Table Of Contenta LANGE medical book
UNDERSTANDING
HEALTH POLICY
A Clinical Approach
EIGHTH EDITION
Thomas Bodenheimer, MD
Professor Emeritus
Department of Family & Community Medicine
University of california, San Francisco
Kevin Grumbach, MD
Professor and Chair
Department of Family & Community Medicine
University of california, San Francisco
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Contents
Preface v
1. Introduction: The Paradox of Excess and Deprivation 1
2. Paying for Health Care 5
3. Access to Health Care 19
4. Paying Health Care Providers 35
5. How Health Care Is Organized-I: Primary, Secondary, and Tertiary Care 47
6. How Health Care Is Organized-II: Health Delivery Systems 61
7. The Health Care Workforce and the Education of Health Professionals 75
8. Painful Versus Painless Cost Control 91
9. Mechanisms for Controlling Costs 105
10. Quality of Health Care 117
11. Prevention of Illness 135
12. Long-Term Care 145
13. Medical Ethics and Rationing of Health Care 153
14. Health Care in Four Nations 169
15. Health Care Reform and National Health Insurance 185
16. Conflict and Change In America's Health Care System 197
17. Conclusion: Tensions and Challenges 209
18. Questions and Discussion Topics 213
Index 221
iii
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Pref ace
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 sur
gical 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 special
ist 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 appre
ciate 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.
THEGOALOFTHEBOOK
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, we call out the failings as well as the
successes of the US approach to financing and organizing care. 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 pre
sented 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.
v
PREFACE
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 perspec
tives here.
THE RIGHT TO HEALTH CARE
We believe that health care should be a right enjoyed equally by everyone. Certain things in life are considered
essential. No one gets excited if someone is turned away from a movie or concert because he or she cannot afford a
ticket. But sick people who are turned away from a medical practice can make headlines, and rightly so. A simple
statement of the right to health care reads something like this: All people should have equal access to a reasonable
level of appropriate health services, regardless of ability to pay.
In 2009, the United States entered into a fierce debate over whether health care should be a right. The debate
focused on President Barack Obama's campaign to enact universal health insurance. Following a year of public
ferment, Congress passed the Affordable Care Act, which moves in the direction of guaranteeing health care as a
right. Yet, at the time of writing this edition of Understanding Health Policy. the controversy continues.
THE IMPERATIVE TO CONTAIN COSTS
We believe that limits must be placed on the costs of health care. Cost controls can be imposed in a manner that
does relatively little harm to the health of the public. The rapidly rising costs of health care are in part created by
scientific advances that spawn new, expensive technologies. Some of these technologies truly improve health, some
are of little value or harmful, and others are of benefit to some patients but are inappropriately used for patients
whom they do not benefit. Eliminating medical services that produce no benefit is one path to "painless" cost con
trol (see Chapter 8).
Reduction in the rapidly rising cost of administering the health care system is another route to painless cost
containment. Administrative excess wastes money that could be spent for useful purposes, either within or outside
the health care sector. While large bureaucracies do have the advantage of creating jobs, the nation and the health
care system have a great need for more socially rewarding and productive jobs (e.g., home health aides, drug
rehabilitation counselors, childcare workers, and many more) that could be financed from funds currently used for
needless administrative tasks.
There is a growing consensus that health care cost increases are bad for the economy. Employers complain that
the high cost ofh ealth insurance for employees reduces international competitiveness. Ifg overnment health expen
ditures continue their rapid rise, other publicly financed programs essential to the nation's economy (e.g., education
and transportation) will be curtailed and the unsustainable government budget deficits will strain the future of the
nation's well-being.
Rising costs are harmful to everyone because they make health services and health insurance unaffordable.
Many companies are shifting more health care costs onto their employees. As government health budgets bal
loon, cutbacks are inevitable, generally hurting the elderly and the poor. Individuals with no health insurance or
inadequate coverage have a far harder time paying for care as costs go up. As a general rule, when costs go up, access
goes down.
For these reasons, we believe that health care costs should be contained, using strategies that do the least harm
to the health of the population.
THE NEED FOR POPULATION-BASED MEDICINE
Most physicians, nurses, and other health professionals are trained to provide clinical care to individuals. Yet clini
cal care is not the only determinant of health status; standard of living and public health measures have an even
PREFACE vii
greater influence on the health of a population (see Chapter 3). Health care, then, should have another dimension:
concern for the population as a whole. Individual physicians may be first-rate in caring for their patients' heart
attacks, but may not worry enough about the prevalence of hypertension, smoking, elevated cholesterol levels,
uncontrolled diabetes, and lack of exercise in their city, in their neighborhood, or among the group of patients
enrolled in their practices. For years, clinical medicine has divorced itself from the public health community, which
does concern itself with the health of the population. We believe that health caregivers should be trained to add a
population orientation to their current role of caring for individuals.
ACKNOWLEDGMENTS
We could not have written this book by ourselves. The circumstances encountered by hundreds of our patients and
dozens of our colleagues provided the insights we needed to understand and describe the health care system. Any
inaccuracies in the book are entirely our responsibility. Our warmest thanks go to our families, who have provided
both encouragement and patience.
Earlier versions of Chapters 2, 4, 5, 8, 9, and 16 were published serially as articles in the Journal of the
American Medical Association (1994;272:634-639, 1994;272:971-977, 1994;272:1458-1464, 1995;273:160-167,
1995;274:85-90, and 1996;276:1025-1031) and are published here with permission (copyright, 1994, 1995, and
1996, American Medical Association).
CONCLUSION
This is a book about health policy. As such, we will cite technical studies and will make cross-national generaliza
tions. We will take matters of profound personal meaning-sickness, health, caring for individuals in need-and
discuss them using the detached language of "inputs and outcomes," "providers and consumers," and "cost
effectiveness analysis." As practicing physicians, however, we are daily reminded of the human realities of health
policy. Understanding Health Policy: A Clinical Approach is fundamentally about the people we care for: the under
insured janitor with high-deductible insurance enduring the pain of a gallbladder attack because surgery might be
unaffordable, or the retired university professor who sustains a stroke and whose life savings are disappearing in
nursing home bills uncovered by her Medicare or private insurance plans.
Almost every person, whether a mother on public assistance, a working father, a well-to-do physician, or a
millionaire insurance executive, will someday become ill, and all of us will die. Everyone stands to benefit from a
system in which health care for all people is accessible, affordable, appropriate in its use of resources, and of high
quality.
Thomas Bodenheimer
Kevin Grumbach
San Francisco, California
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