physicians. How Is A Shortage of
The health services research community has not Primary Care Physicians Affecting the Quality and
Cost of Medical Care? A Comprehensive Evidence
been in the forefront of primary care, most of
Review. Philadelphia: American College of Physicians,
which is carried out by primary-care physicians. In
2008.
view of the evidence that some health system struc-
Bodenheimer, Thomas, and Kevin Grumbach. Improving
tures and processes have a major impact on
Primary Care: Strategies and Tools for a Better
outcomes, this seems to be a notable oversight Practice. New York: McGraw-Hill, 2007.
concerning an important aspect of investigations Buttaro, Terry Mahan, JoAnn Trybulski, Patricia Polgar
into the role and impact of health services. Bailey, et al. Primary Care: A Collaborative Practice.
Preliminary evidence indicates that at least three 3d ed. St. Louis, MO: Mosby, 2007.
features of health systems and two features of Showstack, Jonathan, Arlyss Anderson Rothman, and
practice have a notable influence on health indica- Susan B. Hassmiller, eds. The Future of Primary Care.
tors at national levels. The systemic features San Francisco: Jossey-Bass, 2004.
include (1) national efforts to distribute health Starfield, Barbara. “Access, Primary Care and the
service resources according to need, (2) nonuse of Medical Home: Rights of Passage,” Medical Care
copayments for primary-care services, and (3) tax- 46(10): 1015–1016, October 2008.
based health or regulated financing systems ensur- Starfield, Barbara. “An Evidence Base for Primary Care,”
ing universal benefits. The practice characteristics Managed Care 17(6): 33–6, 39, June 2008.
most consistently associated with strong primary Starfield, Barbara. “Refocusing the System,” New
care are (1) comprehensiveness of services within England Journal of Medicine 359(20): 2087–2091,
primary care and (2) family orientation of health November 13, 2008.
services. None of these characteristics are covered Steinwald, A. Bruce. Primary Care Professionals: Recent
by U.S. health policy—and practically none by Supply Trends, Projections, and Valuation of Services.
health services research in the nation. Report No. GAO-08–472T. Washington, DC: U.S.
Government Accountability Office, 2008.
Stenger, Joseph, Suzanne B. Cashman, and Judith A.
Future Implications Savageau, “The Primary Care Physician Workforce in
Massachusetts: Implications for the Workforce in
The way that specialists and primary-care physi-
Rural, Small Town America,” Journal of Rural
cians provide healthcare differs. Their roles are
Health 24(4): 375–83, Fall 2008.
different and need to be separately identifiable.
There are almost certainly large differences in
costs and activities, and high national health ser-
Web Sites
vices costs and poor health outcomes result at least
in part from an underuse of primary care and an American Academy of Family Physicians (AAFP)
overuse and misuse of specialty care. Both primary http://www.aafp.org
958 Primary Care Case Management (PCCM)
American Academy of Pediatrics (AAP) serve the Medicaid population promptly and
http://www.aap.org without compromise to the quality of care.
American College of Physicians (ACP) The Balanced Budget Act of 1997 further
http://www.acponline.org amended the Social Security Act to include a new
American Osteopathic Association (AOA) Section 1932 state plan option as an alternative to
http://www.osteopathic.org seeking waivers under Section 1915(b) and research
and demonstration projects under Section 1115.
The new authority permitted states to implement
mandatory managed care without waivers and
Primary Care Case without the cost-neutrality requirements associated
Management (PCCM) with Section 1115. Approval could be obtained
through a state plan amendment, and there was no
The Centers for Medicare and Medicaid Services time limit on the approval. The managed-care state
(CMS) defines Primary Care Case Management plan was also required to offer enrollees in urban
(PCCM) as case management–related services, areas a choice between at least two managed-care
including the locating, coordinating, and moni- organizations or between a PCCM system and a
toring of healthcare services provided by a physi- managed-care organization. In rural areas, there
cian, a physician group practice, or an entity could be one managed-care organization or PCCM
employing or having other arrangements with as long as there was a choice of physicians or case
physicians under a PCCM contract with a state. managers.
These contracts can also be with nurse practitio-
ners, certified nurse midwives, and physician Growth of PCCM Programs
assistants. State Medicaid agencies administer
PCCM programs in which primary-care providers By the mid-1980s, states interested in increasing
are responsible for managing the care of Medicaid access to healthcare while holding providers
recipients, including routine primary and preven- accountable and controlling costs began enrolling
tive services, coordination of care, and arrange- Medicare recipients in PCCM programs. These
ments for specialty services, usually without programs attempted to reduce inappropriate hos-
network restrictions. The primary-care providers pital emergency department use and other types of
receive reimbursement on a fee-for-service basis high-cost care. In many instances, states developed
for the services they provide as well as a flat per- PCCM programs as a stepping stone to risk-based
member-per-month fee or an increase in their managed care, and these programs grew steadily
preventive service fees to compensate for care during the 1990s. When commercial managed-care
management. organizations began declining to serve Medicaid
populations in many markets, even those states
that originally intended to move all their Medicaid
History
recipients to risk-based managed care began con-
PCCM as an approach to Medicaid was enabled sidering PCCM as a viable method for maintaining
by an amendment to Title XIX of the Social Medicaid managed-care delivery systems.
Security Act in the Omnibus Budget Reconciliation Presently, 30 states in the nation use PCCM, and
Act of 1981. The addition of Section 1915(b) it is the model of choice for rural areas, where a
authorized the waiver of statutory requirements relative scarcity of providers and a scattered popu-
that Medicaid programs offer comparable benefits lation have resulted in weaker managed-care pen-
statewide and offer recipients freedom of choice in etration. Due to its flexibility, PCCM is also used in
obtaining services. The amendment also specified urban areas. It is frequently the default enrollment
that PCCM services would be Medicaid-covered for Medicaid recipients who fail to make a choice
and that qualifying PCCM programs must make of a plan. Furthermore, PCCM may be used only
provisions for 24-hour emergency treatment and in specific markets and also statewide, under either
reasonable geographic availability delivery sites as voluntary or mandatory conditions. In markets
well as have a sufficient number of physicians to where feasible, states commonly offer both PCCM
Primary Care Case Management (PCCM) 959
programs and risk models. The resulting competi- Another major difference between PCCM
tion increases recipient choice and motivates both programs and managed-care organizations is the
managed-care organizations and PCCM programs sharing of financial risk. PCCM physicians, with
to improve quality and service. However, states fee-for-service reimbursement supplemented by a
must be careful to apply access, quality, and report- management fee, do not take on additional risk.
ing standards evenly to avoid encouraging man- Therefore, PCCM programs are attractive to phy-
aged-care-organizations’ withdrawal. sicians because they are not disadvantaged when
In addition to the benefits associated with they have a sicker-than-average group of patients.
PCCM’s flexibility from the perspective of states,
it has enjoyed popularity with both patients and
Trends in PCCM Practices
primary-care providers. Medicaid recipients enter-
ing PCCM programs report finding stable relation- State PCCM programs differ because each state
ships with their physician and appreciating the has taken a different approach that depended on
lack of restrictions usually associated with man- its particular managed-care environment, and
aged care. And primary-care providers are pleased policy goals of states also vary. Nevertheless,
not to have to assume the financial risk for the care several trends in the structure and operation of
of their patients and find that they have greater PCCM are apparent and reflect the significant
control over medical decision making as well as evolution of PCCM over time.
less administrative burden. They also recognize
that states are willing to take their concerns seri-
Expanded Eligibility
ously and to find better ways to support them.
In addition to enrolling a core population of indi-
viduals receiving Temporary Assistance for Needy
Comparison of PCCM Programs
Families (TANF), PCCM is also frequently being
and Managed-Care Organizations
used to extend health insurance coverage to hard-
PCCM programs, which are legally recognized as to-serve populations, such as Supplemental Security
managed-care plans, are similar to managed-care Income (SSI) disabled children and adults, the aged,
organizations in several ways. Notably, the struc- and children in foster care. Since the advent of the
ture of PCCM programs includes a panel of physi- State Children’s Health Insurance Program (SCHIP),
cians, and one primary-care provider is charged most states have incorporated SCHIP members into
with the primary responsibility for each recipient. their PCCM programs as well. Many states have
PCCM also structures incentives for both physi- also targeted individuals with chronic medical con-
cians and recipients to encourage appropriate use of ditions and have integrated disease management
healthcare services. Additionally, PCCM programs into their PCCM programs.
typically conduct utilization reviews, patient educa-
tion programs, and quality-monitoring activities.
Provider Recruitment and Retention
An important difference is that states themselves
are in charge of PCCM programs rather than a States are focusing on improving provider
managed-care organization contractor, which recruitment and retention by supporting participat-
means that state Medicaid agencies either directly ing providers through specially designated outreach
administer PCCM or manage a contractor to han- staff, operating provider hotlines, implementing
dle administrative functions. Although such respon- feedback mechanisms such as provider profiling,
sibilities are demanding for Medicaid agencies, this and devising strategies to gain providers’ input and
aspect of PCCM programs offers states an impor- suggestions. Rather than second-guessing the deci-
tant opportunity to tailor programs to their policy sions of physicians, states frequently provide tools
goals in terms of populations, culture, and public to allow providers to police themselves and, when
health priorities. Furthermore, PCCM provides necessary, dedicate resources for working with out-
an assurance of continuity; unlike a for-profit liers to improve their practices. States also have
managed-care organization, a state agency cannot found that providing educational outreach, as by
consider leaving when a market turns unprofitable. disseminating best practices and making available
960 Primary Care Case Management (PCCM)
online instructional models, to be an effective sup- are educating recipients about PCCM and encour-
port for providers. Taken together, these activities aging timely enrollment.
may produce strong state-provider relations and
ultimately result in increased commitment from a Increasing PCCM Active-Care Coordination
wide variety of providers.
Some states are including an active care coordi-
nation component in their PCCM programs, rec-
Quality Activities ognizing that the referral process is the key to
Increasingly, states are applying many of the managing services, and they are making significant
principles commonly used in network management efforts to streamline prior authorization for pro-
to ensure that Medicaid recipients receive quality viders. Additionally, care coordinators who are
care from PCCM programs. For example, states familiar with available resources and the commu-
are putting tighter language into their provider nity are often employed to more effectively respond
contracts and dedicating staff to monitor compli- to questions and concerns from both members and
ance with the stricter standards. In some cases, providers. These care coordinators may also be
PCCM programs also are including strict provider expected to collaborate with existing services, such
credentialing, member surveys, care coordinated as the Women, Infants, and Children (WIC) pro-
across multiple providers and conditions, 24-hour gram, as well as empower local communities to
member services and nurse advice lines, community- change their service delivery system. Care coordi-
based preventive health campaigns, Healthcare nators may also be deployed to work with com-
Effectiveness Data and Information Set (HEDIS) munity service agencies and other providers to
reporting to gauge the primary-care provider’s per- coordinate resources and services on the behalf of
formance, member education and health needs members with special needs.
assessment, disciplined utilization management,
disease management programs, complaint log Provider Reimbursement
reviews, and provider profiles.
States with incentive payment systems have
found that these systems can be very effective in
Enrollment Process reinforcing primary program goals, and some
Informing prospective members about Medicaid state Medicaid agencies have gone beyond the
managed care and its requirements in a manner basic fee approach. To encourage the provision of
that ensures a full understanding of the PCCM certain primary-care services, some states are
program and how to access services remains a reimbursing primary-care providers at enhanced
critical challenge. To overcome the intrinsic issues rates rather than reimbursing them at the standard
associated with enrollment, private enrollment per-member-per-month fee. Other states have
vendors or brokers are increasingly being used to adopted partial capitation for primary care, pay-
conduct enrollment and other functions. A variety ing a capitated amount for basic office visits and
of enrollment strategies is used, including provid- an enhanced payment for targeted services. Still
ing informational materials and instructions about other states allow primary-care providers to receive
how to enroll, holding group educational sessions, a per-member-per-month payment and also par-
operating toll-free help lines, and offering individ- ticipate in a bonus pool that is distributed annu-
ual face-to-face counseling. ally based on a composite measure of the physician’s
The mobility of Medicaid recipients also pres- Medicaid caseload, hospital emergency depart-
ents a significant challenge, creating discontinuity ment use, and defined prevention and quality
between the time individuals are enrolled in goals.
Medicaid and the time they enroll in PCCM. To
address this issue, states are conducting telephone
Future Implications
outreach at the time of the initial Medicaid eligibil-
ity determination. Additionally, some state agencies The primary goals of PCCM programs are to
responsible for Medicaid eligibility determination reduce costs while improving patient outcomes.
Primary-Care Physicians 961
Few evaluations of these programs have been Rawlings-Sekunda, Joanne, Deborah Curtis, and Neva
conducted, and those that have been conduced are Kaye. Emerging Practices in Medicaid: Primary Care
dated. They tended to focus on cost saving and Case Management. NASHP Pub. No. MMC61.
service utilization, but they did not address patient Portland, ME: National Academy for State Health
outcomes except to suggest that PCCM programs Policy, 2001.
improved access, especially to primary care. Smith, Vernon K., Terrisca Des Jardins, and Karin A.
In general, existing evaluations of PCCM pro- Peterson. Exemplary Practices in Primary Care Case
grams have recorded initial savings in the range of Management: A Review of State Medicaid PCCM
Programs. Princeton, NJ: Center for Health Care
5% to 15% as compared with a similar fee-for-
Strategies, 2000.
service population. This level of savings is consid-
Walsh, Edith G., Deborah S. Osber, C. Ariel Nason,
ered comparable to the savings achieved by
et al., “Quality Improvement in a Primary Care Case
managed-care organizations. Savings from PCCM
Management Program,” Health Care Financing
programs have been reported to result from Review 23(4): 71–85, Summer 2002.
changes in utilization patterns. Costs typically
increase for primary-care services and prescription
drugs, but the increases are offset by decreases in Web Sites
the costs of hospital emergency department use
and inpatient services. In addition to the positive American Case Management Association (ACMA):
evaluations, a few of the early evaluations were http://www.acmaweb.org
negative, and as a result some state PCCM pro- Case Management Society of America (CMSA):
grams were abandoned in favor of full-risk or http://www.cmsa.org
managed-care-organization-only models. Given National Association of State Medicaid Directors
the millions of Medicaid recipients enrolled in (NASMD): http://www.nasmd.org
state PCCM programs, much more research needs
to be conducted to evaluate the long-term benefits
and problems of these programs.
Primary-Care Physicians
Deann Muehlbauer
Primary-care physicians generally serve as the first
See also Access to Healthcare; Case Management; Cost
of Healthcare; Managed Care; Medicaid; Primary point of contact to the healthcare system for
Care; Quality of Healthcare; State Children’s Health nearly all of a patient’s medical and healthcare
Insurance Program (SCHIP) needs, including the treatment and diagnosis of
health conditions and the provision of preventive
and continuing care. Under the managed-care
Further Readings model, the primary-care physician also acts as a
gatekeeper who controls access to specialists or
Adams, E. Kathleen, Janet M. Bronstein, and Curtis S.
costly procedures as a mechanism to control
Florence, “Effects of Primary Care Case Management
healthcare costs. Primary-care physicians may fol-
(PCCM) on Medicaid Children in Alabama and
low patients in a variety of healthcare settings,
Georgia: Provider Availability and Race/Ethnicity,”
Medical Care Research and Review 63(1): 58–87,
including outpatient clinics, offices, hospitals,
February 2006. long-term care facilities, and the patient’s home.
Garrett, Bowen, Amy Davidoff, and Alshadye Yemane. Physicians trained in family medicine, general
Effects of Medicaid Managed Care Programs on internal medicine, and general pediatrics typically
Health Services Access and Use. Discussion Paper are considered to be primary-care physicians.
Assessing the New Federalism 02–01. Washington, Additionally, health insurance plans may differ in
DC: Urban Institute, 2002. regard to whether pediatricians and obstetricians/
Momany, Elizabeth T., Stephen D. Flach, Forrest D. gynecologists, who specialize in the care of women,
Nelson, et al. “A Cost Analysis of the Iowa Medicaid are considered primary-care physicians. Family
Primary Care Case Management Program,” Health physicians generally provide comprehensive care to
Services Research 41(4 pt. 1): 1357–71, August 2006. patients from infancy till the end of life. Pediatricians
962 Primary-Care Physicians
are considered primary-care physicians for chil- incentives. And the decline in the number of general
dren, adolescents, teenagers, and young adults, practitioners that had already begun before the war
while internists, who are practitioners of general accelerated. The percentage of primary-care physi-
internal medicine, provide care to adults. cians in the nation declined from more than 80%
Because of the aging of the nation’s population, in the early 1900s to less than 20% by 1960.
greater focus on prevention efforts and lifestyle In response to the growing public concern over
changes, and the prevalence of acute and chronic the reduced number of general practitioners, the
diseases, the need for primary-care physicians has American Academy of General Practitioners (now
grown substantially. In recent years however, the the American Academy of Family Physicians) was
number of primary-care physicians in the United founded in 1947 to assist these practitioners in
States and other developed nations has been declin- preserving and advancing the specialty. The
ing, as most physicians tend to specialize in an area American Academy of Family Physicians later
of practice. A survey conducted by the University joined with the American College of Physicians,
of Missouri-Columbia and the U.S. Department of representing internal medicine, and the American
Health and Human Services (HHS) predicts that Academy of Pediatrics to become one of the largest
by the year 2025, there will be a national shortage organizations representing the primary-care spe-
of 35,000 to 44,000 primary-care physicians. As a cialty of family medicine. Eventually, in 1969, fam-
result, the current and future shortage of primary- ily medicine was established as the 20th primary
care physicians is of concern among policymakers medical specialty recognized by the American
and healthcare planners. Board of Medical Specialties, and as a result of
these efforts, general medicine was reborn.
Overview
Primary-Care Practice
Early practitioners of the science and art of medi-
cine were primarily generalists. The breadth of The scope of primary-care physicians’ practice
their practice included diagnosing and treating a generally includes the basic diagnosis of common
variety of illnesses, using apothecaries, and per- health conditions and nonsurgical treatment and
forming surgery. The concept of primary care, interventions. During the clinical encounter, pri-
however, began to be formalized in the 1960s mary-care physicians gather information about
when the term appeared in the medical literature the patient’s condition, symptoms, and medical
attempting to define its content and the scope and history through interviewing. Primary-care physi-
the role of the primary-care physician. Prior to cians are also trained to order and interpret medi-
this time in the United States, a movement toward cal tests such as routine labs, electrocardiograms,
specialization beginning in the early 1900s resulted and X rays. For more complicated diagnoses,
in the first medical/physician specialty board however, they may refer the patient to a specialist
being formed in 1916. The American Board of with further specialized training or experience.
Medical Specialties (ABMS) was established in After obtaining medical test results, primary-care
1933 to ensure that physicians had a certifiable physicians will make a diagnosis and may send the
body of knowledge. ABMS’s mission was to estab- patient for further testing, referral to specialized
lish and maintain high standards for the delivery care, therapy, diet or lifestyle changes, treatment,
of safe, quality medical care by certified physician and/or follow-up. Primary-care physicians may
specialists. The American Board of Pediatrics also perform routine screenings and immuniza-
(ABP) and the American Board of Internal tions as well as counsel patients on health behav-
Medicine (ABIM) were later established in 1935 iors and self-care.
and 1936, respectively. Today, ABMS member With more than 130 physician specialties and
boards certify physicians in more than 130 differ- subspecialties, there inevitably exist overlapping
ent specialties and subspecialties. boundaries in care. Yet the decision-making of
After World War II, the rise of specialized care primary-care physicians does differ from other
and provider specialization continued. This growth specialized physicians who include some primary-
was supported by economic and professional care services in their practices.
Project HOPE 963
The structure of the primary-care practice may Schoen, Cathy, Robin Osborn, Phuong Trang Huynh,
include a team of physicians and nonphysician et al. “On the Front Lines of Care: Primary Care
health professionals charged with establishing and Doctors’ Office Systems, Experiences, and Views in
sustaining a long-term, personal relationship and Seven Countries,” Health Affairs 25(6): w555–w571,
partnership with individuals and their families. November–December 2006.
Primary-care physicians and members of the Yarnall, Kimberly S. H., Kathryn I. Pollack, Truls
healthcare team serve as advocates for the patient Ostbye, et al. “Primary Care: Is There Enough Time
in coordinating the use of the entire healthcare sys- for Prevention,” American Journal of Public Health
93(4): 635–41, April 2003.
tem to benefit the patient. Additionally, primary-
care physicians assist with helping patients navigate
the system. For example, they may coordinate a
Web Sites
full array of services that are essential for main-
taining and improving the individuals’ health sta- American Academy of Family Physicians (AAFP):
tus while providing nonepisodic interventions http://www.aafp.org
early in the disease process. American Academy of Pediatrics (AAP):
http://www.aap.org
American Board of Medical Specialties (ABMS):
Future Implications http://www.abms.org
The ultimate goal of a healthcare system is to American College of Physicians (ACP):
http://www.acponline.org
provide the highest quality of care, at the lowest
possible cost, to the greatest number of people.
Possible strategies to help accomplish this include
increased financing to support primary-care prac-
tices, revitalizing primary-care education, and Project HOPE
promoting the value of care that is accessible,
comprehensive, coordinated, continuous, and Project HOPE (Health Opportunities for People
accountable, provided by primary-care physicians Everywhere) is a nonprofit, international organiza-
and other nonphysician primary-care clinicians. tion that is dedicated to improving the quality of
life of the most vulnerable members of society, with
Javette C. Orgain a particular emphasis on women and children.
Project HOPE’s mission is to attain sustainable
See also Acute and Chronic Diseases; American Academy
advances in healthcare globally by implementing
of Family Physicians (AAFP); American Academy of
health education programs and humanitarian
Pediatrics (AAP); General Practice; Physicians;
Preventive Care; Primary Care; Primary Care Case assistance. Project HOPE is well-known in the
Management (PCCM) field of health services research for its health pol-
icy journal Health Affairs.
Further Readings
Background
Pathman, Donald E., Thomas R. Konrad, Rebekkah Dann,
et al. “Retention of Primary Care Physicians in Rural
Celebrating its 50th anniversary in 2008, Project
Health Professional Shortage Areas,” American Journal HOPE was founded as a floating hospital by
of Public Health 94(10): 1723–29, October 2004. William B. Walsh. After witnessing poor health
Pham, Hoangmai H., Deborah Schrag, J. Lee Hargraves, conditions, particularly of young children, in the
et al. “Delivery of Preventive Services to Older Adults South Pacific while serving as a medical officer
by Primary Care Physicians,” Journal of the American during World War II, Walsh persuaded President
Medical Association 294(4): 473–81, July 27, 2005. Eisenhower in 1958 to donate a naval ship to pro-
Sandy, Lewis G., and Steven A. Schroeder. “Primary vide charity healthcare. The ship was later trans-
Care in a New Era: Disillusion and Dissolution?” formed into the S.S. HOPE and Project HOPE
Annals of Internal Medicine 138(3): 262–67, was formed. In September, 1960, the S.S. HOPE
February 4, 2003. set sail from San Francisco to Indonesia. Although
964 Project HOPE
the S.S. HOPE was eventually retired in 1974, it maintains close collaborations with local partners
made a total of 11 voyages to various countries to ensure that efforts are not duplicated in meeting
around the world. Today, Project HOPE contin- the needs of those it serves.
ues to operate land-based programs, including
medical training and health education in more
Health Affairs
than 30 countries across 5 continents.
Project HOPE is dedicated to providing sustain- Project HOPE has published the leading peer-re-
able solutions to health problems by helping peo- viewed health policy journal, Health Affairs, since
ple assist themselves. The organization improves 1981. The journal consistently ranks at the top of
the local capacity to sustain improvements in its categories in the Journal Citation Report. Its
health and improve access to healthcare. It has founding editor, John K. Iglehart, is a member of
programs across the globe, in locations including the National Academy of Sciences, Institute of
Africa, the Americas and the Caribbean, Asia and Medicine (IOM) and national correspondent for
the Middle East, Central and Eastern Europe, and the New England Journal of Medicine. The idea
Russia/Eurasia. Project HOPE’s current programs for Health Affairs was spawned in the 1970s
in Africa are fighting to combat HIV/AIDS, malaria, when Walsh, Project HOPE’s founder, concluded
and other diseases; poverty and hunger; infant that it should expand its reach by publishing a
mortality; and maternal mortality. Its programs in journal to focus on the U.S. healthcare system.
South American countries target access to health- Health Affairs is a multidisciplinary journal that
care services for women and children. And in Asia covers topics such as access, costs, and quality of
its programs are focused on addressing infectious healthcare; Medicare; Medicaid; healthcare reform;
diseases and women’s health issues. and prescription drug coverage. The journal is
Project HOPE also provides humanitarian and nonpartisan and publishes a wide range of timely
emergency assistance in areas that are affected by health articles, which focus on research and com-
disasters. Additionally, the organization strives to mentary that are of concern both domestically and
provide long-term access to essential medicines abroad.
and medical supplies to underserved areas. Since Health Affairs is published six times a year with
1987, Project HOPE has shipped nearly $1 billion additional supplements and is also available online.
in humanitarian assistance globally. The authors that contribute to the journal include
The organization also maintains expertise in acclaimed scholars, policymakers, and leaders in
various health and medical disciplines and pro- the healthcare industry. The journal averages about
vides health professionals education through vari- 33,000 readers per printed issue, and the reader-
ous programs, ranging from the training of rural ship includes legislators, healthcare leaders and
health promoters in primary care to the establish- professionals, academics and researchers, health
ment of specialized tertiary-care medical programs. policy analysts, and advocates. Health Affairs is
Project HOPE’s implementation of train-the-trainer widely cited in the national media and press,
methodologies has resulted in millions of health- including The Washington Post, The New York
care professionals being better equipped world- Times, The Wall Street Journal, and CNN, and it
wide. Project HOPE has also laid the foundation has been referred to as the “bible of health policy.”
for a healthier future by building, and training the Between January and July, 2006, alone, the journal
staff needed to operate, hospitals and clinics, espe- was cited 18 times in U.S. congressional testimony,
cially those targeting the special needs of children. which is illustrative of its policy influence.
The facilities serve as national training centers for The journal is divided into the sections of
healthcare providers in addition to being an Feature Articles, Commentary, Interviews, Narrative
invaluable resource to improve the health of chil- Matters, Health Tracking, DataWatch, GrantWatch,
dren in developing countries. UpDate, Book Reviews, and Letters to the Editor.
Project HOPE is a registered organization of the Health Affairs also publishes thematic issues each
U.S. Agency for International Development year that explore a topic in depth as well as on
(USAID) and is a member of the Partnership for “variety issues.”
Quality Medical Donations. The organization
Prospective Payment 965
Future Implications organizations are generally paid in three ways: (1)

on a cost-based basis, (2) on a capitation basis, or
Project HOPE continues its work to improve the
(3) on a case-based basis. On a cost-based basis,
lives of people throughout the world, particularly
such as fee-for-service, the organization is paid
among low- and middle-income countries, by edu-
for all the services it provides, which is a powerful
cating healthcare professionals and volunteers, train-
incentive for high levels of effort and service.
ing community workers, providing essential supplies
Payment on a capitation basis consists of a flat
and medicines, and combating infectious diseases.
payment to the organization per person cared for,
Additionally, Health Affairs remains an influential
with the organization assuming the risk that the
force in informing the public policy debate on issues
payment will cover the cost of the patient’s care.
that are of particular concern in healthcare.
On a case-based basis, the organization is paid a
Jared Lane K. Maeda single payment for an episode of care, and the
payment does not change if fewer or more ser-
See also Access to Healthcare; Healthcare Reform; vices are provided. The various payment types
Health Services Research Journals; International may be either retrospective or prospective.
Health Systems; Medicaid; Medicare; Quality of
Healthcare; Vulnerable Populations
Medicare’s Prospective Payment System
Further Readings The best-known example of case-based payment
in healthcare is Medicare’s prospective payment
Hebert, Paul L., Jane E. Sisk, and Elizabeth A. Howell. system (PPS), which was mandated by the U.S.
“When Does a Difference Become a Disparity? Congress to control community hospital inpatient
Conceptualizing Racial and Ethnic Disparities in costs in 1983. Under this system, the Medicare
Health,” Health Affairs 27(2): 374–82, March–April
program changed its mode of payment for hospi-
2008.
tal inpatient care from a retrospective cost-based
Igelhart, John K. “Forging a New Path Down a Very
system to a prospective case-based system.
Challenging Road,” Health Affairs 25(2): 310–311,
After the Medicare program was established in
March–April 2006.
Project Hope. 2007 Project Hope Annual Report.
1965 the costs of hospital care soared. One of the
Millwood, VA: Project Hope, 2007.
major factors that led to rising costs was the retro-
Ridley, David B., Henry G. Grabowski, and Jeffrey L. spective cost-based payment system. Under this
Moe. “Developing Drugs for Developing Countries,” system, hospitals submitted their bills to Medicare
Health Affairs 25(2): 313–24, March–April 2006. after the care had been given and the costs to the
Smedley, Brian D. “Moving Beyond Access: Achieving hospital were known. Hospitals were then paid for
Equity in State Health Care Reform,” Health Affairs the care they provided, as allowed by Medicare
27(2): 447–55, March–April 2008. rules, regardless of whether the costs were high or
low, excessive or appropriate. Consequently, there
was little incentive for hospitals to be cost-effective.
Web Sites On the other hand, the prospective case-based
Health Affairs: http://www.healthaffairs.org payment system set payment rules prior to when
Project HOPE: http://www.projecthope.org the care was given. By setting a fixed reimburse-
Project HOPE: Forty Years of American Medicine ment level per case based on diagnosis, the PPS
Abroad: http://americanhistory.si.edu/hope provided economic incentives to conserve the use of
resources. Hospitals that used more resources than
covered by the flat rate lost the difference. Those
with costs below the rate retained the difference.
Prospective Payment
Diagnosis Related Groups
The manner in which healthcare organizations
are paid for the services they provide can influ- Under Medicare’s PPS, the amount paid to hos-
ence their organizational behavior. Healthcare pitals is based on their patients’ Diagnosis
966 Prospective Payment
Related Groups (DRGs). Specifically, each Financial Conditions of Hospitals

patient is assigned into one of more than 500
Because Medicare’s PPS puts a degree of finan-
DRGs, based on principal diagnosis, age, and
cial stress on hospitals, particularly on those that
medical complications. The DRGs aggregate
have higher than usual costs, there was a concern
patients with similar resource-consumption and
about their financial viability. When PPS was first
hospital length-of-stay patterns. Medicare then
established, its fixed payment rates proved suffi-
pays the hospitals a set amount for each DRG.
ciently generous, and average hospital operating
The government calculates the payment for each
margins increased. However, over time, the rates
DRG based on national averages. It also modi-
were lowered. By the late 1980s and through the
fies that amount somewhat based on local wage
early 1990s, average operating margins for the
rates, geographic location (e.g., rural versus
Medicare segment of hospital patients tended to be
urban area), and whether the hospital is a teach-
negative.
ing hospital.
Overall Effects on Costs

Effects of Medicare’s The main objective of the Medicare PPS was to
Prospective Payment System control hospital costs. With regard to the effect of
Extensive research has been conducted to exam- PPS on reducing hospital expenditures, one study
ine the impact of Medicare’s PPS on hospitals and found that for a sample of California hospitals,
patients. This research has focused on the sys- those under the strongest pressure from PPS
tem’s impact on average hospital length of stay, responded by reducing expenditures. Another study
access to and quality of care, financial condition found that PPS reduced Medicare’s hospital costs
of hospitals, overall effects on costs, and hospital substantially. In terms of Medicare’s overall bud-
management. get, the PPS appears to have been effective in slow-
ing down expenditures. The PPS reduced the
historic rates of growth in total Medicare spending.
Average Hospital Length of Stay However, the reduced growth in inpatient spending
was partially offset by increases in spending on
Since Medicare’s PPS pays hospitals a fixed
hospital outpatient care, skilled nursing care, home
amount based on the patient’s DRG, there is an
health care, and physician payment increases.
incentive for hospitals to discharge their patients
as soon as possible. Given that revenue is fixed,
the time a patient spends in the hospital will Hospital Management
determine the profit or loss. As a result, one of The Medicare PPS was designed to create incen-
the ways to increase profits is to reduce the num- tives for the balancing of costs and benefits in
ber of days of care taken to treat a patient. Many treating patients. It led hospitals to begin to
studies have reported that hospital average length explore mechanisms for more accurate product
of stay did drop after the introduction of the costing. Under cost-based payment, when health-
system. care providers were directly reimbursed for what-
ever costs they incurred, accurate cost measurement
was of little concern. However, under PPS, the
Access to and Quality of Care
revenue per patient is not merely a reflection of
With the introduction of Medicare’s PPS, many reported cost but is instead a fixed amount. If the
policymakers and the general public were con- true underlying cost is substantially more than the
cerned that it would induce hospitals to save on revenue for a certain type of patient, the hospital
costs by cutting corners—reducing access to care must be aware of it. Similarly, hospitals must also
and the quality of care—by refusing to treat costly be aware if the cost is much less than the revenue.
patients or by closing treatment units. Researchers Medicare’s PPS encouraged the use of product-line
have addressed these issues to some extent; how- costing, which led to more efficient hospital finan-
ever, the results have been mixed so far. cial management.
Provider-Based Research Networks (PBRNs) 967
Future Implications
Provider-Based Research
After applying PPS to community hospitals, the
federal government developed and applied simi- Networks (PBRNs)
lar systems in other healthcare settings. Medicare
Provider-based research networks (PBRNs) are
now uses PPSs for hospital outpatient services,
collaborative partnerships between academically
inpatient psychiatric hospital care, inpatient reha-
based investigators and community-based physi-
bilitation hospital care, inpatient long-term hos-
cians who share an ongoing commitment to devel-
pital care, skilled-nursing facility care, home
oping and conducting health-related research.
health care, and hospice care. It seems likely that
PBRNs provide the infrastructure and support
these systems will remain in use for many years
necessary to conduct community-based clinical
to come.
research studies on an ongoing basis, thus provid-
Tae Hyun Kim ing stability and continuity that transcends indi-
vidual studies. PBRNs address many shortcomings
See also Centers for Medicare and Medicaid Services of academic medical centers–only research and
(CMS); Cost Containment Strategies; Cost of present several distinct advantages to it; most
Healthcare; Diagnosis Related Groups (DRGs); notably, these entities provide access to a much
Healthcare Financial Management; Hospitals; larger population of prospective clinical research
Medicare; Medicare Payment Advisory Commission trial participants.
(MedPAC)
Clinical research trials are the means by which
medical researchers explore and answer specific
questions about health. Clinical trials, translational
Further Readings research, epidemiological research, health services
Kulesher, Robert R. “Impact of Medicare’s Prospective research, and several other categories are included
Payment System on Hospitals, Skilled Nursing in the broader definition of clinical research.
Facilities, and Home Health Agencies: How the Academic medical centers (AMCs) have long
Balanced Budget Act of 1997 May Have Altered been the centers of clinical research, the develop-
Service Patterns for Medicare Providers,” Health Care ment of new knowledge, and the transfer of that
Managers 25(3): 198–205, July–September 2006. knowledge to the next generation of researchers
Mayes, Rick, and Robert A. Berenson. Medicare and care providers. There, teams of investigators
Prospective Payment and the Shaping of U.S. Health develop research questions and methods for exam-
Care. Baltimore: Johns Hopkins University Press, ining them and also carry out the research through
2006. voluntary enrollment of study subjects who are
Sood, Neeraj, Melinda Beeuwkes Buntin, and Jose J. often patients at the centers. Having AMCs as the
Escarce. “Does How Much and How You Pay center of the clinical research universe has many
Matter? Evidence From the Inpatient Rehabilitation advantages, including the presence of both clinical
Care Prospective Payment System,” Journal of Health and research infrastructure and the synergy that
Economics 27(4): 1046–1059, July 2008. can be developed among academics, researchers,
White, Chapin, “Why Did Medicare Spending Growth and clinicians; but it also has several limitations.
Slow Down?” Health Affairs 27(3): 793–802, May–
In 1961, one of the founders of health services
June 2008.
research in the United States, Kerr L. White,
presented a statistical estimate with far-reaching
implications for both medical education and popu-
Web Sites lation-based clinical research: For every 1,000
Centers for Medicare and Medicaid Services (CMS): adults at risk of being ill or using health services in
http://www.cms.hhs.gov a given month, only one will be referred to an
Healthcare Financial Management Association (HFMA): AMC. While the precision of this estimate has been
http://www.hfma.org debated and patterns of care may have shifted since
Medicare Payment Advisory Commission (MedPAC): 1961, the implications remain relevant today. If this
http://www.medpac.gov estimate is accurate, although the overwhelming
968 Provider-Based Research Networks (PBRNs)
majority of clinical research is conducted in AMCs, projects are variously organized by demographic
less than 1% of the relevant population is being characteristics (e.g., age group, gender, and race),
seen at AMCs, and only a small subset of these disease type (e.g., AIDS, cancer, and heart disease),
individuals is enrolling in clinical research trials. A practice type (i.e., primary care and specialty ser-
tremendous risk of selection bias exists then, jeop- vices), and point on the care continuum (i.e., pre-
ardizing the external validity of the majority of vention, early detection, treatment, or disease
clinical research. Furthermore, limiting clinical survivorship).
research access to only AMCs induces a bottleneck
in completing clinical research studies, consequently
Research Generalizability
slowing the pace of medical progress.
and Medical Progress
In 2006, a contract research organization,
Westat, completed and published the Inventory Among its many benefits, PBRNs broaden the
and Evaluation of Clinical Research Networks: A access points between clinical research studies and
Complete Project Report, a comprehensive world- the total potential participant population, helping
wide study of clinical research networks. This ensure better research with more generalizable
report identified 262 PBRNs with a variety of findings. PBRNs broaden clinical research’s reach
funding sources and organizational structures, and to include more members of the more than 99%
spanning multiple types of research and subject of the population described by White as being “at
populations. The majority of these networks are risk” but not seen at AMCs, thus offering inclu-
less than 10 years old; however, others have been sion of people who would not seek care at the
in existence for 50 years. Currently, 62% of these centers for any number of reasons, including their
networks are funded by the federal government. geographic relation to them, insurance coverage,
Another 10% are funded by nonprofit organiza- perceived nonnecessity of AMC-based care, or
tions, 9% are funded by a government outside the other factors. By including members of this larger,
United States, and 8% are funded by academia. more diverse population, the research is more
Approximately 60% receive funding from more likely to result in findings that are more broadly
than one source; 52% report operations in the representative of it and therefore generalizable.
United States only, while 32% report operations in More comprehensive population representation is
the United States and internationally, and 16% of increasing importance with, for example, the
report exclusively international operations. current growth of genetics research. With striking
Universities and AMCs continue to play a domi- limitations on the geographic reach of AMCs,
nant role in many networks, while other network PBRNs help give such genetics-based studies a
members span the healthcare spectrum and include broader reach, which may prevent the exclusion
the following: state and federal government health- of potentially geographically clustered and geneti-
care facilities, community hospitals, individual or cally distinctive populations. These efforts help
group physician practices, clinical laboratories, medical researchers improve the understanding of
pharmaceutical companies, foundations, contract genetic pathways of disease and extend the appli-
research organizations, and health maintenance cability of research findings to these populations.
organizations (HMOs). By opening the access points to a larger popula-
The research areas vary widely, and include tion, PBRNs also serve to expedite the pace of
epidemiology, behavior modification, health com- medical discovery. Simply put, patient enrollment is
munication, patient care, medical practice, clinical one of the most time-consuming components of
quality improvement, research-centered surveil- most clinical trials. Individual studies can spend
lance, and clinical process improvement, among many years enrolling a sample of individuals suffi-
others. Approximately 60% of the studies con- cient to allow the statistical power to demonstrate
ducted through PBRNs are clinical trials, 24% are an intervention’s effectiveness. With PBRNs’ access
epidemiology and other observational studies, 6% to a broader population, there is an increased prob-
are other interventional research, and 2% are out- ability of an individual with the right trial-specified
come oriented. As far as the populations being clinical characteristics seeking care at a location
studied are concerned, these research network that offers access to the trial. This greater rate of
patient-to-trial exposure can translate into more most care is delivered in community settings.
rapid overall trial enrollment and, consequently, Consequently, for many community-based provid-
more rapid trial completion. A prime example of ers, evidence-based practice awaits more practice-
this is cancer prevention research, which is often based evidence. These observations suggest that the
conducted among healthy populations. acceptance and implementation of evidence-based
Because cancer prevention trials often require a clinical services in community-based practice settings
very large participant sample size to allow for sta- depends less on dissemination, which connotes a
tistically powerful analysis, this type of project may one-way flow of knowledge from researchers to pro-
be impractical at an AMC. Beyond potentially lim- viders, than on knowledge exchange, which involves
ited trial access to the less than 1% of individuals two-way communication between researchers and
at risk who seek care at AMCs, a large proportion providers. In PBRNs, this exchange is structurally
of patients have considerable health concerns that facilitated, as community-based providers assume
would preclude their enrollment in the trial. PBRNs primary responsibility for seeing patients and for col-
open the door to a dramatically larger, generally lecting research data and participating in other
healthier population that sees their geographically aspects of the research process. On the discovery-to-
more accessible practitioners for everything rang- delivery continuum, the process of seeing patients
ing from annual checkups and flu shots to symp- represents the critical process of implementation,
tom-induced visits for transient health issues to which remains a daunting challenge no matter how
ongoing care needs that are not severe enough to strong or credible the evidence.
either warrant referral to the AMC or preclude the For all but the simplest clinical services, success-
patient from a prevention trial. Most recently, this ful implementation depends on administrative sup-
benefit of PBRNs has perhaps been visible as a sig- port, adequate financial and human resources, and
nificant component of the National Institutes of organizational culture that values scientifically
Health’s (NIH’s) Roadmap, which is the federal based practice. Indeed, systematic reviews indicate
plan for medical research in the 21st century. that multifaceted interventions that target organi-
zational staffing, office workflow, and information
systems are more effective in changing provider
Translating Research Into Practice
behavior than interventions that increase provider
As part of NIH’s Roadmap, the importance of awareness and knowledge, such as continuing edu-
developing new partnerships among patient com- cation and academic detailing. These findings sug-
munities, community-based physicians, and aca- gest that the implementation of evidence-based
demic researchers is recognized. Indeed, several clinical services necessitates systemic organiza-
institutions and federal agencies are developing tional changes, including the development of a
PBRNs or have them already in place. To this end, supportive infrastructure and culture for both aca-
the NIH and other federal agencies are aware of demic settings and, perhaps more important,
the role PBRNs can play in both translating community-based practice settings.
research results into better care and closing the These systemic organizational changes are of
gap between discovery and delivery. growing importance because the recent healthcare
For many medical-care innovations, providers market trends emphasize efficiency and may serve
often remain unconvinced that sufficient evidence to erode the professional values and norms that
exists to support the implementation of research- emphasize scientifically based practice and the
tested clinical services in real-world practice settings. conduct of historically inefficient clinical research.
The national Institute of Medicine’s (IOM) 1998 PBRNs involve both knowledge exchange and
report, Bridging the Gap Between Practice and systemic organizational changes. As such, they are
Research: Forging Partnerships With Community- a promising model for both disseminating and
Based Drug and Alcohol Treatment, describes how implementing evidence-based clinical services
the clinical-care community perceives an excess of and, ultimately, improving the quality of care.
“efficacy” research and a simultaneous dearth of Knowledge exchange occurs through community-
“effectiveness” research. Many have noted that most based participatory research (CBPR). By engaging
research on clinical services takes place in AMCs, yet providers in the research process, researchers gain
970 Provider-Based Research Networks (PBRNs)
insight into the clinical issues and needs of For all practical purposes, PBRNs cannot func-
community-based practice settings, obtain provider tion without independent funding. Traditionally,
input on study design and the feasibility of imple- clinical practice has cross-subsidized concomitant
mentation, and discover the tacit practice-based clinical research; however, this is no longer sustain-
knowledge that exists in community-based practice able because the healthcare environment increas-
settings and the acceptability of the intervention. ingly emphasizes efficiency as well as increasingly
CBPR promotes a sense of trust and ownership that complex, burdensome, and resource-intensive
enhances providers’ acceptance of clinical research research and regulatory requirements. Lack of
results and strengthens their commitment to acting such resources has had a negative impact on
on research findings. However, CBPR does not PBRNs’ abilities to pursue specific lines of research
occur spontaneously or effortlessly. and on some PBRNs’ abilities to complete already
initiated studies. The pressures and uncertainty of
obtaining new and ongoing funding are ever pres-
Keys to Success
ent, and the time spent seeking funding displaces
Substantial federal commitment exists to develop the time that could be spent performing the
and support PBRNs as a means for improving and research. Restrictions placed on some funding
advancing the nation’s research agenda as well as sources can further limit how and where PBRN
disseminating and implementing evidence-based efforts are directed. Some PBRNs receive stable
clinical services in community settings. Yet reports funding through federal support, which mitigates
indicate that PBRNs themselves are encountering some of this pressure and uncertainty, and enables
challenges to implementation and sustainability. more consistent operations, while some PBRNs
Several studies have elucidated characteristics that take as much of a business perspective as a research
are associated with successful performance of perspective when determining research agendas
PBRNs and the challenges they face, including and carrying out research, as they constantly focus
developing a research agenda, obtaining member on costs and efficiency of operations.
buy-in and sustaining member interest, consistently In addition to being costly, clinical research is
obtaining sufficient funding, creating a clinical time-consuming. Investigators in PBRNs often
research infrastructure, and coping with regulatory experience exceptional time pressure because they
compliance issues. are often also responsible for maintaining a viable
Perhaps the most fundamental characteristics clinical practice. These investigators often have
associated with PBRN success is the commitment little or no directly supported time to develop or
of both the lead- and coinvestigators and their conduct research, let alone analyze study data or
continuous active involvement in the PBRN. These develop and publish the findings. As such, their
individuals must establish a clear vision for the success is often tied to their ability to create an
organization, typically in the form of scientific organizational infrastructure to support the many
focus, goals, and priorities. They must also keep a time-consuming aspects of clinical research. PBRN
close watch on the environment and remain open member provider organizations often must imple-
to new ideas and ways of remaining energized and ment systemic changes in organizational staffing,
at the forefront of research, including through con- office workflow, information systems, and reward
tinually developing new relationships with new structures to appropriately encourage staff support
investigators. They must also develop the relation- and participation and operational success. Some
ship both inside and outside the PBRN, including PBRNs have a more centralized model, where the
those partners with the relevant patient popula- research staff is funded in dedicated support of
tions, the prospective partners who would interact research, operate out of a central nonclinical office
with those populations, and the funding groups or setting, and only interact with clinical staff to iden-
agencies that support the ongoing infrastructure tify and enroll patients and carry out the strictly
necessary to conduct the research. Indeed, the sus- research-related aspects of study participants’ oth-
tainability of PBRNs has been strongly and directly erwise usual course of care. Some PBRNs, on the
tied to the ability to acquire ongoing sponsorship other hand, employ a more decentralized model in
of research, which can be a very costly endeavor. which the same staff members support both patient
care and the requirements of the clinical research Future Implications

protocol. In either case, two infrastructure ele-
PBRNs have broadly demonstrated their success
ments, good staffing and strong information tech-
in allowing access to new populations and enhanc-
nology (IT), remain key components to success.
ing enrollment in clinical trials. To cite just one
Successful PBRNs consistently extol the value of
example, a National Cancer Institute (NCI) PBRN,
a well-trained staff to carry out the many special-
the Community Clinical Oncology Program, has
ized functions within the PBRN. These roles
allowed a successful expansion from cancer treat-
include data managers and statistical support staff
ment trials into cancer prevention and control
who assist in the development of research proto-
trials. In addition to effectively opening the door
cols and also help manage and analyze data,
to prevention trials, it currently accounts for 30%
research nurses who interact with study partici-
of all enrollments to treatment trials sponsored by
pants, administrative staff who help ensure that all
the NCI.
sorts of regulatory requirements, including interac-
Although many PBRNs have shown that they
tions with local institutional review boards (IRBs)
can complete studies and advance medical knowl-
and government agencies such as the Food and
edge, the extent to which PBRNs actually promote
Drug Administration (FDA), are met, and study
the use of evidence-based clinical services in com-
coordinators and managers who oversee and coor-
munity-based practice settings remains largely
dinate all these roles. To fulfill these roles, PBRN
unknown. The few studies that have been done
staff efficiency, effectiveness, and general produc-
have demonstrated a benefit of enhanced utiliza-
tivity are often influenced by having IT systems.
tion of new therapies for nontrial patients com-
As it pertains both to internal PBRN operations
pared with patients in practices that do not do
as well as PBRN interaction with sponsors and
clinical research. The scope, details, and generaliz-
other agencies, many recent advances in IT have
ability of these relationships largely remain to be
been facilitators of PBRN success. With many
proved, since many PBRNs are too new, too small,
PBRNs spread across multiple states and even mul-
or lack reliable outcome data to measure their
tiple countries, the utility of an IT resource for
impact as a model for dissemination. With the NIH
communication and operations support is obvious.
Roadmap’s recent emphasis on PBRNs, a growing
New government-sponsored IT resources such as
opportunity exists to conduct empirical evaluations
the Clinical Trials Support Unit (CTSU), cancer
of the benefits of PBRNs in terms of their ability to
Biomedical Information Grid (caBIG), Network for
directly influence clinical practice and facilitate the
Effective Collaboration Technologies through
translation of research into practice.
Advanced Research (NECTAR), and other resources
have facilitated access to information on clinical William R. Carpenter and Bryan J. Weiner
trial availability, contributed to relieving the regu-
latory burden of trial participation for practitio- See also Academic Medical Centers; Clinical Practice
ners, and allowed much greater consistency and Guidelines; Community-Based Participatory Research
efficiency in participant enrollment and ongoing (CBPR); Evidence-Based Medicine (EBM); Quality
trial management. Some other, more forward- Indicators; Quality of Healthcare; Randomized
looking research programs have begun to develop Controlled Trials (RCT); White, Kerr L.
patient-centric IT systems in which patients enter
responses to trial-relevant questions on checking in
for a clinic visit. With implications for practice at Further Readings
both AMCs and community-based practices, these Kuo, Grace M., Jeffrey R. Steinbauer, and Stephen J.
data are stored for trial analysis with other patients’ Spann. “Conducting Medication Safety Research
responses. Additionally, they are analyzed in real Projects in a Primary Care Physician Practice-Based
time to inform and improve practice immediately Research Network,” Journal of the American
by both providing useful educational information Pharmacists Association 48(2): 163–70, March–April
to participants or patients and also informing the 2008.
care provider regarding the most pertinent matters Lamb, Sara J., Merwyn R. Greenlick, and Dennis
to address during the concomitant clinic visit. McCarty, eds. Bridging the Gap Between Practice and
972 Public Health
Research: Forging Partnerships With Community- and collaboration. This latter point is tied to a
Based Drug and Alcohol Treatment. Washington, DC: major concern about health equity for all. At a
National Academy Press, 1998. practice level, this agenda would also be pursued
Lindbloom, Erik J., Bernard G. Ewigman, and John by preventing epidemics and the spread of disease,
Hickner. “Practice-Based Research Networks: The protecting people from environmental hazards,
Laboratories of Primary Care Research,” Medical prevention of injuries, responding to disasters and
Care 42(4 Suppl.): III45–III49, 2004. helping people and communities in the recovery
Tierney, William M., Caitlin C. Oppenheimer, Brenda L. period, and assuring accessibility of health services
Hudson, et al. “A National Survey of Primary Care
for everyone. Public health is thus population
Practice-Based Research Networks,” Annals of Family
based and not generally a provider of clinical ser-
Medicine 5(3): 242–50, May–June 2007.
vices. Public health agencies work with other com-
Zerhouni, Elias A. “Medicine: The NIH Roadmap,”
munity health partners to carry out the mission of
Science 302(5642): 63–72, October 3, 2003.
public health and a vision for a healthier future.
Web Sites
Major Functions and Essential Services
Public health has 3 major functions and 10 essential
http://www.ahrq.gov
Center for Participatory Research (CPR):
services that will successfully impact a local public
http://hsc.unm.ed/som/fcm/cpr
health system. The first function is assessment,
National Institutes of Health (NIH): http://www.nih.gov which involves the identification of health problems
Networks for Clinical Research: in a community and a determination of all quantita-
http://www.clinicalresearchnetworks.org tive and qualitative considerations of that problem.
The function of policy development involves the
creation of solutions and action steps with appro-
priate rules, regulations, statutes, and laws, and
Public Health protocols related to these solutions. The final func-
tion involves assurance, which relates to the imple-
mentation of the solutions in the area of action.
Public health involves promoting health and pre- A clarification of these core functions involves
venting disease for all people in a community. The the public health system carrying out the 10 essen-
mission of public health is to promote health and tial public health services:
mental health and prevent disease, injury, and dis-
ability for all the inhabitants of a community or
1. Monitor health status to identify community
other jurisdiction. Society has an interest in pro-
problems.
tecting its population and making assurances to
that population that the society will endeavor to 2. Diagnose and investigate health problems and
create conditions for all people to be healthy. health hazards in the community.
Public health practitioners carry out the mission of 3. Inform and educate people about health issues
public health through assessment, policy develop- and empower them to deal with the issues.
ment, and the application of the essential public
health services. The vision of public health is to 4. Mobilize community partnerships to identify
promote a healthy people in healthy communities and solve health problems.
agenda. At a scientific level, this means that 5. Develop policies and plans that support
research and practice will be oriented to prevent- individual and community health efforts.
ing disease before it occurs (primary prevention),
6. Enforce laws and regulations that protect
finding ways to prolong life, encouraging healthy
health and ensure safety.
lifestyles with individual responsibility for main-
taining these lifestyles, and developing a public 7. Link people to needed personal health
health system that promotes health for all its services and ensure the provision of
population through organized community efforts healthcare when otherwise unavailable.
Public Health 973
8. Ensure a competent public health and funding in the state. However, the subdivisions
personal healthcare work force. within state agencies are not common among all
states. For example, environmental public health
9. Evaluate effectiveness, accessibility, and quality
programs may be in a different agency than popu-
of personal and population-based services.
lation-based programs. In Illinois, for example,
10. Conduct research for new insights and family health programs are in the Illinois
innovative solutions to health problems. Department of Human Services and not in the
Illinois Department of Public Health. State health
agencies are involved in a range of activities from
Structure of the American
drinking water regulation; vital statistics and epi-
Public Health Service System
demiologic surveillance; food safety; tobacco pre-
Most public health agencies in the United States vention and control; Women, Infants, and Children
are found at the state and local levels. Although (WIC) programs; health professions licensing;
the American public health system tends to be health facility regulation; medical and forensic
decentralized, with different structures between examination; public health laboratories; mental
states and localities, it is possible to see a public health; drug and alcohol abuse prevention; envi-
health presence at the national level. The U.S. ronmental health and regulation; and Medicaid.
Public Health Service includes the Office of Public On a day-to-day basis, most of the work of
Health and Science (OPHS) and eight operating public health professionals is carried out at the
agencies. These agencies are (1) the Health local level. It is estimated that there are about
Resources and Services Administration (HRSA), 3,200 local health departments in the United
(2) Indian Health Service (IHS), (3) Centers for States at the regional, district, county, or munici-
Disease Control and Prevention (CDC), (4) pal level. About 60% of these local health depart-
National Institutes of Health (NIH), (5) Food and ments are county based. The remainder are
Drug Administration (FDA), (6) Substance Abuse city-county agencies, multicounty agencies, or
and Mental Health Services Administration some other hybrid. In terms of governance, these
(SAMHSA), (7) Agency for Toxic Substances and entities are either a freestanding part of the local
Disease Registry (ATSDR), and (8) the Agency for government, a local agency where all staff are
Healthcare Research and Quality (AHRQ). part of the state agency, a mixed model with both
There are also 10 Regional Health Administrators state and local shared responsibility, a mixed
for the federal regions of the country. Under pattern, or, in a few instances, a not-for-profit
Section 330 of the Public Health Service Act, there agency such as a hospital contracting with the
are also a number of Community Health Centers local government to manage the public health
(CHC) around the country that provide ambula- programs of the jurisdiction. Most local health
tory healthcare in areas where there are few health departments are small organizations. About 70%
services for a population or a special needs popula- serve a population of 50,000 or less. More than
tion. These centers coordinate federal, state, and 80% of these agencies are associated with a local
local resources to deliver health and social services board of health.
to a designated population. The federal govern- In recent years, there has been an initiative to
ment also provides funds to the states for desig- develop an operational definition of a functional
nated program development, such as HIV/AIDS local health department. In concert with this activ-
programs. In fact, the federal government is the ity, there has been an initiative to develop a volun-
largest purchaser of health-related services. tary national accreditation process for local health
All 50 states have a public health presence departments. Some experts believe that an opera-
within some state agency. State public health agen- tional definition may lead to a reduction in the
cies are either freestanding or units of a multipur- number of local health departments as some
pose health and human services agency. These smaller programs consolidate with other local
agencies are responsible for identifying and meet- agencies or other small agencies into some region-
ing the health needs of the residents of the states. ally based model. Regardless of structure or pat-
They are often responsible for monitoring federal tern of governance, a functional health department
974 Public Health
would need to meet certain standards, such as the •• Use and contribute to the evidence base of
following: public health.
•• Strategically plan its services and activities,
evaluate performance and outcomes, and make
•• Understand the specific health issues confronting
adjustments as needed to continually improve its
the community.
effectiveness, enhance the community’s health
•• Investigate health problems and health threats.
status, and meet the community’s expectations.
•• Prevent, minimize, and contain adverse health
effects from communicable diseases, disease
outbreaks from unsafe food and water, chronic These standards are closely allied to the core
diseases, environmental hazards, injuries, and functions and essential public health services dis-
risky health behaviors. cussed above. These standards can serve as guide-
•• Lead planning and response activities for public lines for the fundamental responsibilities of the
health emergencies. local health department. They also will be critical
•• Collaborate with other local responders and with in any agency accreditation process.
state and federal agencies to intervene in other
emergencies with public health significance.
Public Health Workforce
•• Implement health promotion programs.
•• Engage the community to address public The public health workforce is composed of indi-
health issues. viduals from diverse backgrounds, education, and
•• Develop partnerships with public and private training in fields including medicine, nursing, psy-
healthcare providers and institutions, chology, social work, epidemiology, biostatistics,
community-based organizations, and other laboratory science, law, public administration,
governmental agencies engaged in services that business, economics, pharmacy, veterinary medi-
affect health to collectively identify, alleviate, cine, social sciences, education, and public health.
and act on the sources of public health This diversity serves both as strength and a weak-
problems. ness in the definition of public health and in the
•• Coordinate the public health system’s efforts in dimensions of how to carry out the work of public
an intentionally noncompetitive and health. The U.S. census reports about 250,000 full-
nonduplicative manner. time equivalent health workers employed by local
•• Address health disparities. governments. In 2004, there were about 550,000
•• Serve as an essential resource for local governing full-time equivalent workers in the governmental
bodies and policymakers on up-to-date public sector at the federal, state, and local levels. In a
health laws and policies. more recent survey of the public health workforce
•• Provide science-based, timely, and culturally in local public health departments, it was estimated
competent health information and health alerts that there were 160,000 in 2005. Managers and
to the media and the community. administrators constitute about 6%, nurses 24%,
•• Provide its expertise to others who treat or environmental specialists/scientists 10%, clerical
address issues of public health significance. staff 27%, health educators 3%, nutritionists 3%,
•• Ensure compliance with public health laws and and other designated health professionals such as
ordinances using enforcement authority when physicians constitute about 4%; the remaining
appropriate. 23% are uncategorized workers. With regard to
•• Employ well-trained staff members who have physicians, it is estimated that there will be a need
the necessary resources to implement best for 10,000 more public health physicians in the
practices and evidence-based programs and coming decades than we have now. Currently,
interventions. there are about 10,000 public health physicians.
•• Facilitate research efforts, when approached by It is also estimated that there will be critical
researchers, that benefit the community. shortages of public health nurses, environmental
Public Health 975
health specialists, health educators, epidemiologists, additional content areas: (1) informatics, (2) genomics,
and information technology (IT) specialists in the (3) communication, (4) cultural competence,
future. Since September 11, 2001, there has been an (5) community-based participatory research, (6)
increase in the number of public health workers global health, (7) policy and law, (8) ethics, (9) lead-
involved in emergency preparedness and response. ership, (10) public health emergency preparedness,
As federal funding for these activities declines, it is and (11) clinical and community preventive services.
predicted that there will be some decline in the gov-
ernmental public health workforce.
Public Health Emergency Preparedness
Since the terrorist attacks of September 11,
Public Health Education Programs 2001, emergency preparedness and response
Although there are many individuals in the public have become major activities for local public
health workforce, many have not been specifically health departments. These local entities have
trained in public health. Schools of public health and significantly increased their ability to address
public health programs that are accredited by the public health emergencies with federal funding
Council on Education for Public Health (CEPH) from the Centers for Disease Control and
provide academic training in public health. Currently, Prevention (CDC). Whereas only 20% of local
there are 39 accredited Schools of Public Health and health departments had comprehensive emer-
67 accredited graduate public health programs in the gency response plans in 2001, more than 90%
United States. All the schools have curricula that are have such a plan in late 2007. Funding is begin-
competency based. A credentialing process has been ning to be cut, with concern about the ability to
developed to credential master’s of public health maintain this emergency preparedness momen-
(MPH) graduates of the schools and other accred- tum in the future. About 20% of local health
ited public health programs. The first credentialing departments hold that they are fully prepared
examination was held in the summer of 2008. now, and 77% hold that improvements have
There are a number of core competencies that been made since 2001. Since 2005, funding has
have been developed to demonstrate the skills that declined by almost 30%. With these funding
are needed for successful public health practice. cuts, local public health agencies have had to cut
These competencies include analytic/assessment or lay off staff. Workforce training programs
skills; policy development/program planning skills; have been curtailed as a result. More than 55%
community dimensions of practice skills; basic public of local public health agencies do not think that
health sciences skills; communication skills; cultural they can achieve their deliverables within the
competency skills; financial planning and manage- designated time frames. In addition, local public
ment skills; and leadership and systems thinking. health agencies are finding it difficult to find and
Prior to 2002, five major curriculum content hire emergency preparedness planners, epidemi-
areas were designated as important for public ologists, and nurses. The only positive element
health practice: (1) biostatistics, (2) epidemiology, has been an increase in funding for pandemic
(3) environmental health sciences, (4) health ser- influenza planning. Staff have been redeployed
vices administration, and (5) social and behavioral to address this new health priority.
sciences. A number of educational programs also
Louis Rowitz
included content on community health and labora-
tory sciences. See also American Public Health Association (APHA);
During this first decade of the 21st century, the Centers for Disease Control and Prevention (CDC);
national Institute of Medicine (IOM) has strongly Community-Based Participatory Research (CBPR);
advocated the addition of a number of other Community Health; Community Health Centers
content areas that are critical for public health (CHCs); Emergency and Disaster Preparedness;
practice in the new century. They have identified 11 Epidemiology; Preventive Care
976 Public Health Policy Advocacy
Further Readings
Aday, Lu Ann, ed. Reinventing Public Health: Policies
Public Health
and Practices for a Healthy Nation. San Francisco: Policy Advocacy
Jossey-Bass, 2005.
Institute of Medicine. The Future of the Public’s Health Almost every decision made by policymakers
in the 21st Century. Washington, DC: National influences public health. Whether a given policy is
Academies Press, 2003. directly related to healthcare, or whether it indi-
Institute of Medicine. Training Physicians for Public rectly affects human health or the environment,
Health Careers. Washington, DC: National public health advocates must be cognizant of the
Academies Press, 2007. policy-making process and how to influence that
National Association of County and City Health process. Examples of issues affecting public health
Officials. Operational Definition of a Functional
range from environmental regulation to education
Local Health Department. Washington, DC: National
policy and from transportation projects to con-
Association of County and City Health Officials,
sumer protection. And, of course, key to public
2005.
health policy analysis are issues involving access,
National Association of County and City Health
costs, and quality of healthcare.
Officials. Federal Funding for Public Health
Emergency Preparedness. Washington, DC: National
Association of County and City Health Officials,
2007. Developing a Policy Action Plan
National Association of County and City Health To advocate for a public health policy, a policy
Officials. Informatics at Local Health Departments. action plan should be developed. The basic issues
Washington, DC: National Association of County for developing such a plan are discussed below.
and City Health Officials, 2007.
National Association of County and City Health
Officials. The Local Health Department Workforce. The “Commodity” of Information
Washington, DC: National Association of County
and City Health Officials, 2007.
For each issue, information must be collected,
Rowitz, Louis. Public Health for the 21st Century: The analyzed, assimilated, and delivered. A Policy
Prepared Leader. Sudbury, MA: Jones and Bartlett, Action Plan should be developed to clearly and
2006. concisely provide a strategy for consensus building.
Turnock, Bernard J. Public Health: What It Is and How Types of information to be collected include data
It Works. 3d ed. Sudbury, MA: Jones and Bartlett, from research-based studies, epidemiological stud-
2004. ies, and cost-benefit analyses as well as informa-
tion about previous policy approaches to addressing
the issue from other jurisdictions, and adopted
Web Sites policies. Information about policymakers should
also be collected. Who cares most about this issue?
Why? Can they assist in advocacy efforts? Advocacy
http://www.apha.org
channels are also a key consideration. Is the issue
Association of Schools of Public Health (ASPH):
best addressed by legislators, or should relief be
http://www.asph.org
sought through administrative routes?
Association of State and Territorial Health Officials
(ASTHO): http://www.astho.org
Council on Education for Public Health (CEPH): Legislative Branch
http://www.ceph.org
National Association of County and City Health Most policy-making venues have both legislative
Officials (NACCHO): http://www.naccho.org and executive branches. Understanding how to
Trust for America’s Health (TFAH): navigate through the policy-making infrastructure is
http://www.healthyamericans.org key to effective policy advocacy. On the legislative
Public Health Policy Advocacy 977
side, advocates need to familiarize themselves with school, it may be best to seek out solutions at the
the bill-making process, committee structures, and local school level. If the issue concerns county
individual legislators and their staff. Each jurisdic- health departments, it may be most effective to
tion has slightly different rules for how a bill advocate the issue with the proper county policy-
becomes law. Key legislative committees will include makers. An effective advocate will determine
those relating to healthcare, public health, health which local or regional policymakers chair the
disparities, education, justice reform, environment, relevant committees, which ones are passionate
and transportation, to name a few. Appropriations about the topic, which ones have direct experience
committees often operate under a different set of with the topic, and so on. The same analysis holds
rules that may significantly influence how programs true with issues at the state, federal, and interna-
are funded and administered. tional levels.
Identifying external stakeholders is another
important exercise that policy advocates must
Executive Branch undertake. What constituency and interest groups
On the executive side, policy advocates need to will support or oppose the initiative? Which orga-
understand the agency structure, the rule-making nizations will take a lead role in assisting in advo-
process, and key administrators. Executive cacy efforts? Other external stakeholders, including
branches at the local, regional, state, and federal private-sector organizations such as hospitals,
level often mirror each other. For instance, at the healthcare systems, insurance companies, and
federal level, the U.S. Department of Health and pharmaceutical companies, should also be cata-
Human Services (HHS) houses most of the key logued as potential advocacy channels. Which
public health and healthcare agencies, including organizations’ Web pages, newsletters, or events
the Centers for Disease Control and Prevention can be used for advocacy? Advocates should also
(CDC) and the National Institutes of Health research private funders, including nonprofit foun-
(NIH). At the same time, most federal funding dations and corporate foundations, to determine
flows through state departments of health and opportunities to leverage funding.
human services, which have subagencies for each
relevant funding stream.
Delivering Information/Direct Advocacy Channels
The administrative rulemaking process deter-
mines how funds flow to various agencies and the Often, advocates have opportunities to discuss
rules under which those funds will be distributed. their issue directly with policymakers. A single
At the federal level, information on the rulemaking meeting, if handled correctly, can have a tremen-
process is found in the Federal Register. Typically, dous impact on the policy-making process. Direct
each state’s administrative code can be accessed advocacy channels range from formal meetings to
through the state’s official Web site. While many happenstance encounters at, say, the pharmacy.
localities also house their ordinances and local Most often, formal meetings can occur in an
rules online, advocates may be required to make elected policymaker’s capital or district office.
the trip to city hall to obtain a copy of relevant Careful consideration should be given to where the
regulations. meeting occurs and who attends. Elected policy-
makers are often passionate about public health
issues and can easily be approached to discuss a
Identifying Stakeholders
specific issue. Most direct advocacy opportunities,
Effective public health policy advocacy must however, will occur in a short meeting; advocates
include an analysis of the various stakeholders. must be well prepared to maximize the contact.
The inquiry should begin by identifying the proper Formal and informal meetings with administra-
venue for advocacy. Is the issue best addressed at tive policymakers are an often overlooked oppor-
the local, state, country, or international level? For tunity for effective issue advocacy. Regulators are
example, if the issue concerns children’s health in generally well informed about the intricacies of the
978 Public Policy
policy-making process as well as the complexities Further Readings

of implementing policies on particular issues. Bodenheimer, Thomas S., and Kevin Grumbach.
Establishing relationships with regulators can pro- Understanding Health Policy: A Clinical Approach.
vide unmatched advocacy opportunities, particu- 3d ed. New York: McGraw-Hill, 2002.
larly when the individual has a direct interest in the Dye, Thomas R. Understanding Public Policy. 12th ed.
issue or where the affected agency has the issue as New York: Prentice Hall, 2007.
a core competency. Longest, Jr., Beaufort B. Health Policymaking in the
United States. 4th ed. Chicago: Health Administration
Advocacy Tools Press, 2006.
Teitelbaum, Joel B., and Sara E. Wilensky. Essentials of
In addition to direct contact with policymakers, Public Health Law and Policy. Sudbury, MA: Jones
advocates deliver information in various written and Bartlett, 2007.
formats. The most widely used written document
is a fact sheet—a one-page summary of the issue,
recommended action, and rationale for the pro- Web Sites
posed action. Fact sheets should also include a
messaging component as well as a clearly articu-
http://www.apha.org
lated summary of the request. Other written advo-
cacy tools include issue papers, correspondence,
http://www.kff.org
letters to the editor, brochures, and Web pages, to National Association for Public Health Policy (NAPHP):
name a few. Policymakers pay significant attention http://www.naphp.org
to handwritten letters from their constituents.
Other types of letters include form letters signed by
individuals and those listing supporting organiza-
tions. In addition to written communications, Public Policy
advocates sometimes use messaging tools such as
pins and bumper stickers. Public policy represents the codification of main-
stream values. Policy comes in the form of legisla-
Future Implications tion, regulation, executive decisions, budget
allocations, and court decisions. Public policy rep-
To be most effective, public health policy advo- resents the official direction or pronouncement of
cates should carefully map out a policy action governmental institutions (the legislature, execu-
plan for each issue. Methods for collecting, ana- tive, or judicial branches) on a particular subject
lyzing, assimilating, and delivering relevant infor- or issue. In the United States, public policy is pro-
mation to policymakers at the local, regional, mulgated at the federal, state, and local levels of
state, national, and international levels should be government by elected and appointed officials. As
carefully considered. Tools for advocacy should mainstream values change over time, so does pub-
include face-to-face meetings as well as written lic policy. This change may be the result of elec-
communication. Meetings should be short, and tions, interpretations of the courts concerning
written documents should be clear and concise. legislation, lobbying, or public opinion. Policy
Without question, public health policy advocates represents the product of a priority-setting pro-
can influence the policy-making process on sig- cess. Public policy in the area of healthcare, there-
nificant issues relating to healthcare, health dis- fore, represents the official decisions of government
parities, and the environment, among others. on access, allocation of resources, delivery, financ-
William C. Kling ing, and organization of healthcare services.
See also Equity, Efficiency, and Effectiveness in Basic Premises

Healthcare; Forces Changing Healthcare; Healthcare
Reform; Health Disparities; Public Health; Public In the United States, the basic value at the founda-
Policy; Regulation tion of public policy concerning healthcare is that
Public Policy 979
healthcare is not a legal right of citizenship. Instead, Hospital Expansion

healthcare is considered to be a privilege usually
After World War II, President Truman assigned
associated with a benefit of employment. Only for
a high priority to health insurance. He built on the
those 65 years of age or older and those with very
proposals developed in 1938 and included the fol-
low incomes has the nation created a legal entitle-
lowing components: expansion of hospitals,
ment to health insurance coverage, thus establish-
increased support for public health, support for
ing a right to healthcare for these citizens.
maternal and child health services, increased fed-
The basic model is that healthcare is an indi-
eral support for medical research and education,
vidual, private responsibility for all those in the
and, most significantly, a single health insurance
age range of 18 to 65 whose incomes do not fall
program to provide coverage for all segments of
below the poverty line and who are not disabled,
society. These reforms were defeated for the same
veterans, American Indians, or Alaska Natives.
reasons and by the same coalition that had defeated
The U.S. healthcare system stands out in two
these kinds of proposals in the past.
other ways, which also reflect mainstream values.
It was, however, during the Truman
The first is that it devotes the largest share of its
Administration that part of his vision was realized:
gross domestic product (GDP) to healthcare in
the expansion of hospitals. The U.S. Congress
contrast to other developed nations. In the middle
passed the Hospital Survey and Construction Act,
of the 20th century, less than 5% of its GDP was
also known as the Hill-Burton Act of 1946, which
devoted to healthcare. That percentage rose to
provided for $1 dollar of federal funds for every $2
nearly 14% by the end of the century. Yet the sys-
spent by states in the construction of community-
tem does not necessarily produce superior health
based hospitals.
outcomes (e.g., low infant morality or greater life
With the defeat of the various proposals for
expectancy). The second unique feature of the U.S.
universal health insurance coverage between 1915
healthcare system is that it is not based on some
and 1946, the post–World War II era in healthcare
form of universal healthcare. The system relies, for
was characterized by an expansion of Blue Cross
the most part, on private healthcare providers with
and Blue Shield and other commercial insurance
a mix of private and public insurance as well as
products as well as an increase in prepaid, direct
extensive government regulatory intervention.
service plans, such as the one developed by Henry
Kaiser.
Policy-Making Process
Policy is the product of a process consisting of the
Medicare and Medicaid
following stages: (a) problem definition; (b) for-
mulating options for consideration; (c) debate and With the passage of the Title XVIII (Medicare)
deliberation over the available options; (d) adop- and Title XIX (Medicaid) amendments to the
tion of a particular option; (e) implementation of Social Security Act in 1965, the role of the federal
the selected option, including appropriation of government was fundamentally changed. These
resources to support the option; and (f) assess- programs represented a major change in the gov-
ment or evaluation. This process may vary depend- ernment’s approach to the design, financing, and
ing on which political institution or level of delivery of healthcare. As part of the New Frontier,
government is involved. President Kennedy had flirted with the reintroduc-
tion of a national health insurance proposal.
President Johnson, subsequently, succeeded in the
Legal and Regulatory Foundations
enactment of Medicare, which provided an entitle-
Much of public policy since World War II in the ment to every citizen who reached the age of 65.
healthcare area can be traced to changes in laws Part A of the Medicare program (i.e., reimburse-
and regulations related to healthcare. These policies ment for inpatient, hospital-based treatment) was
relate to access, financing, organization, and service mandated, and Part B (i.e., outpatient care and
delivery. Taken together, these laws and regulations reimbursement for physicians) was to be volun-
represent public policy in American healthcare. tary. Between 1965 and 1985, Medicare helped
980 Public Policy
restructure financing and reimbursement policies ing trend of hospitals not providing treatment to
for all the American healthcare system and not just those who could not afford to pay for the services
for this particular program, because private insur- they were receiving. EMTALA requires hospitals
ance companies adopted reimbursement policies that are receiving any Medicare revenues (which
that were indexed to Medicare. includes almost all the hospitals in the nation) to
Medicaid represented a federal-state partner- provide treatment to all patients seeking care for
ship to provide medical services to low-income emergency medical conditions regardless of the abil-
individuals who meet the eligibility criteria. The ity to pay and regardless of their eligibility for
theory behind Medicaid was that eligible individu- Medicare. The statute requires hospitals to provide
als should be given the buying power in the health- patients with “appropriate medical screening,” and
care marketplace that would provide free choice of patients must also be stabilized, before they can be
providers and open-ended reimbursement, based transferred to another facility.
on reasonable costs and fee-for-service, for nonin- At approximately the same time, there was
stitutional providers. The statute also provided increasing concern in the public and private sector
nonhospital providers with the choice to accept or alike over the rising costs of healthcare and more
reject Medicaid patients. The program provided intensive skepticism over the effectiveness of the
for a core minimum set of services that all states traditional fee-for-service system. This system was
must provide and a second set of services that considered to be user-friendly, allowing for flexi-
states had the option to provide. bility and discretion for providers and patients
alike. However, it did not seem that it could con-
trol costs. Health insurance premium increases, for
Health Maintenance Organization Act example, of 15% to 20% per year were common-
Subsequent to Medicare and Medicaid, the U.S. place in the mid- to late 1980s. In 1990, when
Congress enacted the Health Maintenance employer-sponsored group insurance premiums
Organization (HMO) Act of 1973. This statute increased “by only 14%,” this was considered to
represented a new approach in federal healthcare be good news, because they had risen by 24% in
policy: It was an attempt to gain control over the previous year. This inability to control cost
healthcare pricing by encouraging the development increases was considered to be the fatal flaw of the
of fully integrated healthcare organizations that fee-for-service system.
imposed vertical controls on the cost of services This indictment led to the increased popularity
furnished to their member providers. Congress of managed-care arrangements. The term managed
envisioned that 1,700 HMOs would be developed care encompasses a broad range of healthcare
by 1976, but only a fraction of that number was organizational arrangements that are intended to
ultimately developed. This innovative legislation, eliminate unnecessary and inappropriate care and
proposed by the Nixon Administration, foresaw a to reduce costs. The basic theory of managed care
trend in American healthcare that would ultimately is to control costs by restricting access and services
become quite popular in the 1990s. In 1988, for while maintaining quality. The basic features of
example only 25% of those with employer-based managed care include contractual arrangements
insurance were enrolled in managed-care plans; by with selected providers to furnish a comprehensive
1997, the number increased to 80%. set of healthcare services to its members, significant
financial incentives to steer patients toward provid-
ers and treatments/medical procedures within the
Emergency Medical Treatment
plan, and ongoing accountability of providers for
and Active Labor Act
their clinical and financial performance through
Federal involvement in healthcare was aug- formal quality assurance and utilization review. A
mented in 1986 with the enactment of the Emergency central feature of managed care is the use of a lim-
Medical Treatment and Active Labor Act (EMTALA). ited number of providers who are selected on the
This statute was a response to the growing problem basis of their clinical-practice patterns and specialty
of access to healthcare in the United States. This law and their acceptance of financial incentives for cost
was also in response to what appeared to be a grow- conscious utilization of resources.
Public Policy 981
These managed-care arrangements allow for the job to accept another). It also bars exclusionary
provision and financing of healthcare in a structure practices of insurance companies that are designed
substantially different from the accepted fee-for- to deny coverage to individuals who are bad risks
service arrangement, and they enable managed- because of preexisting medical conditions.
care organizations to take an active role in
monitoring and controlling the amount and type of
Employee Retirement Income Security Act
services provided to patients by physicians and
other caregivers. They differ in the amount of State government has traditionally held the
financial risk that the managed-care organizations right to regulate the insurance industry. Insurance
assume, the way they share risk with providers, the law, certification, and licensing requirements have
restrictiveness of the provider policies, and the level provided states with a measure of control over the
of out-of-pocket costs that the beneficiaries bear. healthcare industry. However, in 1974, the U.S.
Congress passed the Employee Retirement Income
Security Act (ERISA), a comprehensive, uniform
Health Security Act
national system for employee benefit plans, which
With the growing concern over costs, the cri- mandated inclusion of healthcare benefits. ERISA
tique of the fee-for-service system, and the growing provisions have resulted in preemption of state
popularity of managed care, healthcare became a initiatives, especially those oriented at universal
campaign issue in the 1992 presidential race. coverage provided through employer mandates. In
Following his election, President Clinton intro- addition, ERISA has often been interpreted by the
duced a comprehensive proposal (Health Security federal courts to preempt virtually all of the vast
Act [HSA] of 1993) to reform the American body of state insurance, contracts, and other laws
healthcare system. The proposed legislation began or regulations applicable to healthcare plans.
with the premise that healthcare was a legal right As already indicated, the focus of healthcare
for all citizens. This act envisioned universal access policy and law since 1930 has been containment of
to healthcare for all citizens. It used principles of healthcare expenditures. Cost containment efforts
managed competition to increase access and qual- have led to a transformation in the organization
ity of healthcare at the same time. The plan was to and financing of the American healthcare system,
restructure the financing and delivery of services with the government-financed Medicare program
through providing incentives to private insurance serving as a standard for reimbursement. However,
companies, enabling the formation of small groups neither the cost-containment initiatives nor the
and purchasing cooperatives, and by increasing the new programmatic statutes such as EMTALA or
role of government in providing access and ser- HIPAA have addressed what many employers,
vices, as required. During this same time period, at consumers, and third-party payers consider to be
least 10 alternative proposals to reform the nation’s the major flaws with the traditional fee-for-service
healthcare system were introduced by members of system. This has led to the growing acceptance of
the U.S. Congress. None of these proposals, managed care.
including the HSA, were adopted. National data suggest that managed-care organi-
zations are substantially more efficient than indem-
nity plans in controlling costs. The average premiums
Health Insurance Portability
paid for by employers for health benefits decreased
and Accountability Act
substantially between 1989 and 1999. Health
The debate over Clinton’s proposed health plan, insurance premiums began to increase again over
did, however, highlight some of the problems of the the past several years. It could be argued that these
nation’s healthcare system. This recognition led to rate increases are linked to the negative impact of
the adoption of the Health Insurance Portability regulation on managed care. In 1989, the average
and Accountability Act (HIPAA) of 1996. HIPAA premium increase per year was 18%, and by 1996
provides for continued health insurance coverage it was only 1%. The sweeping changes in the orga-
for individuals who might otherwise lose their cov- nization and financing of the healthcare system can
erage as part of a group plan (e.g., for leaving one be attributed to the spread of managed care.
982 Public Policy
However, the growing reliance on managed care of managed-care plans to direct the flow of patients
in the private marketplace and in Medicaid pro- to specific providers, prohibit contracts between
grams was also accompanied by consumer and managed-care plans and provisions that establish
provider dissatisfaction with these new financing, exclusive relationships (contracts that do not per-
administrative, and organizational arrangements. mit providers to sign contracts with other man-
Providers and consumers have advocated for a aged-care plans), and mandate that any provider
larger panel of providers in managed-care networks willing to meet the price terms of the health plan
and less restrictiveness on stepping outside the net- must be accepted into the network—the so-called
work to obtain reimbursable medical services from Any Willing Provider legislation (statutes that
nonnetwork providers. Consumers are looking for stipulate that any provider who meets the criteria
less restricted access to providers than they have in for inclusion in a managed-care organization’s net-
many managed-care plans. Providers, being shut work must be given the opportunity to join the
out of selective contracting and fearing loss of managed-care organization); at least 14 states
income from the closed panels of managed-care have enacted comprehensive Any Willing Provider
organizations, are advocating for unrestricted access laws, and another 14 states have enacted more
for patients. Providers are also demanding that the limited versions of these laws.
administrators of these organizations remove them- Proposed laws that regulate the relationship
selves from, in effect, making therapeutic decisions between managed-care organizations and health-
that result from financing decisions. For example, care consumers include legislation that would
providers and consumers alike strongly object to allow patients direct access to specialists without a
so-called gag clauses, which prevent providers from referral (the so-called direct access laws), which
informing patients about treatment options that the mandates a minimum stay in hospitals for births
managed-care plan does not cover; to policies that and other procedures, and that allows enrollees to
limit hospital stays for childbirth; and to restric- sue managed-care organizations for refusing neces-
tions on patients’ rights to sue managed-care orga- sary treatment.
nizations for denial of needed care. The commonality between these various forms
In response to the growing criticisms of man- of managed-care regulation is that they all focus
aged care by providers and consumers and the on issues of cost and access. A central feature of
increasingly adverse coverage of managed care by managed care’s ability to restrain the rapid rise of
the popular press, state legislatures and the U.S. healthcare costs is its restriction on access and
Congress began to respond with a regulatory strat- choice. Managed care restricts access through the
egy. Since the defeat of the Clinton healthcare use of a limited number of providers who are
reform proposal, states have taken the lead in selected to be part of the plan and through the use
enacting a set of laws limiting the flexibility of of financial incentives to steer patients to providers
managed-care organizations in their contracting who are part of this plan. Elimination or restraint
for and delivery of services. of either of these features significantly affects the
The specific features of managed-care regula- ability of the managed-care organization to con-
tion vary from state to state, but the types of trol costs. Issues of increased access to a broad set
regulation can be divided into two categories: (1) of providers and, hence, increased choice and cost
laws that regulate the relationship between man- control appear to be mutually exclusive if one is
aged-care organizations and healthcare providers trying to adhere to principles of managed care.
and (2) laws that regulate the relationship The plethora of anti-managed-care regulations
between managed-care organizations and health- put forward appears to be a disjointed attempt by
care consumers. state legislators to satisfy disgruntled constituen-
Laws that regulate the relationship between cies by violating the fundamental principles of
managed-care organizations and healthcare pro- managed care that can make it successful. The con-
viders affect how the organizations select, deselect, tinued pressure on state legislatures to respond to
compensate, and control the physicians whom constituent pressure for relief from managed-care
they employ directly or contract with to provide restrictions is not the only issue healthcare reform-
healthcare. These

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Editorial Board

Jeffrey A. Alexander Jack Hadley

Ronald M. Andersen Michael A. Morrisey

SAGE Publications Ltd.

SAGE Publications India Pvt. Ltd.

SAGE Publications Asia-Pacific Pte. Ltd.

Printed in the United States of America.

Library of Congress Cataloging-in-Publication Data

Encyclopedia of health services research/edited by Ross M. Mullner.

This book is printed on acid-free paper.

Publisher: Rolf A. Janke

Annotated Bibliography 1197

AARP Anderson, Odin W.

Chiropractors Diagnosis Related Groups (DRGs)

Gates Foundation Health Services Research in Sub-Saharan Africa

Malpractice National Health Policy Forum (NHPF)

Primary-Care Physicians Single-Payer System

Sackett, David L. Volume-Outcome Relationship

Access to Care Associations

National Citizens’ Coalition for Nursing Home Brook, Robert H.

Donabedian, Avedis Disease, Disability, Health,

TRICARE, Military Health System Case Management

Health Services Research, Origins Healthcare Effectiveness Data and Information

Epidemiology Nursing Home Quality

Editor-in-Chief Who in America, and Who’s Who in the World. He

Lu Ann Aday David J. Ballard Peter Broderick

Kayla Chase Julie S. Darnell Caswell A. Evans

Lisa Chimento Pritha Dasgupta Rupert M. Evans

Llewellyn J. Cornelius Xinjian Du Daniel M. Fox

Sumul Gandhi James C. Hagen William C. Hsiao

Michele A. Kelley Scott M. Leikin Harold S. Luft

Janet B. Mitchell Daniel J. O’Brien E. Carol Polifroni

Kristin Rosengren Heather Sherman Susan M. Swider

Surrey M. Walton Saul J. Weiner Brad Wright

Determining Appropriate Quality Indicators

states and CMS in public reporting. The culmina- Further Readings

provided expert technical assistance, objective AcademyHealth consists of 21 members who

Working to Build the Field These activities supplement AcademyHealth’s

of reasoned action (TRA) is based on the notion Future Implications

on the type of organization or program (2 years Further Readings

The Three Epidemiological Revolutions “killing bacteria, or battling an infection.” In con-

Web Sites medical supplies, and equipment for the cardiac-

Further Readings and/or the U.S. Food and Drug Administration

with advancing age. Even though most medica- Further Readings

Adverse Selection The Lemon’s Principle

Prize for Health Services Research, the Ernest A. Further Readings

Organization Physician. Other publications include Family

Web Sites district chairpersons. Members also vote each year

the AAP, with federal grants awarded to support

Organization and Structure produces legislative updates on issues effecting

informing and educating the public policy com-

requirements such as completing 40 hours of con- career-planning assistance. Additionally, HECRC

wealth of knowledge and experience, along with Further Readings

Background The AHCA relies on its members’ clinical exper-

components—public affairs and both grassroots Further Readings

Web Sites known as Blue Cross. In 1942, the AHA spear-

The AHA offers many data- and information- Web Sites

Nurse, and a year later, the first state nursing

History Affiliate Organizations

ANA. The ANF raises funds and awards grants to Publications

Web Sites framework developed in connection with that sur