McCarthy's Introduction to Health Care Delivery (6th Edition) PDF

 n i McCarthy’s A Primer for Pharmacists Sixth Edition Kenneth W. Kimbe...

 n i McCarthy’s A Primer for Pharmacists Sixth Edition Kenneth W. Kimberly S. Plake, PhD Schafermeyer, PhD Robert L. McCarthy, PhD Associate Professor Professor and Director Professor and Dean Emeritus Department of Pharmacy Practice Office of International Programs School of Pharmacy Purdue University, College of Pharmacy St. Louis College of Pharmacy University of Connecticut World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 [email protected] www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to [email protected]. Copyright © 2017 by Jones & Bartlett Learning, LLC, an Ascend Learning Company All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of Jones & Bartlett Learning, LLC. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by Jones & Bartlett Learning, LLC and such reference shall not be used for advertising or product endorsement purposes. All trademarks displayed are the trademarks of the parties noted herein. McCarthy’s Introduction to Health Care Delivery: A Primer for Pharmacists, Sixth Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product. There may be images in this book that feature models; these models do not necessarily endorse, represent, or participate in the activities represented in the images. Any screenshots in this product are for educational and instructive purposes only. Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only. The authors, editor, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use of the products and procedures described. Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used. 09842-6 Production Credits VP, Executive Publisher: David D. Cella Publisher: Cathy L. Esperti Editorial Assistant: Carter McAlister Production Manager: Tina Chen Director of Marketing: Andrea DeFronzo VP, Manufacturing and Inventory Control: Therese Connell Composition: Cenveo® Publisher Services Cover Design: Kristin E. Parker Rights & Media Specialist: Jamey O’Quinn Media Development Editor: Shannon Sheehan Cover Image: Assortment of multicolored pills: © Peter Topp Enge Jonasen/iStockPhoto; hundred dollar bills: © isak55/Shutterstock; U.S. Supreme Court building: © Orhan Cam/Shutterstock; male pharmacist © racorn/Shutterstock Printing and Binding: Edwards Brothers Malloy Cover Printing: Edwards Brothers Malloy Library of Congress Cataloging-in-Publication Data Names: Plake, Kimberly S., editor. | Schafermeyer, Kenneth W., editor. | McCarthy, Robert L., editor. Title: McCarthy’s introduction to health care delivery : a primer for pharmacists / [edited by] Kimberly S. Plake, Kenneth W. Schafermeyer ; founding editor, Robert L. McCarthy. Other titles: Introduction to health care delivery. | Introduction to health care delivery Description: Sixth edition. | Sudbury, MA : Jones & Bartlett Learning, | Preceded by: Introduction to health care delivery. 5th ed. c2012. | Includes bibliographical references and index. Identifiers: LCCN 2016027014 | ISBN 9781284094107 (pbk. : alk. paper) Subjects: | MESH: Delivery of Health Care | Pharmaceutical Services | Drug Industry | Economics, Pharmaceutical | United States Classification: LCC RA395.A3 | NLM W 84 AA1 | DDC 362.10973—dc23 LC record available at https://lccn.loc.gov/2016027014 6048 Printed in the United States of America 20 19 18 17 16 10 9 8 7 6 5 4 3 2 1  To my parents, Ralph and Joyce Illingworth, who instilled in me a love for learning. —Kimberly S. Plake To my wife, Donna, and my daughters, Julia and Valerie. —Kenneth W. Schafermeyer For my grandchildren, Patrick, Cole, Ellie, Oliver, Sawyer, and Charlie. —Robert L. McCarthy © Peter Topp Enge Jonasen/iStockPhoto  Contents Preface................................................................ xvii Contributors............................................................. xx PART I­—SOCIAL ASPECTS OF HEALTHCARE DELIVERY........................ 1 Chapter 1—Healthcare Delivery in America: Historical and Policy Perspectives...... 3 Jennifer L. Tebbe-Grossman Case Scenario......................................................... 3 Learning Objectives.................................................... 4 Chapter Questions..................................................... 4 Introduction.......................................................... 5 Paradoxes of the U.S. Healthcare System................................... 5 Health, Disease, and Health Practitioners in Colonial America.................. 9 America in the 19th Century: The Healthcare Environment................... 10 Continuity and Change in Health Institutions and Professions................. 15 Health and Sickness Patterns in Historical Perspective....................... 21 Health Policy Overview: 1900–1950...................................... 25 Post–World War II Healthcare Changes.................................... 26 The Patient Protection and Affordable Care Act (PPACA)..................... 28 Conclusion.......................................................... 31 © Peter Topp Enge Jonasen/iStockPhoto Questions for Further Discussion........................................ 31 Key Topics and Terms................................................. 31 References........................................................... 32 iv  Contents n v Chapter 2—Healthcare Professionals and Interdisciplinary Care.................. 43 Suvapun Bunniran and David J. McCaffrey III Case Scenario........................................................ 43 Learning Objectives................................................... 43 Chapter Questions.................................................... 44 Introduction......................................................... 44 Professions.......................................................... 44 Collaboration with Healthcare Providers.................................. 59 The Patient Centered Medical Home (PCMH)............................... 63 Defining Quality...................................................... 64 Important Trends Affecting Healthcare Professionals........................ 69 Conclusion.......................................................... 73 Questions for Further Discussion........................................ 74 Key Topics and Terms................................................. 74 References........................................................... 75 Chapter 3—The Pharmacist and the Pharmacy Profession....................... 81 Erin R. Holmes Case Scenario........................................................ 81 Learning Objectives................................................... 81 Chapter Questions.................................................... 82 Introduction......................................................... 82 Evolution of the Profession and Medication Use Systems..................... 83 Expanding the Pharmacist’s Role.........................................86 Pharmacy Education and Training....................................... 92 Professional Pharmacy Organizations..................................... 94 Pharmacy Technicians................................................. 97 Technology and the Pharmacy Profession.................................. 99 Pharmacy Workforce................................................. 102 Conclusion......................................................... 104 Questions for Further Discussion....................................... 105 Key Topics and Terms................................................ 105 References.......................................................... 105 vi n Contents Chapter 4—The Patient................................................... 109 Kimberly S. Plake Case Scenario....................................................... 109 Learning Objectives.................................................. 110 Chapter Questions................................................... 110 Introduction........................................................ 111 Definitions......................................................... 111 Demographics....................................................... 111 Treatment versus Prevention........................................... 112 Patients’ Expectations................................................ 113 Access to Health Information...........................................113 Models of Care...................................................... 114 Adherence.......................................................... 118 Cultural Influence on Health........................................... 121 Health Literacy...................................................... 122 Health Behavior Models............................................... 123 Interventions........................................................ 128 Conclusion......................................................... 132 Questions for Further Discussion....................................... 132 Key Topics and Terms................................................ 132 References.......................................................... 132 Chapter 5—Drug Use, Access, the Supply Chain, and the Role of the Pharmaceutical Industry.................................. 137 Kyle D. Ross, Kimberly S. Plake, and Louis P. Garrison Jr. Case Scenario....................................................... 137 Learning Objectives.................................................. 138 Chapter Questions................................................... 138 Introduction........................................................ 139 Drugs as Remedies, Poisons, or Magical Charms........................... 139 Consumer Perspective on Drug Use......................................140 Health Professionals’ Role in Drug Use................................... 142 Path of a Pharmaceutical from Idea to Prescription......................... 143  Contents n vii Future Trends in the Pharmaceutical Sector............................... 153 Conclusion......................................................... 154 Questions for Further Discussion....................................... 154 Key Topics and Terms................................................ 154 References.......................................................... 155 Chapter 6—Public Health................................................. 159 Ardis Hanson, Peter D. Hurd, and Bruce Lubotsky Levin Case Scenario....................................................... 159 Learning Objectives.................................................. 160 Chapter Questions................................................... 160 Introduction........................................................ 160 Historical Perspective.................................................161 Epidemiology....................................................... 162 Social Determinants of Health: Public Health Model........................ 164 Health Disparities.................................................... 164 Changing Health Priorities............................................. 165 Models for Change................................................... 168 Prevention.......................................................... 169 Pharmacy and Public Health........................................... 172 Conclusion and Implications for Pharmacy............................... 178 Questions for Further Discussion....................................... 178 Key Topics and Terms................................................ 178 References.......................................................... 178 Chapter 7—Quality Improvement and Patient Safety........................... 185 Kyle E. Hultgren and John B. Hertig Case Scenario....................................................... 185 Learning Objectives.................................................. 186 Chapter Questions................................................... 186 Introduction........................................................ 186 Theory of Human Error............................................... 187 Culture of Safety..................................................... 189 viii n Contents Medication Use Process............................................... 190 Error Prone Drug Products............................................. 195 Root Cause Analysis and Failure Mode Effects Analysis..................... 197 Continuous Quality Improvement....................................... 199 PDSA Cycle......................................................... 200 Conclusion......................................................... 206 Questions for Further Discussion....................................... 206 Key Topics and Terms................................................ 206 References.......................................................... 206 PART II—ORGANIZATIONAL ASPECTS OF HEALTHCARE DELIVERY........... 209 Chapter 8—Hospitals..................................................... 211 Catherine N. Otto and William W. McCloskey Case Scenario....................................................... 211 Learning Objectives.................................................. 211 Chapter Questions................................................... 212 Introduction........................................................ 212 Historical Perspective.................................................212 Financing Hospital Care............................................... 213 Value-Based Purchasing............................................... 214 Hospital Characteristics............................................... 214 Hospital Management.................................................216 American Hospital Association......................................... 217 Hospital Accreditation................................................ 217 The Future of Hospitals............................................... 217 The Pharmacist’s Role in a Hospital-Based Practice......................... 218 Responsibilities of the Hospital Pharmacy................................ 219 Drug Distribution Systems............................................. 220 Centralized versus Decentralized Pharmacy Services....................... 221 Intravenous Admixture Services........................................ 222 Nondistributive Pharmacy Services..................................... 222 Adverse Drug Reaction Monitoring...................................... 223  Contents n ix Hospital Formulary System............................................ 224 Purchasing and Inventory Control....................................... 225 Residency and Fellowship Programs..................................... 225 Conclusion......................................................... 226 Questions for Further Discussion....................................... 226 Key Topics and Terms................................................ 227 References.......................................................... 227 Chapter 9—Ambulatory Care.............................................. 229 David M. Scott Case Scenario....................................................... 229 Learning Objectives.................................................. 229 Chapter Questions................................................... 230 Introduction........................................................ 230 Growth of Ambulatory Care............................................ 230 Types of Medical Practices............................................. 235 Managed Care....................................................... 236 Medical Homes...................................................... 236 Hospital-Related Ambulatory Services................................... 238 Emergency Services.................................................. 240 Freestanding Services.................................................241 Government Programs................................................ 241 Miscellaneous Programs...............................................245 Ambulatory Pharmacy Services......................................... 247 Conclusion......................................................... 251 Questions for Further Discussion....................................... 251 Key Topics and Terms................................................ 251 References.......................................................... 251 Chapter 10—Long-Term Care.............................................. 255 Aleda M. H. Chen and Emily Laswell Case Scenario....................................................... 255 Learning Objectives.................................................. 256 x n Contents Chapter Questions................................................... 256 Introduction........................................................ 256 Patients Who May Require Long-Term Care Services........................ 257 Financing Long-Term Care............................................. 259 Increasing Need for Facilities.......................................... 261 Institutional Services................................................. 263 Home and Community-Based Services................................... 265 Future of Long-Term Care............................................. 267 Pharmacy Services in Long-Term Care................................... 268 Conclusion......................................................... 276 Questions for Further Discussion....................................... 276 Key Topics and Terms................................................ 276 References.......................................................... 277 Chapter 11—Behavioral Health Services..................................... 283 Ardis Hanson, Carol A. Ott, and Bruce Lubotsky Levin Case Scenario....................................................... 283 Learning Objectives.................................................. 284 Chapter Questions................................................... 284 Introduction........................................................ 284 Epidemiology of Mental Disorders...................................... 286 Landmark Reports and Legislation in Mental Health........................ 289 Behavioral Health Services Delivery and the Community Pharmacist.......... 290 Evidence-Based Practice/Treatment Guidelines............................ 291 Mental Health Teams and the Role of the Pharmacist....................... 292 Prevention and Promotion............................................. 293 The Role of Pharmacists in Rural America................................ 294 ERISA and Pharmacy Benefits Managers................................. 295 Legal and Ethical Issues............................................... 296 Implications for Pharmacists and Pharmacy Practice........................ 297 Questions for Further Discussion....................................... 298  Contents n xi Key Topics and Terms................................................ 298 References.......................................................... 298 Chapter 12—Home Care.................................................. 305 William W. McCloskey Case Scenario....................................................... 305 Learning Objectives.................................................. 305 Chapter Questions................................................... 306 Introduction........................................................ 306 Home Care Industries................................................. 306 Factors that Influence the Home Care Industry............................ 311 The Role of the Home Care Pharmacist................................... 314 Conclusion......................................................... 319 Questions for Further Discussion....................................... 319 Key Topics and Terms................................................ 319 References.......................................................... 319 Chapter 13—Government Involvement in Health Care......................... 321 William G. Lang IV Case Scenario....................................................... 321 Learning Objectives.................................................. 321 Chapter Questions................................................... 322 Introduction........................................................ 322 Committees......................................................... 323 Federal Agencies.................................................... 325 Federal Agencies with Healthcare Related Missions........................ 326 Federal Public Health Agencies......................................... 327 Role of Citizens in the Iron Triangle..................................... 333 The Patient Protection and Affordable Care Act of 2010..................... 336 Conclusion......................................................... 338 Questions for Further Discussion....................................... 338 Key Topics and Terms................................................ 338 References.......................................................... 339 xii n Contents PART III—ECONOMIC ASPECTS OF HEALTHCARE DELIVERY................. 347 Chapter 14—Basic Economic Principles Affecting Health Care................... 349 Kenneth W. Schafermeyer and Scott K. Griggs Case Scenario....................................................... 349 Learning Objectives.................................................. 349 Chapter Questions................................................... 350 Introduction........................................................ 350 Economic Concepts in Individual Consumer Decision Making................ 351 Law of Diminishing Marginal Utility.................................... 352 The Law of Demand.................................................. 353 The Law of Supply................................................... 358 Equilibrium Price.................................................... 361 Elasticity of Demand................................................. 363 Determinants of Elasticity of Demand.................................... 366 Elasticity of Demand for Prescription Drugs............................... 367 Conclusion......................................................... 368 Questions for Further Discussion....................................... 368 Key Topics and Terms................................................ 369 Chapter 15—Unique Aspects of Health Economics............................. 371 Kenneth W. Schafermeyer Case Scenario....................................................... 371 Learning Objectives.................................................. 371 Chapter Questions................................................... 372 Introduction........................................................ 372 Perfectly Competitive Industries........................................ 372 Other Market Structures............................................... 373 The Healthcare Market................................................ 374 Improving Economic Performance of the Healthcare System................. 378 Conclusion......................................................... 381 Questions for Further Discussion....................................... 381 Key Topics and Terms................................................ 381  Contents n xiii References.......................................................... 382 Acknowledgment.................................................... 382 Chapter 16—Private Health Insurance....................................... 383 Kenneth W. Schafermeyer and Taehwan Park Case Scenario....................................................... 383 Learning Objectives.................................................. 383 Chapter Questions................................................... 384 Introduction........................................................ 384 Iron Triangle of Health Care............................................ 385 History of Health Insurance............................................ 388 The Health Insurance Industry......................................... 391 Basic Principles and Strategies of Health Insurance......................... 393 Administration of Prescription Drug Programs............................. 398 Impact of Health Insurance on Pharmacy................................. 402 Conclusion......................................................... 403 Questions for Further Discussion....................................... 404 Key Topics and Terms................................................ 404 References.......................................................... 404 Chapter 17—Managed Health Care......................................... 407 Kenneth W. Schafermeyer and Taehwan Park Case Scenario....................................................... 407 Learning Objectives.................................................. 408 Chapter Questions................................................... 408 Introduction........................................................ 408 The History of Managed Care...........................................408 Types of Managed Care Organizations................................... 409 Consumer-Driven Health Plans......................................... 413 Managing the Pharmacy Benefit........................................ 413 Ethical Issues in Managed Care......................................... 419 Quality in Managed Care.............................................. 421 Creating Incentives................................................... 423 xiv n Contents Impact of Managed Care on Pharmacists.................................. 423 Conclusion......................................................... 424 Questions for Further Discussion....................................... 424 Key Topics and Terms................................................ 424 References.......................................................... 425 Chapter 18—Medicare and Medicaid........................................ 427 Scott K. Griggs, Taehwan Park, and Kenneth W. Schafermeyer Case Scenario: Medicare.............................................. 427 Learning Objectives.................................................. 427 Chapter Questions: Medicare........................................... 428 Chapter Questions: Medicaid...........................................428 Medicare: Legislative History.......................................... 428 Program Structure....................................................429 Eligibility.......................................................... 429 Financing.......................................................... 430 Administration...................................................... 430 Medicare Services and Cost Sharing..................................... 431 Expenditures........................................................ 436 Spending by Type of Service........................................... 436 Medicare Supplement (Medigap) Insurance............................... 437 Case Scenario: Medicaid.............................................. 438 Medicaid: Legislative History.......................................... 438 Eligibility.......................................................... 439 Financing and Administration.......................................... 441 Medicaid Services and Cost Sharing..................................... 442 Expenditures........................................................ 443 State Flexibility..................................................... 444 Comparison of Medicare and Medicaid.................................. 445 Pay for Performance.................................................. 445 Medicare’s Hospital Readmissions Reduction Program...................... 446 Medicare Star Ratings.................................................446  Contents n xv Questions for Further Discussion....................................... 447 Key Topics and Terms................................................ 447 References.......................................................... 447 Chapter 19—Pharmacoeconomics.......................................... 451 Scott K. Griggs, Craig I. Coleman, Taehwan Park, and Kenneth W. Schafermeyer Case Scenario....................................................... 451 Learning Objectives.................................................. 452 Chapter Questions................................................... 452 Introduction........................................................ 453 Comparing Pharmacoeconomic Methodologies............................ 454 Steps for Conducting a Pharmacoeconomic Evaluation...................... 457 Pharmacoeconomic Methodologies...................................... 467 Approaches to Conducting Pharmacoeconomic Studies..................... 474 Critical Appraisal of a Pharmacoeconomic Study.......................... 478 Conclusion......................................................... 478 Questions for Further Discussion....................................... 478 Key Topics and Terms................................................ 479 References.......................................................... 479 Chapter 20—International Healthcare Services............................... 483 Ana C. Quiñones-Boex and Gregory A. Garcia Case Scenario....................................................... 483 Learning Objectives.................................................. 484 Chapter Questions................................................... 484 Introduction........................................................ 485 “Developed” and “Developing” Countries................................ 485 Healthcare Delivery Systems in Selected Nations.......................... 489 International Healthcare Systems: Implications for the United States.......... 505 Conclusion......................................................... 507 Questions for Further Discussion....................................... 507 Key Topics and Terms................................................ 507 References.......................................................... 507 xvi n Contents Chapter 21—Healthcare Reform............................................ 513 Catherine N. Otto and Thomas E. Buckley Learning Objectives.................................................. 513 Chapter Questions................................................... 513 Introduction........................................................ 514 Identification of the Problem........................................... 514 An Issue of Access................................................... 515 The Best Health Care?................................................ 515 Demand versus Need................................................. 515 Healthcare Reform Efforts by the Federal Government...................... 516 Healthcare Reform Efforts by the States.................................. 522 The Pharmacy Profession and Healthcare Reform: A Call for Action........... 528 Conclusion......................................................... 529 Questions for Further Discussion....................................... 529 Key Topics and Terms................................................ 529 References.......................................................... 530 Glossary............................................................... 533 Index.................................................................. 557  Preface When the First Edition was published in 1998, Professor McCarthy hoped to meet a textbook need he felt was not adequately met. As an instructor who taught healthcare delivery, systems, and policy, he had long sought a book that provided an introduction to this rapidly evolving area, but that would do so from the perspective of pharmacy. In subsequent editions, we believe that we have been true to his original intent. Over the years, as we developed new editions, we tried to be responsive to the needs of our colleagues by adding, subtracting, and changing subject matter; by providing active learning exercises; and by developing online resources for instructors and students. Given the rapidly changing nature of healthcare delivery, we have also been committed to an aggressive revision schedule; this Sixth Edition is being published just 18 years after the First Edition. The Sixth Edition includes several major revisions and chapter restructures to reflect the myriad changes that have occurred since the last edition 5 years ago. Chapter 7, Quality Improvement and Patient Safety, was added to reflect the growing importance in pharmacists’ work in this area. A new author has joined us and completely rewritten Chapter 13, Government Involvement in Health Care, using his many years of governmental relations experience to provide the reader a comprehensive, yet easy to follow, overview of how government impacts health care delivery in the United States each day, especially as we enter the sixth year of The Patient Protection and Affordable Care Act. Chapter 20, International Healthcare Services, again offers an opportunity for the reader to compare the wide array of health care delivery systems around the world, even as the United States opens a new chapter in its relationship with Cuba. We hope you will find the Sixth Edition of Introduction to Health Care Delivery: A Primer for Pharmacists achieves the goals of its forebears, but also enables instructors and students of healthcare delivery to consider, more fully, how healthcare services in general—and pharmacy services in particular—are delivered. Moreover, we hope that the text and its supplementary materials—including those provided online—will facilitate thoughtful discussions among students, faculty, and practitioners about not only how health care is delivered, but how the system might be improved for all those seeking care. © Peter Topp Enge Jonasen/iStockPhoto Kimberly S. Plake, West Lafayette, Indiana Kenneth W. Schafermeyer, St. Louis, Missouri Robert L. McCarthy, Storrs, Connecticut 2016 xvii  What’s New to this Edition The sixth edition of McCarthy’s Introduction to Health Care Delivery: A Primer for Pharmacists includes new and updated information to reflect recent changes since the previous edition was published. This edition incorporates important updated material relating to the Affordable Care Act, Medicare and Medicaid, as well as an expanded section on pharmacist roles in public health, including immunizations, bioterrorism, and community health clinics. It includes information on post-graduate education, resources, and credentialing as well as scope of practice and related leg- islation and information on fellowships. Information on improving patient safety, drug safety, and pharmaceutical industry and drug devel- opment is included in the new Chapter 7, Quality Improvement and Patient Safety. This chapter also covers new information on medication use processes including prescribing, monitoring, med- ication errors, and error prone drug products. Chapter 13, Government Involvement in Health Care, was greatly rewritten to provide new infor- mation focusing on government’s perspective on the role of pharmacists and specific examples of state health insurance programs, including challenges of the Veterans Health Administration system. Information on global health care and developing countries was also added to this edition. Recent developments and changes to online healthcare availability led to new information on E-commerce, internet pharmacy, and other technologies used in the health care field today. This edition also discusses electronic prescribing and electronic health records as well as Patient Safety and Clinical Pharmacy Services Collaborative (PSPC). Information on technologies used to im- prove safety and efficiency is included. New resources were also added to Chapter 17, Managed Health Care, to discuss details on formu- laries, and drug utilization review, DUR, in greater detail. New information to Chapter 19, Pharmacoeconomics was added to discuss consumer-driven healthcare and pharmacy reimbursement. This chapter also contains additional resources such as documents concerning a consolidated health economic evaluation reporting standards checklist, comparative effectiveness research, information on health technology assessment, and health-re- © Peter Topp Enge Jonasen/iStockPhoto lated quality of life. Additionally, updated and new information was added about basic policy issues affecting health care today, pharmacy benefit managers, basic epidemiology, including discussion of incidence, prevalence, and risk, and information on the distribution process including wholesalers and prevention of coun- terfeits. New information on therapies used at home, as well as new funding for community health centers, patient-centered medical homes, and ambulatory care data was also added to this edition. xviii  What’s New to this Edition n xix NEW TO THE SIXTH EDITION Updated and enhanced content relating to: Expanded section regarding pharmacist roles Examples of pharmacist roles in public Post-graduate education/resources health (immunizations, bioterrorism, Credentialing/resources community health clinics, etc.) Affordable Care Act Continuous quality improvement Medicare and Medicaid Measures of quality Contrasting views of health policy Root cause analysis Government’s perspective on role of E-prescribing pharmacists (provider status) Technologies to improve safety and Examples of state health insurance efficiencies programs Reimbursement Challenges of the VHA system The Joint Commission E-commerce, internet pharmacy, and other Multihospital systems, horizontal/vertical technologies integration Interdisciplinary models of care Fellowships Scope of practice and related legislation Ambulatory care data Sources of patient information LTC statistics Health and illness behavior New funding for community health centers Culture, health literacy, health behavior New therapies used at home change and motivational interviewing Economic principles affecting health care Role of quality improvement in patient The uninsured safety Prescription drug plans Drug safety Difference between private pay and Pharmaceutical industry and drug Medicaid development Expand discussion on HEDIS Electronic prescribing and electronic health Supply-side and demand-side controls records Consumer-driven healthcare Patient Safety and Clinical Pharmacy PBMS, pharmacy reimbursement Services Collaborative (PSPC) Details on formularies Pharmacy benefit managers DUR Basic policy issues affecting health care Specialty pharmacies Connections between medication use Cognitive reimbursement and MTM systems and health care delivery models Transitions of Care Demographics, including compression of Formulary review for expensive biotech morbidity drugs Basic epidemiology, including discussions of Health technology assessment incidence, prevalence, risk, etc. Pharmacoeconomic methods Distribution process, e.g., wholesalers Quality of life and health outcomes Counterfeits and efforts to prevent measurement occurrence Health education Internet pharmacy Developing countries DTC advertising Accountable care organizations (ACOS) E-Commerce Patient-centered medical homes (PCMS) Health care disparities Consumer driven health care  Contributors Thomas E. Buckley, MPH, RPh Scott K. Griggs, PharmD, PhD Associate Clinical Professor Assistant Professor of Pharmacy University of Connecticut, School of Administration Pharmacy St. Louis College of Pharmacy Storrs, Connecticut St. Louis, Missouri Ardis Hanson, PhD, MLS Suvapun Bunniran, PhD Social and Behavioral Researcher; Principal Researcher Research Coordinator Comprehensive-Health-Insights | Humana Dean’s Office Louisville, Kentucky College of Behavioral and Community Sciences Aleda M. H. Chen, PharmD, MS, PhD University of South Florida Assistant Professor of Pharmacy Practice and Tampa, Florida Vice Chair, Pharmacy Practice/Social Sciences Cedarville University, School of Pharmacy John B. Hertig, PharmD, MS, CPPS Cedarville, Ohio Associate Director Center for Medication Safety Advancement Craig I. Coleman, PharmD Purdue University College of Pharmacy Professor Fishers, Indiana University of Connecticut, School of Pharmacy Erin R. Holmes, PharmD, PhD Storrs, Connecticut Associate Professor of Pharmacy Administration Gregory A. Garcia, PharmD University of Mississippi PGY1 Pharmacy Resident University, Mississippi Alameda Health System Highland Hospital Oakland, California Kyle E. Hultgren, PharmD Director Louis P. Garrison Jr, PhD Center for Medication Safety Advancement Professor for Pharmaceutical Outcomes, Purdue University College of Pharmacy Research, and Policy Program Fishers, Indiana Department of Pharmacy © Peter Topp Enge Jonasen/iStockPhoto Adjunct Professor Peter D. Hurd, PhD Departments of Global Health and Health Professor, Pharmacy Administration and Chair Services Department of Pharmaceutical and University of Washington, School of Administrative Sciences Pharmacy Saint Louis College of Pharmacy Seattle, Washington St. Louis, Missouri xx  Contributors n xxi William G. Lang IV, MPH Catherine N. Otto, PhD, MBA Senior Policy Advisor Dean American Association of Colleges of Pharmacy Health Occupations, Physical Education and Alexandria, Virginia Business Shoreline Community College Emily M. Laswell, PharmD, BCPS Shoreline, Washington Assistant Professor of Pharmacy Practice, School of Pharmacy Taehwan Park, PhD Cedarville University Assistant Professor of Pharmacy Cedarville, Ohio Administration St. Louis College of Pharmacy Bruce Lubotsky Levin, DrPH, MPH St. Louis, Missouri Associate Professor and Head Behavioral Health Concentration Ana C. Quiñones-Boex, PhD, MS Department of Community and Family Health Associate Professor of Pharmacy College of Public Health Administration Associate Professor and Director Midwestern University, Chicago College of MS Degree in Child & Adolescent Behavioral Pharmacy Health Downers Grove, Illinois College of Behavioral and Community Sciences University of South Florida Kyle D. Ross, PhD Tampa, Florida Assistant Professor of Economics Department of Economics David J. McCaffrey III, BS, MS, PhD Kansas State University Assistant Dean for Student Affairs Manhattan, Kansas St. John Fisher College School of Pharmacy David M. Scott, MPH, PhD Rochester, New York Professor of Pharmacy Practice and Public Health William W. McCloskey, BA, BS, PharmD North Dakota State University, College of Professor of Pharmacy Practice Health Professions Massachusetts College of Pharmacy and Fargo, North Dakota Health Sciences Boston, Massachusetts Jennifer L. Tebbe-Grossman, PhD Professor of Political Science and American Carol A. Ott, PharmD, BCPP Studies Clinical Associate Professor of Pharmacy Massachusetts College of Pharmacy and Practice Health Sciences Clinical Pharmacy Specialist, Psychiatry Boston, Massachusetts Eskenazi Health/Midtown Community Mental Health Purdue University College of Pharmacy West Lafayette, Indiana  Reviewers Susan dosReis, PhD Roland A. Patry, DrPH Associate Professor Professor and Chair Department of Pharmaceutical Health Department of Pharmacy Practice Services Research Texas Tech School of Pharmacy University of Maryland School of Pharmacy Amarillo, Texas Baltimore, Maryland Tatjana Petrova, PhD David Gettman, BS Pharm, MBA, PhD Assistant Professor Professor Chicago State University College of D’Youville College School of Pharmacy Pharmacy Buffalo, New York Chicago, Illinois Laura Happe, PharmD, MPH John M. Polimeni, PhD Director of Research and Publications, Associate Professor Humana Albany College of Pharmacy and Health Editor in Chief, Journal of Managed Care & Sciences Specialty Pharmacy Albany, New York Louisville, Kentucky Crescent Rowell, PharmD, PhD Andrea Kjos, PharmD, PhD Assistant Professor Assistant Professor Lipscomb University College of Pharmacy Drake University College of Pharmacy and Nashville, Tennessee Health Sciences Des Moines, Iowa Justin Scholl, PharmD Assistant Professor Isaac D. Montoya, PhD Lake Erie College of Osteopathic Medicine Professor School of Pharmacy University of Texas, Houston Erie, Pennsylvania Houston, Texas Patricia Shane, PhD, MPH Kam Nola, PharmD, MS Professor Vice-Chair, Pharmacy Practice and Associate Touro University Professor Vallejo, California © Peter Topp Enge Jonasen/iStockPhoto Lipscomb University College of Pharmacy Nashville, Tennessee xxii  Reviewers n xxiii Charles D. Shivley, PhD, RPh Michael A. Veronin, PhD, RPh Associate Professor, Pharmaceutical Sciences Associate Professor and Pharmacist-in-Charge, PC Community Texas A&M University Health Science Center Care Pharmacies Rangel College of Pharmacy Presbyterian College School of Pharmacy Kingsville, Texas Clinton, South Carolina Tatiana Yero, PharmD, BCPP Walter Siganga, PhD Assistant Professor Professor Lake Erie College of Osteopathic Medicine Southern Illinois University Edwardsville School of Pharmacy School of Pharmacy Bradenton, Florida Edwardsville, Illinois Karen L. Smith, MS, PhD, RPh Assistant Professor Regis University School of Pharmacy Denver, Colorado  pa rt 1 SOCIAL ASPECTS OF HEALTHCARE DELIVERY © Peter Topp Enge Jonasen/iStockPhoto 1 © Peter Topp Enge Jonasen/iStockPhoto  chapter 1 Healthcare Delivery in America: Historical and Policy Perspectives Jennifer L. Tebbe-Grossman Case Scenario The Palmers, a large, extended family, immigrated to New England in the early 1700s. In the 18th and early 19th centuries, the family and their descendants lived on farms in New England. They prospered through farming and some occasional work in small factories in nearby towns. Around 1860, family members moved to the growing cities. A number took jobs in factories; others were fortunate enough to go to high school and even college and found positions in the new professions of teaching, business, and health care. In the 20th century, some family members thrived, especially in the period of rapid economic growth after World War II. Others were barely able to make ends meet, relying at times on government programs and private charities. One constant in the extended Palmer family is that from the time of their arrival in New England in 1740, various family members kept journals and wrote letters (and later emails or Facebook entries) recording information about their extended family members’ daily lives. Suppose that in the 21st century, you have found some of these records spanning several centuries. As a future health professional, you learn about the health and disease history of the Palmer family members: what they thought caused disease and what their philosophies of health and disease were when they made their choices to seek health services, what kinds of diseases family members confronted, the differences public health improvements and technological changes made in their lives, how their health services were paid for, from whom and where they got or didn’t get their health services, and why and what they thought about different healthcare policies presented by politicians and branches of government as these policies changed over time in the United States. The written or electronic record covers much of what appears in this chapter. Based on the material in this chapter, what might you find out about the health experiences and beliefs of the Palmer family members, given their differing socioeconomic backgrounds over time? What might you think about how much or how little healthcare services and their models of delivery © Peter Topp Enge Jonasen/iStockPhoto have improved over time for American populations? 3 4 n Chapter 1  Healthcare Delivery in America: Historical and Policy Perspectives LEARNING OBJECTIVES Upon completion of this chapter, the student shall be able to: Explain paradoxes of the U.S. healthcare system. Explain health conditions in 18th- and 19th-century America in relation to disease patterns and causation theories. Explain types of health practices and practitioners and factors explaining access to health care in 19th-century America. Explain the various roles of government in healthcare delivery in 18th- and 19th-century America. Explain the differences between orthodox and sectarian practitioners and their patients in relation to their perspectives on therapeutics and the delivery of health care. Explain changes in the character, organization, and purposes of hospitals as health delivery sites from the early 19th century through the early 21st century. Describe reforms in medical education at the turn of the 20th century and the consequences of the Flexner Report of 1910. Identify the golden age of medicine and describe what replaced it in the late 20th and early 21st centuries. Explain the ways in which medicine and pharmacy pursued professionalization in the late 19th and 20th centuries and how these professions define themselves in the 21st century. Explain how the factors of public health, lifestyle (diet, housing, personal hygiene), and medical practice influenced the decline of infectious diseases and increase in life expectancy at the turn of the 20th century. Discuss the occurrences of infectious and chronic diseases in the 21st century. Discuss the types of government policy that affected healthcare delivery in the 20th and early 21st centuries, particularly in relation to the implementation of public and private health insurance. Discuss the implementation of Medicare and Medicaid in the 1960s, the 1973 Health Maintenance Organization (HMO) Act, the 1996 Health Insurance Portability and Accountability Act, the 1997 Children’s Health Insurance Program, and the 2010 Patient Protection and Affordable Care Act (PPACA). Explain the benefits and costs of the Medicare Part D Drug Plan. Explain problems associated with incremental healthcare reform. Discuss the major components and the significance of the PPACA. CHAPTER QUESTIONS 1. What kinds of health beliefs did Americans hold in the 18th and 19th centuries? 2. What factors account for the decline in mortality rates and increases in life expectancy at the turn of the 20th century? 3. What were the benefits and drawbacks of the reforms in education that pharmacists and physicians implemented in the early 20th century as part of the professionalization process? 4. Who provided healthcare services for Americans and in what kinds of settings during the 18th, 19th, 20th, and 21st centuries? 5. What kinds of changes in private and public health insurance plans were considered by Americans in the past? 6. What is the potential for improved healthcare delivery in implementing patient-centered care, interdisciplinary care, and the medical home model of care? 7. How is the 2010 PPACA characteristic of incremental healthcare reform? 8. What are the two most important meanings of the 2012 U.S. Supreme Court ruling in the National Federation of Independent Business v. Sebelius regarding the PPACA? 9. What is the meaning of the 2015 U.S. Supreme Court ruling in the King v. Burwell case regarding the PPACA?  Paradoxes of the U.S. Healthcare System n 5 INTRODUCTION This chapter examines the historical evolution of health care and health services in the United States. Emphasis is placed on the changes in social spaces where Americans experience healthcare services—from the home, physician’s office, neighborhood dispensary, or hospital—to the outpa- tient clinic, multigroup specialty practice, community pharmacy, or federally qualified commu- nity health center. Patterns of health and illness in the United States are examined in the context of mortality and life expectancy and the occurrence of infectious and chronic diseases. The chang- ing social meanings of health and disease, the roles of health professionals, such as pharmacists and physicians, and the expectations of citizens as patients and consumers in an increasingly complex healthcare delivery environment are explored. Of particular concern is the context of changes in attitudes and practice toward individual and social responsibility in the delivery of healthcare services. PARADOXES OF THE U.S. HEALTHCARE SYSTEM The U.S. healthcare system is characterized by paradoxes. The United States has the best, most advanced technology available—yet we have a very high rate of medical errors. There are gaps in who has access to health care with different groups of Americans living with “persistent and increasing disparities in health status” (Health Policy Brief: Health Gaps, 2013). Compared to other industrialized nations, the United States has one of the most expensive healthcare systems, especially in terms of administrative costs. The U.S. healthcare system is also fragmented in terms of how it is financed and how healthcare services are organized and delivered. The following over- view highlights the paradoxes of health in America, some key components influencing the contin- uing crisis, as well as reforms that have addressed some U.S. health system problems contained in the PPACA. Health Expenditures and Technology The United States easily surpasses all other countries in spending based on data taken from such sources as the Organization for Economic Cooperation and Development, which conducts cross-country analysis of spending, prices, and utilization of health services. The United States spent $9,086 per person on health care in 2013, or 17.1% of GDP, even though this represents a decrease in national expenditures generally attributed to the global financial crisis that occurred between 2007 and 2009. Health spending in the United States is likely to rise to $5.4 trillion and in the context of GDP to 19.6% by 2024. In 2013, it was twice as much as France’s expenditures, the next highest spending country compared to the United States with 11.6% of GDP. The United States spends a far greater amount on technology and has higher prices in administrative costs and for pharmaceuticals than other high-income countries. In addition, high healthcare spending in the United States outweighs what is spent on the provision of social services in comparison to other countries that spend more on these areas and have better health outcomes (Keehan et al., 2015; Squires & Anderson, 2015). To examine one paradox of health spending, magnetic resonance imaging systems, new diagnos- tics, transplant surgeries, biotechnology-based products, genetic engineering, telemedicine, new reproductive technologies, and health information technology are just a few of the rapid tech- nologic advances that have emerged in recent years in the United States. These developments offer hope for improved quality of life, quicker diagnoses and better treatments, and increased life expectancy. However, reliance on technologic innovation also creates problems. Most Americans 6 n Chapter 1  Healthcare Delivery in America: Historical and Policy Perspectives expect to receive only the best technical care available, which often leads to overuse of technologic advances. New technologies tend to be updated quickly, often without sufficient examination of cost, effectiveness, or patient safety threat issues. While the meaningful use of electronic health records (EHRs) offers opportunities for cost savings, reduction in medical errors, and improved patient access and outcomes, health professionals raise concerns that in implementing electronic medical records they may lose focus on the interaction between the sick and the healer, thereby leading them to “suspend thinking, blindly accept diagnoses, and fail to talk to patients in a way that allows deep, independent probing” (Hartzband & Groopman, 2008; Ralston, Coleman, Reid, Handley, & Larson, 2010). While many Americans regard access to medical imaging as a sign of the superiority of the U.S. healthcare system, recent health research has focused on the avoidable pub- lic health threat that arises from investing so many resources in performing so many procedures as well as the dangers of radiation overdoses in single procedures (Bogdanich, 2010; Lauer, 2009). Finally, technology’s benefits are not equally distributed among patient populations, including such preventive measures as breast cancer screening (2014 National Healthcare Quality & Dispar- ities Report, 2015). Health Insurance In 2007, the Commonwealth Fund estimated that nearly 25 million Americans had insurance pol- icies in 2007, but were underinsured, meaning their policies often didn’t cover important aspects of care, including such items as preventive care health practitioner visits, prescription drug, med- ical tests, surgery or other medical procedures, or catastrophic medical conditions, and/or poli- cies required significant out-of-pocket payments for services (Gabel, McDevitt, Lore, Pickreign, & Whitmore, 2009). In a 2009 Centers for Disease Control and Prevention National Health Interview survey, 46.3 million Americans of all ages were without health insurance. Between 2008 and 2009, there was an increase in the percentage of adults (18–64 years) lacking health insurance cover- age from 19.7% to 21.1%. The survey also indicated 10.9% of the 46.3 million had been without health insurance for more than 1 year (Cohen, Martinez, & Ward, 2010).With the passage of the PPACA in 2010 and successive provisions that have gone into effect since then, there has been a significant increase in the numbers of American who have health insurance. In the early months of 2015, the rate of uninsured Americans was predicted to be 10.7% and the U.S. Department of Health and Human Services anticipated that over 11 million Americans would be enrolled in PPACA plans by the end of 2016 with 4 million of these under the age of 35. This decrease in the numbers of those without health insurance is attributed to more Americans being able to obtain insurance through employers (since the rate of employment had risen) and increased number of individuals able to obtain Medicaid eligibility and to have access to coverage through Health Insurance Marketplaces in the new PPACA. Despite the substantial reform of the PPACA, many low-income working families still lack health insurance because of costs they cannot afford, and people of color are at especially at a higher risk of being uninsured (Humer, Reuters, 2016; Kaiser Family Foundation, 2015; National Center for Health Statistics, 2015). Health Standards While health care in the United States is the most expensive across the globe, inadequate, improper, and even dangerous care is all too prevalent. In reports on the performance of healthcare systems internationally, the Commonwealth Fund has found that the United States “consistently underperforms on most dimensions of performance” including in areas of “access, patient safety, coordination, efficiency, and equity” (Bodenheimer, Chen, & Bennett, 2009). Major problems for U.S. patients occur in health worker shortages and the ratio of healthcare clinicians to patients, especially in regard to physicians, nurses (including nurse practitioners), physician assistants, pharmacists, and community health and public health workers providing primary care services  Paradoxes of the U.S. Healthcare System n 7 in rural and underrepresented areas. With increasing numbers of Americans needing primary care for chronic care services, researchers have called for such new national workforce policies as those fostering interdisciplinary and multidisciplinary care delivered in primary care settings, new financial payment systems for primary care practices and clinics, and increased education of health professionals from underrepresented population groups (Davis, Schoen, & Stremikis, 2010). In 1999, the Institute of Medicine issued a major report, To Err Is Human: Building a Safer Health System, presenting data that showed 44,000 to 98,000 people die each year from medical errors, a higher number than those dying from breast cancer or auto accidents. The report outlined ways to reduce medical errors and urged Congress to create a national patient safety center. In 2005, the federal government enacted the Patient Safety and Quality Improvement Act to continue the effort to foster safety cultures in healthcare institutions. A study commissioned by the Society of Actuar- ies based on insurance claims data reported that medical errors and the problems that ensued from them resulted in costs of $19.5 billion to the U.S. economy in 2008 (Hobson, 2010). For the same year, the Henry K. Kaiser Foundation stated that “serious medication errors occur in the cases of five to 10 percent of patients admitted to hospitals” (Woo, Ranji, & Salganicoff, 2008). Those studying patient safety disagree on what progress has been made. Some argue that progress has been made in developing new adverse event reporting systems with the introduction of health information technology systems, advancing national data collection and accreditation standards, and promoting new patient safety initiatives supported by such groups as the Joint Commission and the Institute for Healthcare Improvement. Others, including Donald Berwick, an author of To Err Is Human and the new director of the Center for Medicare and Medicaid Services, have seen a change in awareness of medical safety but not fundamental change in the nature of the American healthcare industry (Beresford, 2009; Bosk, Dixon-Woods, Goeschel, & Pronovost, 2009; Furukawa, Raghu, Spaulding, & Vinze, 2008; Gawande, 2010; National Healthcare Quality Report, 2009; Wachter, 2010). Berwick wanted safety responsibility relocated in “the offices and work of leaders of healthcare institutions” and “new safety initiatives … fostered by teams working at unprecedented levels of collaboration, reaching across traditional boundaries” (Berwick quoted in Beresford, 2010). Government agencies and private foundations studying healthcare quality stan- dards in U.S. health facilities agree that much more work is necessary to ensure safe care for the American population. Despite many new efforts to reduce medical errors, numbers have risen. As an example, the authors of a study published in 2014 found that “on any given day approximately 1 of every 25 inpatients in U.S. acute care hospitals has at least one health-associated infection” (Magill et al., 2014). In rec- ognizing these problems, the PPACA contains provisions that include naming targets for reducing hospital-associated health infections. The Hospital-Acquired Condition Reduction Program went into effect in October 2014 and requires Medicare payment reductions for some hospitals with the worst performance records (Center for Medicare & Medicaid Services, 2015; Emanuel, 2014). Health Outcomes Health professionals and ordinary Americans have consistently been preoccupied with the state of American health through the examination of various outcomes. A study published in 2006 comparing health outcomes in populations with diabetes, hypertension, heart disease, myocar- dial infarction, strokes, lung disease, and cancer in the United States and the United Kingdom concluded that “based on self-reported illnesses and biological markers of disease, U.S. residents are much less healthy than their English counterparts” (Banks, Marmot, Oldfield, & Smith, 2006). In this study, differences existed at all levels of socioeconomic status, although health disparities were largest for those with the least education and income. The paradox: The United States spends far more on medical care than the United Kingdom does on a per capita basis (Banks et al., 2006). 8 n Chapter 1  Healthcare Delivery in America: Historical and Policy Perspectives An often-cited statistic is that the United States ranks lower than many other nations—especially such industrialized nations as Germany, Sweden, and Canada—in terms of infant mortality rates while spending more to prevent infant deaths. In 2010, the United States ranking in reference to infant mortality rates among Organization for Economic Co-operation and Development countries was 26th, with 6.1 deaths per 1,000 live births (MacDorman, Matthews, Mohangoo, & Zeitlin, September 24, 2014). There are a number of reasons to account for the United States’ relatively low standing among other nations. For instance, the United States still has significant disparities in infant mortality rates based on race and ethnicity due to such factors as less access to prenatal care, including receiving no prenatal care or not receiving any until the third trimester. In 2013, according to the U.S. Department of Health and Human Services Office of Minority Health, African Americans have 2.2 times the infant mortality rate as non-Hispanic whites (CDC, 2015; Mathews, MacDorman, & Thoma, 2015). Government programs and corporate-sponsored programs such as “Every Child Succeeds” (ESC) in Cincinnati, Ohio, have achieved success in improving infant mortality rates. In 2006, in seven counties in the Cincinnati area, 8.3 of every 1,000 infants died before the age of 1 year, but for those in the “Every Child Succeeds” program, the infant mortality rate was 2.8, which is a rate that is lower than those reported in every industrialized country. Although the program enrolled 1,800 mothers, its funding allowed only one fifth of the needy women in the Cincinnati area to participate (Naik, 2006). In testimony delivered to the Senate Medicaid Committee in June of 2015, a representative from “Every Child Succeeds” reported that a major goal of the ESC program continued to be the prevention of infant mortality. They noted that infant mortality rates within their program continued to be significantly lower, 4.7/1,000 births, than for the county in which ESC worked—Hamilton Country—8.9/1,000 births, and in Ohio in general, 7.6/1,000 live births (Ammerman, June 3, 2015). Comparisons of life expectancy show similar race-based disparities. In 1900, the life expectancy in the United States for women was 51.1 years, and for men it was 48.3 years. In 2013, life expectancy for all Americans was 77.8 years—81.2 years for women and 76.4 years for men. In comparing race-based data for 2013, life expectancy for African Americans was 75.5 and 79.1 years for white Americans. Many factors account for disparities in life expectancy, including differences in the quality of neighborhood living environments and access to preventive care services (Epstein, 2003; Kinsella, 1992; National Center for Health Statistics, Revised June 2015; U.S. Census Bureau, 2010). According to the 2014 National Healthcare Quality & Disparities Report, racial, ethnic, and socio- economic disparities have continued in the United States since the report was first issued in 2003. The 2014 report indicated that “disparities in quality and outcomes by income and race and ethnicity are large and persistent, and were not, through 2012, improving substantially”(2014 National Healthcare Quality & Disparities Report, 2015). Based on outcomes as measures of healthcare risks in the United States, several major concerns were highlighted in the first decade of the 21st century. In examining targets that the Department of Health and Human Services set in Healthy People 2010, the incidence of smoking among adults decreased between 1998 (24%) and 2008 (21%), but did not reach the 12% target decrease that had been set in 2000. In addition, the small progress made was threatened with recent decreases in funding for prevention efforts (Koh, 2010, pp. 2475-2576). Nearly one third of Americans 20 years or older have been identified as obese in 2010. In con- necting this obesity statistic to understanding the importance of decreasing the incidence of dia- betes, Healthy People focused on this disease state and identified a baseline in 1997 of 40 cases of clinically diagnosed diabetes per 1,000 population. Unfortunately, in 2008, the rate of cases  Health, Disease, and Health Practitioners in Colonial America n 9 increased to 59 per 1,000 population. The Healthy People target of 25 cases per 1,000 population for reducing diabetes prevalence in the United States was obviously not achieved, and increased evidence-based diabetes interventions will need to be made by multidisciplinary health profes- sionals in a variety of healthcare settings to assist in caring for these individuals. Thus, the Healthy People 2020 plan has included the addition of the following two new goals: first, “promoting qual- ity of life, healthy development, and healthy behaviors across life stages; and second, creating social and physical environments that promote good health” (Koh, 2010, p. 1656). All these existing paradoxes in the U.S. healthcare system are important to consider when review- ing the evolution of health care and the delivery of healthcare services in a variety of settings within American communities over time. HEALTH, DISEASE, AND HEALTH PRACTITIONERS IN COLONIAL AMERICA As different groups of European settlers arrived in the Americas in the 16th and 17th centuries, they found a variety of societies and cultures. Some of the indigenous inhabitants of North Amer- ica only hunted and gathered. Other groups occupied more permanent settlements and subsisted through both agricultural production and hunting and gathering. Contrary to the belief of many Europeans that the Americas promised a new Eden of good health, Native Americans endured significantly high mortality rates. Malnutrition, violence, accidents, fungal infections, anthrax, tapeworms, tuberculosis, and syphilis were common causes of death. European settlers brought influenza—which may not have been seen previously in the Americas—and other new illnesses— including yellow fever, malaria, smallpox, and measles—against which Native Americans had no immunity. Thus, as the historian of medicine, Gerald Grob, notes, the result of early contact between Europeans and Native Americans “was a catastrophe of monumental proportions that resulted in the destruction of a large majority of the indigenous population and facilitated Euro- pean domination of the Americas” (2002, p. 27). Arriving debilitated from sea travel, settlers of England’s North American colonies did not encoun- ter an Edenic or a utopian environment. Rather, in the early years, many fell victim to malnutrition and dysentery—the consequences of poor food and insufficient clean water supplies. The colo- nists suffered from a wide range of endemic and epidemic infectious diseases such as yellow fever, measles, smallpox, and malaria. The British government did not implement broad public policies to address problems of health and illness or encourage the establishment of health practitioners or institutions (Cassedy, 1991). Colonial officials addressed such public health problems as gar- bage disposal, street maintenance, and the regulation of water supply and sanitation occasionally, and with little success in enforcement. Partially because of health emergencies (especially such epidemic outbreaks as smallpox or measles), towns and cities did become accustomed to govern- ments enacting more extensive public health regulations. Examples included quarantines of ships arriving from areas affected by epidemic diseases, setting up isolation or pest houses, and fumigat- ing houses where victims of smallpox or other infectious diseases had lived. Still, the medical his- torian James Cassedy argued that the application of these public health benefits was “so irregular, tentative, and inconsistent that the benefit to the public health must have been negligible” (1991, pp. 13,14). When colonists became sick, they depended on various members of the community for access to the healing arts, looking as much for simple human and religious comforts as for therapeutic services. Although physicians, apothecaries, midwives, clergy, and public officials responded to individual or community health needs, it was just as common for family members or neighbors, often the females in the household, to diagnose, make medicines, and physically support the sick. 10 n Chapter 1  Healthcare Delivery in America: Historical and Policy Perspectives Until at least 1825, women commonly depended on their female friends and relatives, and mid- wives when they were available, to attend to them in childbirth in their homes (Bogdan, 1992). European physicians did not look to the colonies, which had small and widely scattered popula- tions, as locations that offered great professional or economic opportunity. Few physicians emi- grated, and since medical education in the North American colonies was not considered a priority of government or private agencies, only a minority of physicians or apothecaries completed for- mal training. Physicians often compounded and dispensed medicines in shops next door to their medical practices. Apothecaries appeared only in small numbers as compounders, dispensers, or sometimes manufacturers and wholesalers of medicines. In the growing colonies, all these practitioners of the healing arts shared health beliefs that relied on a combination of folklore; mineral, plant, and vegetable herbal remedies; and magic as well as improvisation based on what they found in their environments. The colonists used health prac- tices and medications that were common in Europe and England, such as mercury and opium preparations. They also adopted such Native American health remedies as cinchona bark, which contained quinine (Christianson, 1987; Duffy, 1993; Tannenbaum, 2002). AMERICA IN THE 19TH CENTURY: THE HEALTHCARE ENVIRONMENT As the nation expanded westward and its population grew in the early 19th century, Americans exhibited a local outlook on health care that was similar to their attitudes toward economic and political life. A person’s health experience as a resident of a town or city on the eastern seaboard was different from the health experience of a farmer in the rural southern or Midwestern areas or of an immigrant traveling west into the new territories. Rural and Urban Health Self-reliance was a necessity for farmers and travelers. Poverty, loneliness, exhaustion, accidents, exposure to the elements, and dangerous plant and animal life took their toll. Family members and midwives, who also functioned as social healers within communities, played the most important roles in caring for ordinary people in times of illness. From the era of the American Revolution, the number of physicians who practiced medicine in their own homes and traveled to make house calls in the homes of their patients increased significantly in the 19th century in rural areas and small towns. Both midwives, or social healers, and physicians treated entire families—men, women, and children—and juggled the responsibilities of their health practices with their domestic and com- munity responsibilities. Payment for services was in cash and often in kind, or what families pro- duced by their labor. Many patients could not pay, however, so midwives and physicians needed to rely on other sources of income. Rural and small-town residents could request compounded and proprietary medicines through both physicians and apothecaries. They could also purchase pro- prietary medicines in the general store and from itinerant healers or medicine men who regularly traveled from town to town (Cassedy, 1991; Leavitt, 1995, p. 4; Ulrich, 1990; Young, 1992). In urban areas, in the 19th century, social class largely affected a person’s quality of life and access to health care. The wealthy and growing upper middle class, including those members of the Palmer family (introduced in the case scenario at the beginning of the chapter) who were well off, had servants, lived in neighborhoods that provided clean air and water, gardens and parks, and health practitioners of their choice. The lower middle classes—including skilled workers, clerks, tradesmen, and widows—could afford food and housing and occasional visits to public parks. They tried to keep their domestic spaces clean despite the unsanitary living conditions offered by tenement landlords. They could pay minimal amounts for self-dosing remedies, medicines, or  America in the 19th Century: The Healthcare Environment n 11 doctor bills. Most major towns and cities began to provide dispensaries that offered such services as the writing of prescriptions, minor surgeries for fractures, and vaccinations for workers who could pay little or nothing at all (Rosenberg, 1974). The working classes shared problems with the poor, including lack of such basic municipal ser- vices as garbage and sewage removal. As part of the Industrial Revolution, members of the working classes breathed air polluted by coal dust from the factories and railroads that were next to their residences. Congestion, noise, the frenetic pace of commercial life, and the accelerated influx of new waves of immigrants led to a rapid accumulation of new and old health problems, especially rising mortality rates due to infectious diseases. In addition, African Americans confronted even higher degrees of difficulty in relation to quality of life indicators because of slavery and discrim- ination. They experienced lack of access to health education, health facilities, and basic public health services (Byrd & Clayton, 2000; Cassedy, 1991; Hoy, 1995). Health Values, Therapeutics, and Practitioners Health practitioners and the general public have long disagreed about theories regarding the causes of disease and the public policies needed to address them. Some believed that supernatural forces inflicted disease because of human sin. Some believed in contagion or environmental (miasmic) theories of disease. Still others believed that the individual who did not take precautions to lead a healthful life was responsible for disease (Tesh, 1988). Regardless of their beliefs about disease causation, most Americans generally shared the same val- ues when it came to health, disease, and the body—that is, they looked to Galen’s second-century concept of humoralism. The body was an interconnected whole with a natural balance (Warner, 1997, p. 87). As Charles Rosenberg (1985) noted, “every part of the body was related inevitably and inextricably with every other. In health, the body’s system was in balance; in disease, the body lost its balance and suffered disequilibrium. If health practitioners were to treat disease effectively, they needed to know about individual patients and their body’s system of ‘intake and outgo’” (p. 40). What could be observed empirically happening to the patient’s body was therapeutically important. Orthodox physicians (also referred to as allopathic, regular, or mainstream physicians), who had some didactic medical education or at least an apprenticeship under a practicing physician, offered their mostly middle- and upper-class patients heroic medical therapy. They adopted mostly depletive measures, whereas members of the lay public—drawing upon popular domestic medical texts and almanacs—more often employed both depletive and strengthening measures (tonics and astringents) (Horrocks, 2003). Orthodox physicians assumed an active, aggressive role whereby the patient and the family could see very visible changes in secretions and excretions in the body as a result of the physician’s interventions. Using leeches, medical instruments, and a variety of drug therapies, orthodox physicians bled, purged, puked, and sweated their patients. Because cures were not often the result of a physician’s care during serious illnesses, patients and families could at least share in the knowledge that they had observed the physician’s efforts to do something. Rosenberg has noted the ways in which depletive drugs were used in this system: Drugs had to be seen as adjusting the body’s internal equilibrium; in addition, the drug’s action had, if possible, to alter these visible products of the body’s otherwise inscrutable internal state. Logically enough, drugs were not ordinarily viewed as specifics for particular disease entities; materiamedica texts were generally arranged not by drug or disease, but in categories reflecting the drug’s physiological effects: diuretics, cathartics, narcotics, emetics, diaphoretics (1985, p. 41). Orthodox physicians competed with sectarians (also called irregulars), who offered a variety of alternative practices, cures, and remedies that were less heroic, including folk medicines, 12 n Chapter 1  Healthcare Delivery in America: Historical and Policy Perspectives strengthening tonics, and astringents sold by both itinerant quacks and druggists. Sectarians advocated temperance from alcohol; homeopathy, the infinitesimal dose therapeutic that differed significantly from the usually higher levels of medicines required by heroic dosing (Kaufman, 1971); and regimens of fresh air, exercise, and water cures (hydropathy) taken in what Susan E. Cayleff has referred to as comfortable “cure establishments,” situated in “natural surroundings” in “country settings” (1987, p. 77). In his popular Thomson’s Almanac, Samuel Thomson vigorously attacked the orthodox physician’s primary reliance on what he deemed excessive depletive mea- sures and advocated his own medical philosophy primarily emphasizing self-treatment through the use of his regimen of herbal medicines, sweating baths, emetics, and purgatives (Haller, 2000; Horrocks, 2003, p. 120). Sylvester Graham worried about the sexual passions and advocated a vegetarian and high-fiber diet and exercise regimen that forbade spices, alcohol, tea, and coffee, in an effort to control those passions (Nissenbaum, 1980). The commercial manufacture of proprietary medicines developed rapidly during the first half of the 19th century, replacing the functions of the domestic practitioner who formulated the family’s home remedies over the hearth fire. Physicians dispensed drugs in their offices and on home visits while “pharmacists began to open stores in towns and cities to fill prescriptions for patients of physicians and to compound drugs requested by their customers” (Cowen & Kent, 1997; Roth- stein, 1996a, p. 376). Gregory Higby has observed that pharmacists, as part of a shift of “allegiance from physicians to their customers,” also began counter prescribing—that is, “refilling prescrip- tions without physician authorization, and diagnosing and treating customers” (1992, p. 5). By 1860, many Americans could buy relatively cheap commodities called patent medicines, which were manufactured in small factories, advertised in newspapers, and delivered to any town or city through improved transportation systems. As the 19th century progressed, pharmacists “sold bottles of their own or physicians’ concoctions” and became retailers of the prepared drugs (Roth- stein, 1996a, p. 376). At the same time, social reformers and public officials sought to label the production and distri- bution of patent medicines as “quackery” and warned the consuming public that patent medicine products were dangerous and fraudulent in their claims. Reformers were unsuccessful in their efforts to pass national legislation regulating the industry until the enactment of the Pure Food and Drug Act (1906), which addressed accurate labeling. Nevertheless, such patent medicines as Lydia Pinkham’s Vegetable Compound remained popular among middle-class women as a treatment for female complaints because it was seen as an “alternative to orthodox treatments they believed to be unsafe” (Cayleff, 1992, p. 317). Americans sought out a variety of alternative therapies because they often viewed orthodox (reg- ular) physicians as elitist practitioners who sought to mon