Transcript Document 7205795

The Social Transformation of
American Medicine
James G. Anderson, Ph.D.
Purdue University
A Half Century of Growth
Resources
Acute Care
Hospital Beds
Physicians
1950
2000
3.3/1000
4,5/1000
141/100,000
271/100,000
A Half-Century of Growth
Medical Education
• 40 new schools so medicine
• 8 new schools of osteopathy
• 13 new schools of dentistry
New Federal Legislation
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Medicare/Medicaid 1965
Regional Medical Programs
Comprehensive Health Care Planning Assistance
Health Professions Education Assistance
Maternal and Infant Care
Children and Youth Projects Title V SS Act
Neighborhood Health Centers and Head Start,
Economic Opportunity Act
National Health Expenditures
$3,000.00
$2,637.40
$2,500.00
$2,000.00
$1,500.00
$1,311.10
$1,000.00
$699.40
Millions $
$247.30
$500.00
$41.10
$0.00
1965
1980
1990
2000
2010
National Health Expenditures
20.00%
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
15.90%
12.20%
13.10%
8.90%
5.70%
1965
% GDP
1980
1990
2000
2010
Explosive Growth of For-Profit
Health Care
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19% Acute Care hospital Beds
50% Nongovernmental Psychiatric Beds
77% Nursing Homes
33% Diagnostic Laboratories
40% Hemodialysis Centers
Managed Care
• Integrated financing and delivery of health care
• Contracts with selected providers to furnish
comprehensive services to enrolled members at a
predetermined rate
• Utilization and quality controls
• Financial incentives for members to use
providers associated with the plan
• Assumption of some financial risk by providers
Growth of Managed Care Plans
Type of Plan
1988
1993
1996
1999
Conventional
73%
46%
27%
9%
Managed Care
27%
54%
73%
91%
Controls Over Type and Amount
of Care Delivered
• Selection of physicians and hospitals (Pro/File
Computer-based system)
• Use of primary care physicians as gatekeepers
• Financial incentives to influence medial practice
• Computer-based systems to review
appropriateness of surgical and diagnostic
decisions
Controls Over Type and Amount
of Care Delivered
• Payment to primary care physicians based on
utilization and quality
• Use of clinical rules:
Treatment protocols
Administrative constraints
Practice guidelines
Changes in the Practice of Medicine
• Industrialization of Health Care
Monitoring
Emphasis on productivity
Substitution of allied health professionals
• Emphasis on Cost Containment
• Patient Dumping
• Salaried Physicians
50% under 35
18% over 40
Changes in the Practice of Medicine
• Rise of Commercialism
MD entrepreneurs
Bonuses for patient referrals
Hospitals pay group practices and provide incentives
Ambulatory care clinics paid commission on charges
Development of for-profit hospitals
Changes in the Practice of Medicine
• Conflicts of Interest (Florida study)
40% MDs have investments in centers to which
they refer patients
60% clinical labs are MD owned
93% diagnostic imaging centers are MD owned
80% radiation therapy centers are MD owned
50% physical therapy are MD owned
Changes in the Practice of Medicine
• Dispirited Physicians/Disgruntled Patients
Erosion of public confidence (70% of public is
dissatisfied)
Decrease in medical school applicants
Unhappy practicing physicians
Struggle between Managed Care
and Fee-for-Service
• Congressional “Patient Protection Act”
• State laws requiring health plans to accept
“any willing provider”
• State patient protection acts
The Future
• Centralized government regulatory
mechanisms and global budgets
• Individual incentives for cost control in a
pluralistic privately dominated system.