Understanding health policy: a clinical approach

404 Pages·2016·9.07 MB·English

by  Thomas Bodenheimer

SEVENTH EDITION
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UN DERSTAN DI NG
HEALTH POLICY
A Clinical Approach
SEVENTH ED IT~O N
Thomas Bodenheimer, MD
Professor fmeritus
Departlrnent of Family & Community Medi:cine
LI niversity of Ca lifom ra, San Francisco
Kevin Grumbach, MD
Professor and Ch al r
Departrnent of Family & Community Medicine
lJ niversity of Ca lifom ia, San Francisco
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New York Chicago San Fm nal sco lisbon lo:nd on Madrrd Mexico City
Milan New Delhi Singapore Sydney Toronto
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ISBN: 978-1-25-958476-3
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Contents
Preface
1. Introduction: The Paradox of Excess and Deprivation
2. Paying for Health Care
3. Access to Health Care
4. Paying Health Care Providers
5. How Health Care Is Organized—I: Primary, Secondary, and
Tertiary Care
6. How Health Care Is Organized—II: Health Delivery Systems
7. The Health Care Workforce and the Education of Health
Professionals
8. Painful Versus Painless Cost Control
9. Mechanisms for Controlling Costs
10. Quality of Health Care
11. Prevention of Illness
12. Long-Term Care
13. Medical Ethics and Rationing of Health Care
14. Health Care in Four Nations
15. Health Care Reform and National Health Insurance
16. Conflict and Change in America’s Health Care System
17. Conclusion: Tensions and Challenges
18. Questions and Discussion Topics
Index
Preface
Understanding Health Policy: A Clinical Approach is a book about health
policy as well as individual patients and caregivers and how they interact
with each other and with the overall health system. We, the authors, are
practicing primary care physicians—one in a public hospital and clinic and
the other, for many years, in a private practice. We are also analysts of our
nation’s health care system. In one sense, these two sides of our lives seem
quite separate. When treating a patient’s illness, health expenditures as a
percentage of gross domestic product or variations in surgical rates between
one city and another seem remote if not irrelevant—but they are neither
remote nor irrelevant. Health policy affects the patients we see on a daily
basis. Managed care referral patterns determine to which specialist we can
send a patient; the coverage gaps for outpatient medications in the Medicare
benefit package affects how we prescribe medications for our elderly
patients; and differences in access to care between families on Medicaid and
those with private coverage influences which patients end up seeing one of us
in the private sector over the other in a public hospital. In Understanding
Health Policy, we hope to bridge the gap separating the microworld of
individual patient visits and the macrouniverse of health policy.
THE AUDIENCE
The book is primarily written for health science students—medical, nursing,
nurse practitioner, physician assistant, pharmacy, social work, public health,
and others—who will benefit from understanding the complex environment
in which they will work. Physicians feature prominently in the text, but in the
actual world of clinical medicine, patients’ encounters with other health care
givers are an essential part of their health care experience. Physicians would
be unable to function without the many other members of the health care
team. Patients seldom appreciate the contributions made to their well-being
by public health personnel, research scientists, educators, and many other
health-related professionals. We hope that the many nonphysician members
of the clinical care, public health, and health science education teams as well
as students aspiring to join these teams will find the book useful. Nothing can
be accomplished without the combined efforts of everyone working in the
health care field.
THE GOAL OF THE BOOK
Understanding Health Policy attempts to explain how the health care system
works. We focus on basic principles of health policy in hopes that the reader
will come away with a clearer, more systematic way of thinking about health
care in the United States, its problems, and the alternatives for managing
these problems. Most of the principles also apply to understanding health
care systems in other nations.
Given the public’s intense concerns about health care in the United States,
the book concentrates on the failures of the system. We spend less time on
the successful features because they need less attention. Only by recognizing
the difficulties of the system can we begin to fix its problems. The goal of
this book, then, is to help all of us understand the health care system so that
we can better work in the system and change what needs to be changed.
CLINICAL VIGNETTES
In our attempt to unify the overlapping spheres of health policy and health
care encounters by individuals, we use clinical vignettes as a central feature
of the book. These short descriptions of patients, physicians, and other
caregivers interacting with the health care system are based on our own
experiences as physicians, the experiences of colleagues, or cases reported in
the medical literature or popular press. Most of the people and institutions
presented in the vignettes have been given fictitious names to protect privacy.
Some names used are emblematic of the occupations, health problems, or
attitudes portrayed in the vignettes; most do not have special significance.
OUR OPINIONS
In exploring the many controversial issues of health policy, our own opinions
as authors inevitably color and shade the words we use and the conclusions
we reach. We present several of our most fundamental values and