How Health Care Services are Delivered

Question 1

review of the US model

Answer 1

• (Fragmented – elements of all four system models)
  
  • 1.Beveredge –socialized medicine for veterans, military, Native Americans.
  • 2.Bismark – social insurance for most people with jobs
  • 3.National Health Insurance - for Americans over the age of 65, some who are poor or disabled
  • 4.Out of Pocket – for those who don’t qualify or have health insurance, or can pay
• Last week…
• Pre- ACA, which is an attempt to at least move in the direction of universal coverage…
• in 2010 (pre-ACA):
  
  • 27% of U.S. residents were covered under public programs (both Beveridge and National Health Insurance models)
  • 56% received primary coverage through private insurers
  • 16% lacked health insurance entirely.
• When it comes to treating veterans, we’re like Britain or Cuba.
• For Americans over the age of 65 on Medicare, we’re like Canada.
• For working Americans who get insurance on the job, we’re like Germany.
• For the 15 percent of the population who have no health insurance, we are like most of the developing countries, with access to a doctor available if you can pay the bill out-of-pocket at the time of treatment or if you’re sick enough to be admitted to the emergency ward at the public hospital.
• The United States is unlike every other country because it maintains so many separate systems for separate classes of people. All the other countries have settled on one model for everybody. This is much simpler than the U.S. system; it’s fairer and cheaper, too.

Question 2

Structures of medical practice

Answer 2

• Physician offices – dispersed independent fee-for-service. Physicians admitted and cared for patients in hospitals - supporting hospital services. Dispersed, independent
• Multispecialty Group Practices. Physicians salaried, practice collected fees-for-services.
• Community Health Centers – team approach, comprehensive medical and public health care, targeting low-income populations.
• Prepaid Group Practice/Health Maintenance Organizations (HMOs). Think Kaiser.
  
  • Vertical integration – “under one roof”
  • Virtual integration – networks; i.e. Independent Practice Associations (IPAs).
• Preferred Provider Organization (PPO)
• MDs also worked in hospitals , admitting and caring for their patients there. Symbiotic relationship with hospitals – brought in patients, for medical wards, surgery, ICU, other services that hospitals could bill for.
• Dispersed independent fee-for-service.
• Multispecialty Group Practices. Physicians salaried, practice collected fees-for-services.
• Opposed by AMA and others.
• Kaiser-Permanente – Medical Care Program – largest HMO
  
  • 1.Kaiser Foundation Health Plan – insurer
  • 2.Kaiser Foundation Hospitals Corporation – owns and administers hospitals
  • 3.Permanente Medical Group – physician organizations that administer group practices and provide medical services to Kaiser plan members under capitated contracts
• PPOs – pts can see any providers, but lower costs if using in-network. Providers agree to accept payment as set by insurer.
• Vertical HMOs tend to rank higher in measures of quality of care. Virtual models offfer some benefits in coordination, but less different from FFS.
• Prepaid Group Practice name change to HMOs in 70s partly to avoid the socialism accusations from AMA and others. ​

Question 3

dispersed - integrated models

Answer 3

• Dispersed private solo or small group practices are joining together or being incorporated into large organizations.

Question 4

multispecialty group practices

Answer 4

• Mayo Clinic
• Menninger Clinic
• Palo Alto Medical Foundation
• While recommended by a national policy committee in 1932, vigorously opposed by AMA as detracting from control and personal nature of individual private practice
• Mayo – physician brothers, 1890s -> multiple sites, 3 states, > 3,000 physician, hospitals, research, medical school, PA program and fellowships…

Question 5

Independent practice associations

Answer 5

• Association of many physicians
• Physicians maintain ownership of their practice
• IPA negotiates and administers HMO contracts
• The group can contract with many HMOs

Question 6

integrated medical groups

Answer 6

• Providers are employees; don’t own the practice
• Typically large corporations, hospitals, and medical schools

Question 7

preferred provider organization (ppo)

Answer 7

• Providers contract with insurer to provide care at set rates and fees
• Patients pay less if they see providers that are in the network of the PPO (can see out-of-network providers, but pay higher out-of-pocket proportion and responsible for whatever the provider charges)

Question 8

prepaid group practices

Answer 8

• Combine insurance and health care services
• Monthly or annual payments to health care provider organization to cover all (covered) medical treatments
• Mainly for employees of large organizations or large populations

Question 9

prepaid group practice - kaiser

Answer 9

• 1938, for Kaiser employees building Grand Coulee Dam
• Now the largest – 8 states, around 10 million pts
• Three Parts:
  
  • Insurance: Kaiser Foundation Health Plan
  • Hospitals: Kaiser Foundation Hospital Corp.
  • Providers: Permanente Medical Group (contract with Kaiser to provide care)

Question 10

the kaiser model of an HMO

Answer 10

• “Health Maintenance Organization” (HMO) name coined in early 1970s
• Kaiser:
• Providers are salaried
  
  • ½ primary care, ½ specialists
• Regionalized care
  
  • Population based health care
• Vertical integration
• “HMO” coined in early 70s to sell the idea, and counter the populist legacy of prepaid group practice movement, and organized medicine’s opposition as a “socialist threat”
• Kaiser Permanente is three distinct but interdependent groups of entities:
  
  • 1. Kaiser Foundation Health Plan, Inc. (KFHP) and its regional operating subsidiaries - Kaiser Foundation Health Plans (KFHP) work with employers, employees, and individual members to offer prepaid health plans and insurance. The health plans are not-for-profit and provide infrastructure for and invest in Kaiser Foundation Hospitals and provide a tax-exempt shelter for the for-profit medical groups.
  • 2. Kaiser Foundation Hospitals - operates medical centers in California, Oregon, Washington and Hawaii, and outpatient facilities in the remaining Kaiser Permanente regions. The hospital foundations are not-for-profit and rely on the Kaiser Foundation Health Plans for funding. They also provide infrastructure and facilities that benefit the for-profit medical groups.
  • 3. Permanente Medical Groups (regional) - physician-owned organizations, which provide and arrange for medical care for Kaiser Foundation Health Plan members in each respective region. The medical groups are for-profit partnerships or professional corporations and receive nearly all of their funding from Kaiser Foundation Health Plans.

Question 11

2nd HMO Model

Answer 11

• “Virtual” network
  
  • Generally not non-profit (like Kaiser), but large for-profit insurers (i.e. Aetna, BCBS)
• Panel of providers paid a capitated rate for a panel of patients (can also see non-HMO pts)
• Independent Practice Associations (IPAs)
  
  • can contract with multiple HMOs
• HMOs set up by multiple large insurance companies, to control costs

Question 12

Comparisons of HMO and IPA/PPO

Answer 12

• HMO
  
  • vertical or virtual integration
  • better at quality measure
  • pt generally has to be referred by PCP
• IPA and PPO
  
  • dispersed, non-integrated
  • may offer more personal care
  • pt may self-refer

Question 13

Community health centers

Answer 13

• Early 20th Century,
• Iowa and Appalachia
• Relied on nursing outreach and primary care, referrals to physicians for secondary care and hospitalization
• Originally before most modern medical treatments (antibiotics, etc).
• Waned as focus for nursing shifted to hospitals

Question 14

community health centers

Answer 14

• Revived as centers for community care in 1965 with Johnson’s War on Poverty
• Federally Qualified Health Centers (FQHC) – a CMS designation (includes rural health clinics and Indian Health Clinics)
• Non-profits, governed by majority community member/patient board
• Receive federal funding (approx. 10-50% of budget), and special Medicaid/Medicare reimbursement rates (PPS)
• Required to see all, regardless of ability to pay.
• Now over 1,300 organizations with > 9,000 sites, serving ~25 million patients

Question 15

rural health cooperatives

Answer 15

• Flourished in the 1940s, but faded under opposition from organized medicine
• Replaced in latter part of 20th Century with Rural Health Clinics (required to have a PA or NP on staff, seeing the majority of patients; also designated as FQHCs, so preferential reimbursement from CMS)

Question 16

accountable care organizations

Answer 16

• Provider groups, hospitals, services share risks and rewards
• Medicare Shared Savings Program
• Motivation to provide coordinated care between all providers and hospital
• Patients free to see who they want, costs are attributed
• More direct involvement by providers.
• (More on these later…)

Question 17

who are health care workers?

Answer 17

• Physicians (several types)
• Nurses (several types)
• Dentists
• Pharmacists
• Physician assistants (PAs)
• Occupational, physical, & respiratory therapists
• Massage therapists
• Speech-language pathologists
• Clinical laboratory scientists
• Medical/clinical lab technicians
• EMTs, NAs, MAs, CHWs
• … etc.
• And others, direct services, support services, and enabling services.
• Will concentrate on California’s health care industry, which employed more than 1.3 million people in 2012. Among these workers, slightly more than 50% were employed in ambulatory settings, about 30% in hospitals, and 20% in nursing or residential care facilities. An aging population, population growth, and federal health reform will likely contribute to increased demand.

Question 18

expanded workforce

Answer 18

• Patient Navigators
• Nurse Case Managers
• Care Coordinators
• Community Health Workers
• Care Transition Specialists
• Pharmacists
• Living Skills Specialists
• Patient and Family
  
  • Activators
• Medical Assistants
• Dental Hygienist
• Behavioral Health
• Social Workers
• Occupational Therapists
• Physical Therapists
• Grand-Aides
• Health Coaches
• Paramedics
• Home Health Aids
• Peer and Family Mentors

Question 19

health care workers in california

Answer 19

• More than 1.4 million people in 2015.
• 55% were employed in ambulatory settings
• 25% in hospitals
• 20% in nursing or residential care facilities
• The number of PAs in California grew 37% between 2012 and 2015. The Northern and Sierra region had more licensed PAs per capita than the rest of the state.
• Increased demand in coming years
  
  • aging population,
  • population growth
  • federal health reform
• California’s health care industry employed more than 1.3 million people in 2012. Among these workers, slightly more than 50% were employed in ambulatory settings, about 30% in hospitals, and 20% in nursing or residential care facilities. An aging population, population growth, and federal health reform will likely contribute to increased demand.

Question 20

two main types of physicians in the US

Answer 20

• Medical Doctor (M.D.) - allopathic physician
• Doctor of Osteopathy (D.O.) - osteopathic physician
• Both types of physicians may use all accepted treatment methods including drugs and surgery, but D.O.s generally place special emphasis on the body’s musculoskeletal system, incorporate more preventive medicine, and utilize holistic health care practices. D.O.s are most likely to be primary care specialists although they can be found in all specialties.
• Also homeopaths, naturopaths, chiropractors, podiatrists,

Question 21

naturopaths (NDs)

Answer 21

• Graduate from credited four-year residential naturopathic medical school and pass an extensive postdoctoral board examination (NPLEX)
• Licensed in 17 states to perform diagnostic and therapeutic modalities: clinical and laboratory diagnostic testing, nutritional medicine, botanical medicine, naturopathic physical medicine (including naturopathic manipulative therapy), public health measures, hygiene, counseling, minor surgery, homeopathy, acupuncture, prescription medication, intravenous and injection therapy, and naturopathic obstetrics (natural childbirth)

Question 22

Chiropractors

Answer 22

• Doctor of Chiropractic (D.C.) degree
• State license
• Doctor of Chiropractic programs typically 4 years
• Employ hands-on spinal manipulation and other alternative treatments; principle that proper alignment of the body’s musculoskeletal structure, particularly the spine, will enable the body to heal itself without surgery or medication.

Question 23

Education/training of allopathic and osteopathic physicians in the US

Answer 23

• Undergraduate education: BS or BA degree, with biology, chemistry, and physics
• Medical school Four years, consisting of preclinical and clinical parts.
• Residency program (graduate medical education): three to seven years or more of professional training under the supervision of senior physician educators.
• Fellowship: One to three years of additional training in a subspecialty (i.e. gastroenterology, a subspecialty of internal medicine and of pediatrics, or child and adolescent psychiatry, a subspecialty of psychiatry).

Question 24

Licensure and regulation of physicians

Answer 24

• United States Medical Licensing Examination (USMLE)
• Step 1: concepts of the basic sciences, usually taken after the second year of medical school
• Step 2: two parts - clinical sciences essential for patient care (usually during the fourth year of medical school)
  
  • 9-hour exam multiple-choice examination.
  • simulated patient interactions with 12 Standardized Patients (SPs)
• Step 3: medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine (typically at the end of the first year of residency)

Question 25

Licensure and regulations of physicians

Answer 25

• State Medical Boards require:
• Graduation from an accredited medical school,
• Completion of an accredited residency program,
• Pass the medical licensing examinations (USMLE 1, 2, and 3)

Question 26

history of physician training 18th century

Answer 26

• Indentured internships (running errands, washing bottles, mixing drugs, spreading the plasters, and bleeding patients, pulling teeth, etc.)
• 1750: informal classes and demonstrations, mainly in anatomy
• 1752: Pennsylvania Hospital - Thomas Bond & Benjamin Franklin
• 1765: College of Philadelphia – created a professorship in the theory and practice of medicine.
• Our first medical school was thus soundly conceived as organically part of an institution of learning and intimately connected with a large public hospital. The instruction aimed, as already pointed out, not to supplant but to supplement apprenticeship. A year’s additional training, carrying the bachelor’s degree, was offered to students who, having demonstrated a competent knowledge of Latin, mathematics, natural and experimental philosophy, and having served a sufficient apprenticeship to some reputable practitioner in physic, now completed a prescribed lecture curriculum, with attendance upon the practice of the Pennsylvania Hospital for one year. This course was well calculated to round off the young doctor’s preparation, reviewing and systematizing his theoretical acquisitions, while considerably extending his practical experience.
• …the local rivalry ominous as the first of its kind—of the newly established medical department of the University of Pennsylvania; but wise counsels averted disaster, and in 1791 the two institutions joined to form a single faculty, bearing, as it still bears, the name of the university…

Question 27

early college/university medical schools

Answer 27

• Kings College, New York (1767), became College of Physicians and Surgeons, Columbia
• Harvard College (1783)
• Yale (1810)
• Before the close of the century three more ‘medical institutes,’ similar in style, had been started: one in 1708 in New York, as the medical department of King’s College, which, however, temporarily collapsed on the British occupation, and was only indirectly restored to vigor by union in 1814 with the College of Physicians and Surgeons begun by the Regents in 1807; another, the medical department of Harvard College, opened in Cambridge in 1783, and twenty‑seven years later removed to Boston, to gain access to the hospitals there; last of the group, the medical department of Dartmouth College, started in 1798 by a Harvard graduate, Dr. Nathan Smith, who was himself for twelve years practically its entire faculty—and a very able faculty at that!

Question 28

19th century medical education

Answer 28

• 447 new medical schools in the US and Canada over the course of the 19th century
• Many short lived
• “…for the most part, they can be called schools or institutions only by courtesy…”
• Little to no equipment, supplies, or standards.
• No state licensure
• Currently 141 M.D. programs and 30 D.O. programs in the US.
• Wherever and whenever the roster of untitled practitioners rose above half a dozen, a medical school was likely at any moment to be precipitated. Nothing was really essential but professors. The laboratory movement is comparatively recent; and Thomas Bond’s wise words about clinical teaching were long since out of print. Little or no investment was therefore involved. A hail could be cheaply rented, and rude benches were inexpensive. Janitor service was unknown and is even now relatively rare. Occasional dissections in time supplied a skeleton—in whole or in part—and a box of odd bones. Other equipment there was practically none.
• The teaching was, except for a little anatomy, wholly didactic. The schools were essentially private ventures, money-making in spirit and object. Income was simply divided among the lecturers, who reaped a rich harvest besides, through the consultations which the loyalty of their former students threw into their hands. ‘Chairs’ were therefore valuable pieces of property, their prices varying with what was termed their ‘reflex’ value; only recently a professor in a now defunct Louisville school, who had agreed to pay three thousand dollars for the combined chair of physiology and gynecology, objected strenuously to a division of the professorship assigning him physiology, on the ground of ‘failure of consideration’; for the ‘reflex’ which constituted the inducement to purchase went obviously with the other subject. No applicant for instruction who could pay his fees or sign his note was turned down. State boards were not as yet in existence. The school diploma was itself a license to practice. The examinations brief, oral, and secret—plucked almost none at all; even at Harvard, a student for whom a majority of nine professors ‘voted’ was passed. The man who had settled his tuition bill was thus practically assured of his degree, whether he had regularly attended lectures or not. Accordingly, the business throve.
• Meanwhile, the entire situation had fundamentally altered. The preceptorial system, soon moribund, had become nominal. The student registered in the office of a physician whom he never saw again. He no longer read his master’s books, submitted to his quizzing, or rode with him. the countryside in the enjoyment of valuable bedside opportunities. All the training that a young doctor got before beginning his practice had now to be procured within the medical school. The school was no longer a supplement; it was everything. Meanwhile, the practice of medicine was itself becoming quite another thing. Progress in chemical, biological, and physical science was increasing the physician’s resources, both diagnostic and remedial. Medicine, hitherto empirical, was beginning to develop a scientific basis and method. The medical schools had thus a different function to perform; it took them upwards of half a century to wake up to the fact. The stethoscope had been in use for over thirty years before its first mention in the catalogue of the Harvard Medical School in 1868-69; the microscope is first mentioned the following year.
• …

Question 29

modern era of medical education

Answer 29

• 1893: Johns Hopkins University School of Medicine implemented 4 year graduate course
• Competitive selection of students
• Scientific clinical and laboratory science
• Linkage with a hospital

Question 30

flexner report

Answer 30

• 1910: commissioned by AMA
• Indictment of common proprietary, non-university medical schools
• Many schools closed
• Academic & credentialing standards adopted (LCME)
• Licensure for medical practice adopted by states
• Allopathic, and Osteopathic Models
• Over 18,000 graduates annually now.
• Flexner surveyed all 155 medical and osteopathic educational institutions in the United States and Canada that granted M. D. or D. O. degrees at the time. You can read the full report here.
• Flexner concluded that the education offered by these institutions was substandard, there were too many of them, and that free-standing educational institutions were hard-pressed to produce the funding necessary to maintain a quality level of education. He made several suggestions:
• the schools should have minimum admission standards: a high school education and at least two years of college level or university science.
• medical schools should be 4 years in duration: two years of basic sciences and two years clinical.
• “proprietary” schools should be closed or incorporated into universities.
• It’s hard to overestimate the effect of the Flexner Report. From the year of its publication to 1935 89 medical institutions closed their doors. Particularly hard hit were the osteopathic institutions. Some have said that this was part of the assault on competing disciplines launched by the American Medical Association that has continued to this day.

Question 32

physician residency training

Answer 32

• At least one year required for licensure
• Most finish specialty residency
• 3-6+ years

Question 33

board certification

Answer 33

• American Board of Medical Specialties (ABMS)
• Not required for licensure, but considered by hospitals and payers for privileges and reimbursement.
• Approximately 90%

Question 34

number of physicians licensed in the US

Answer 34

• 2014: 916,264 (total)
• Doctor of Medicine (MD): 841,321 91.8%
• Doctor of Osteopathic Medicine (DO): 72,961 8.0%
• Unknown: 1,982 0.2%
• U.S. / Canadian Graduates (MD/DO): 687,187 75.0%
• International Medical Graduates: 207,840 22.7%
• Unknown: 21,237 2.3%

Question 35

Nurses

Answer 35

• “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.”
• (American Nurses Association)

Question 36

types of nurses

Answer 36

• CNA: Certified Nursing Assistant
• LPN: Licensed practical nursing (licensed vocational nurse - LVN)
• RN: associate degree in nursing (ADN)
  
  • bachelors degree in nursing (BSN)
• MSN: master of science in nursing
• DNSc: doctor of nurse science
• APN: advance practice nurse
  
  • NP: nurse practitioner (FNP, WHCNP, PNP)
  • CNL: clinical nurse leader
  • CNS: clinical nurse specialist
  • CNM: certified nurse midwife
  • CRNA: certified registered nurse anesthetist
• DNP: doctor of nursing practice
• PhD: nursing doctor of philosophy
• Certified Nursing Assistant (CNA) 75-hour vocational course[
• Licensed practical nursing (LPN) or licensed vocational nursing (LVN)programs boast the quickest length to completion, usually about a year.
• LPN-to-Associate’s (ADN) bridge programs are geared toward students interested in becoming an entry-level RN.
• An associate degree in nursing (ADN) program focuses more on technical skills than theory, and for 30 percent of ASN graduates it is their stepping stone to a BSN. This is a good option if you haven’t been working as an LPN/LVN and want to start your career as an RN.
• Your time: An ADN takes about two years and is usually offered at a community college or vocational school
• PN-to-BSN bridge programs account for LPN work experience which means you won’t take the traditional 4-year BSN route, although you will be given a liberal arts education. Once completed, you’ll be eligible to work as an RN.
• Bachelor of Science in Nursing (BSN)
• Another bridge program, an RN-to-BSN degree is designed for registered nurse graduates of associate degree or diploma programs who want to complete their BSN degree.
• Second Degree BSN programs are designed for non-nurses who have bachelor’s degrees in non-nursing fields.
• Master of Science in Nursing (MSN)
• Direct entry MSN programs, sometimes called “graduate entry” or “master’s entry” programs, are perfect for non-nurses who hold bachelor’s degrees in another field.
• nurses for careers in health administration (a PhD is the preferred degree for nursing executives)
• A Doctorate of Nursing Education program is focused on developing advanced practice nurse specialist skills.
• A Doctor of Nursing Practice program is a newer degree and emphasizes clinical practice-oriented leadership development.
• DNSc program are prepared as nurse scientists with the investigative skills of a researcher and the clinical and leadership skills necessary to influence the health care system.
• Advance Practice Nurses (APNs) and include Nurse Practitioners (NPs), Clinical Nurse Leaders (CNLs), Clinical Nurse Specialists (CNSs), Certified Nurse Midwives (CNMs) and Certified Registered Nurse Anesthetists (CRNAs). Nurses with doctoral degrees are Doctors of Nursing Practice (DNPs) or nursing PhDs

Question 37

nurse education

Answer 37

• There is more than one educational pathway leading to eligibility to take the standardized National Council Licensure Examination (NCLEX)-RN.
• Undergraduate Diploma in Nursing, once the most common route to RN licensure and a nursing career, is available through hospital-based schools of nursing
• Associate Degree in Nursing (ADN) is a two-year degree offered by community colleges and hospital-based schools of nursing that prepares individuals for a defined technical scope of practice.
• Bachelor of Science in Nursing (BS/BSN) is a four-year degree offered at colleges and universities:

Question 38

Licensed practical nurses

Answer 38

• Licensed practical nurses (LPNs), also known as licensed vocational nurses (LVNs) in California and Texas, complement the healthcare team by providing basic and routine care consistent with their education under the direction of an RN or health care provider (physician, APN, or PA) in a variety of settings.

Question 39

RNs - registered nurses

Answer 39

• Perform physical exams and health histories
• Provide health promotion, counseling and education
• Administer medications, wound care, and numerous other personalized interventions
• Interpret patient information and make critical decisions about needed actions
• Coordinate care, in collaboration with a wide array of healthcare professionals
• Direct and supervise care delivered by other healthcare personnel like LPNs and nurse aides
• Conduct research in support of improved practice and patient outcomes

Question 40

nurse practice settings

Answer 40

• RNs practice in:
  
  • hospitals,
  • nursing homes,
  • medical offices,
  • ambulatory care centers,
  • community health centers,
  • schools,
  • retail clinics.

Question 41

Advanced Practice registered nurses

Answer 41

• A registered nurse with at least a Master’s educational and clinical practice requirements who provides at least some level of direct care
• Nurse practitioner (NP) – provide a wide range of primary and preventive health care services, prescribe medication, and diagnose and treat common minor illnesses and injuries.
• Certified nurse-midwife (CNM) – CNMs provide well-woman gynecological and low-risk obstetrical care in hospitals, birth centers, and homes.
• Clinical nurse specialist (CNS) – Working in hospitals, clinics, nursing homes, private offices, and community-based settings, handle a wide range of physical and mental health problems, research, education, and administration.
• Certified registered nurse anesthetists (CRNA) – The oldest of the advanced nursing specialties; CRNAs administer virtually all anesthesia in some states.

Question 42

Graduate Nurse Degrees

Answer 42

• Graduate degrees offer additional routes to advancing the expertise of registered nurses:
• Master’s Degree (MSN) programs offer a number of tracks designed to prepare Advanced Practice Nurses, nurse administrators, and nurse educators.
• Doctor of Philosophy (PhD) programs are research-focused whose graduates typically teach and/or conduct research
• Doctor of Nursing Practice (DNP) programs focus on clinical practice or leadership roles

Question 43

Nurse licensure and regulation

Answer 43

• State boards of nursing establish requirements for initial licensure and retaining: basic education, continuing education and/or competency
• Interpret scope of practice parameters, defined by state statute (nurse practice acts)
• Investigate complaints of licensees and disciplinary actions

Question 44

History of Nursing

Answer 44

• During the Crimean War, Florence Nightingale laid the foundations of professional nursing with the principles summarized in Notes on Nursing.
• Nightingale’s revelation of the abysmal care afforded soldiers in the Crimean War prompted reforms.
• Florence Nightingale, OM, RRC (12 May 1820 – 13 August 1910) was a celebrated English social reformer and statistician, and the founder of modern nursing. She came to prominence while serving as a manager of nurses trained by her during the Crimean War, where she organized the tending to wounded soldiers.[1] She gave nursing a highly favorable reputation and became an icon of Victorian culture, especially in the persona of “The Lady with the Lamp” making rounds of wounded soldiers at night.
• Some recent commentators have asserted Nightingale’s achievements in the Crimean War were exaggerated by the media at the time, to satisfy the public’s need for a hero. Nevertheless, critics agree on the decisive importance of her follow-up achievements in professionalizing nursing roles for women. In 1860, Nightingale laid the foundation of professional nursing with the establishment of her nursing school at St Thomas’ Hospital in London. It was the first secular nursing school in the world, now part of King’s College London. The Nightingale Pledge taken by new nurses was named in her honor, and the annual International Nurses Day is celebrated around the world on her birthday. Her social reforms include improving healthcare for all sections of British society, advocating better hunger relief in India, helping to abolish prostitution laws that were over-harsh to women, and expanding the acceptable forms of female participation in the workforce.
• Nightingale was a prodigious and versatile writer. In her lifetime, much of her published work was concerned with spreading medical knowledge. Some of her tracts were written in simple English so that they could easily be understood by those with poor literary skills. She also helped popularize the graphical presentation of statistical data. Much of her writing, including her extensive work on religion and mysticism, has only been published posthumously.
  *

Question 45

Clara Barton

Answer 45

• Clara Barton (1821-1912) provided, organized, directed nursing work during the American Civil War.
• Organized and established the American Red Cross, primarily a disaster relief agency but also supported nursing programs.

Question 46

Nurse education in 19th century

Answer 46

• Nursing professionalized in the late 19th century as larger hospitals set up nursing schools that attracted ambitious women from middle- and working-class backgrounds.
• Nursing schools established in the U.S. and Japan;
• Schools became controlled by hospitals, and formal “book learning” was discouraged in favor of clinical experience. Hospitals used student nurses as cheap labor.

Question 47

Nurse training in hospitals

Answer 47

• After 1880 standards of classroom and on-the-job training rose, as did standards of professional conduct
• Most larger hospitals operated a school of nursing, which provided training to young women, who in turn did much of the staffing on an unpaid basis. The number of active graduate nurses rose rapidly from 51,000 in 1910 to 375,000 in 1940 and 700,000 in 1970.
• Nursing professionalized rapidly in the late 19th century as larger hospitals set up nursing schools that attracted ambitious women from middle- and working-class backgrounds. Agnes Elizabeth Jones and Linda Richards established quality nursing schools in the U.S. and Japan; Linda Richards was officially America’s first professionally trained nurse, graduating in 1873 from the New England Hospital for Women and Children in Boston
• In the early 1900s, the autonomous, nursing-controlled, Nightingale-era schools came to an end. Schools became controlled by hospitals, and formal “book learning” was discouraged in favor of clinical experience. Hospitals used student nurses as cheap labor.
• Before the 1870s “women working in North American urban hospitals typically were untrained, working class, and accorded lowly status by both the medical profession …and society at large”. Nursing had the much the same lowly status in Europe. However D’Antonio shows that in the mid-19th century nursing was transformed from a domestic duty of caring for members of one’s extended family, to a regular job performed for a cash wage. Nurses were now hired by strangers to care for sick family members at home. These changes were made possible by the realization that expertise mattered more than kinship, as physicians recommended nurses they trusted. By the 1880s home care nursing was the usual career path after graduation from the hospital-based nursing school.

Question 48

Nurse training act of 1964

Answer 48

• Moved the locale of nurse education and training from hospitals to universities and community colleges, leading to an increase in the number of nurses.
• Funded collegiate nursing education, spurring development of baccalaureate, advanced practice and PhD programs
• The Nurse Training Act of 1964 transformed the education of nursing, moving the locale from hospitals to universities and community colleges. There was a sharp increase in the number of nurses; not only did the supply increase but more women remained in the profession after their marriage. Salaries went up, as did specialization and the growth of administrative roles for nurses in both the academic and hospital environments.
• Nurse Training Act of 1964, a law signed by U.S. President Lyndon B. Johnson in an effort to solve the problems associated with nursing shortage in the country. Numerous reports depict the prevalence of problems associated with nursing shortage. With the passage of the Nurse Training Act, the government hopes to deal with such problems. One of the provisions of the law calls for the establishment of student loan funds, cooperating public and private non-profit schools of nursing.
• Federal Nurse Training Act of 1964 pumped enormous funding into collegiate nursing education, spurring development of baccalaureate, advanced practice and PhD programs

Question 49

Nurse education

Answer 49

• Hospital diploma schools - nursing students were unpaid, giving hospitals a source of free labor.
• Hospitals moved their schools to universities, but the four-year baccalaureate programs could not produce nurses fast enough to meet a huge shortage.
• Two-year associate degree of nursing program established to provide technically skilled nurses to meet the immediate demand until enough baccalaureate degree nurses could be trained.
• Three ways to become an RN:
• two-year associate degree,
• three-year diploma program
• Four-year baccalaureate program.

Question 50

Currently - shortages of slots for nursing students

Answer 50

• U.S. nursing schools turned away 68,938 qualified applicants from baccalaureate and graduate nursing programs in 2014 due to an insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints.
• Faculty shortages at nursing schools across the country are limiting student capacity at a time when the need for nurses continues to grow. Budget constraints, an aging faculty, and increasing job competition from clinical sites have contributed to this emerging crisis.
• Almost two-thirds of the nursing schools responding to the survey pointed to faculty shortages as a reason for not accepting all qualified applicants into baccalaureate programs.

Question 51

PAs - physician assistants

Answer 51

• As specialization in medical practice grew following World War II, a growing shortage in primary care health manpower has become clear. At Duke University in 1957, the nation’s foremost chair of medicine, and a visionary nurse begin a program to train nurses to provide direct assistance to physicians with emphasis on primary care. Having failed accreditation by the National League for Nursing (NLN), the program was discontinued, but the experience was not forgotten. In an address to the House of Delegates in 1960, an emerging leader of the AMA proposes the training of former military corpsmen as assistants to physicians. In 1965, Duke University establishes such a program with four ex-Navy corpsmen, creating a sensation in the national press. Within four years four other prototypes emerge. The Duke PA and University of Washington MEDEX programs are quickly emulated by other academic medical colleges. Meanwhile, the shortage of generalist physicians is compounded by the creation of Medicare and Medicaid, opening access to health services by millions of new patients. Two national commissions address the issue, promoting expansion of all efforts to support generalist physicians. By the end of the 1960s, the AMA formally endorses the concept of the “physician’s assistant,” and begins to explore accreditation of programs in order to achieve a common standard of training. The existing academic programs form a “registry” to assure the public of the qualifications of their graduates.
• Eugene A. Stead, Jr., MD, disillusioned by organized nursing’s rejection of the advanced nurse clinician program that he and nurse educator, Thelma Ingles, had developed, announces in a letter to Duke Hospital Administrator, Charles H. Frenzel, his intention to develop a program for the “physician’s assistant”, using former military corpsmen, modeled after the relationship between Amos N. Johnson, MD, and Henry Lee “Buddy” Treadwell, his assistant, that was well known in the North Carolina community.
• In California, Governor Ronald Reagan signs Assembly Bill 2109 into law on September 17, 1970. It directs the Board of Medical Examiners to establish this new category of health professional. Thus, California becomes the first state to enact enabling legislation for physician assistants.

Question 52

PAs

Answer 52

• …a licensed medical professional who can examine, test, treat and prescribe medication for patients.
• …the exact duties of PAs depend on the type of medical setting in which they work, their level of experience, their specialty and state laws.
  
  • Obtain patient medical histories
  • Conduct physical exams
  • Diagnose and treat illnesses
  • Order and interpret tests
  • Develop treatment plans
  • Counsel on preventive healthcare
  • Assist in surgery
  • Write prescriptions
• National PA certification exam administered by the National Commission on Certification of Physician Assistants (NCCPA)
• Licensure and regulation by state boards

Question 53

PA education/training

Answer 53

• Pre-requisite – bachelors degree, generally with same courses as medical schools, and > 1 year healthcare experience
• intense, three year graduate-level program with courses in basic sciences, behavioral sciences, and clinical medicine including anatomy, pharmacology, microbiology, physiology, medicine and surgery, and more.
• 2,000 hours of clinical rotations:
  
  • • Family medicine
  • • Internal medicine
  • • OB/GYN
  • • Pediatrics
  • • General surgery
  • • Orthopedics
  • • Emergency medicine
  • • Psychiatry
  • • Geriatrics

Question 55

where do PAs practice nationally

Answer 55

• One-third in primary care
• Others in specialty medicine
• 37.5 percent in hospital settings
• 38.1 percent in a group practice or solo physician office
• The remaining PAs work in a variety of settings, including community health centers, freestanding surgical facilities, nursing homes, school- or college-based facilities, industrial settings and correctional institutions
• The U.S. Department of Veterans Affairs is the largest single employer of PAs
• Thirty-seven percent of PAs work in medically underserved counties

Question 56

dentists

Answer 56

• United States - 210,187
• California - 33,242
• A 2010 study predicted:
• decline in the number of dentists practicing in the United States of 7,000 (almost 4 percent) between 2012 and 2019.4
• U.S. HEALTHCARE WORKFORCE
• SHORTAGES: CAREGIVERS Walt Zywiak
• A 2010 study commissioned by Delta Dental Plans Association predicted:
• decline in the number of dentists practicing in the United States of 7,000
• (almost 4 percent) between 2012 and 2019.4

Question 57

Future supply of Healthcare workers

Answer 57

• 40 percent of practicing physicians are older than 55; about one-third of the nursing workforce is over age 50.
• Economists say a third of physicians could retire in the next 10 years.
• More than half of nurses over 50 say they plan to retire in the next decade.
• Team-based care and an expanded role for advance practice nurses and physician assistants could mitigate the shortage of primary care providers.

Question 58

lifestyle factors affecting supply of health care workforce

Answer 58

• Younger professionals have different practice patterns than their predecessors (e.g., men and women age 25–40 tend to work fewer hours than previous generations of health professionals).

Question 59

projected need for physicians

Answer 59

• Demand is projected to grow by up to 17 percent, by 2025, exceeding supply by 46,000 to over 90,000.
• (The lower range if rapid growth in non-physician clinicians and widespread adoption of new payment and delivery models such as PCMHs and ACOs.)
• Shortages vary by specialty grouping:
  
  • 12,500 - 31,100 primary care physicians.
  • 28,200 - 63,700 non-primary care physicians
• AAMC
• Total physician demand is projected to grow by up to 17 percent, with population aging/growth
• accounting for the majority. Full implementation of the Affordable Care Act accounts for about 2 percent of the projected growth in demand.
  
  • By 2025, demand for physicians will exceed supply by a range of 46,000 to 90,000. The lower range of estimates would represent more aggressive changes secondary to the rapid growth in non-physician clinicians and widespread adoption of new payment and delivery models such as patient-centered medical homes (PCMHs) and accountable care organizations (ACOs).
  • Total shortages in 2025 vary by specialty grouping and include:
• {{ A shortfall of between 12,500 and 31,100 primary care physicians.
• {{ A shortfall of between 28,200 and 63,700 non-primary care physicians, including:
  
  • „5,100 to 12,300 medical specialists
  • 23,100 to 31,600 surgical specialists
  • 2,400 to 20,200 other specialists2

Question 60

The increasing demand for care

Answer 60

• Patient population growing, growing older and requiring more chronic disease care.
• Population growth: population to increase by 13 percent between now and 2025
• Population aging: baby boomers, by 2030, 70 million U.S. residents (20 percent) will be 65 or older (those 65 or older use twice as many physician resources)
• Chronic disease growth: by 2030, half the population will have one or more chronic conditions, (patients with chronic disease average more than twice as many physician visits per year)
• Increasing demands for care in the United States come from a patient population
• which is growing, growing older and requiring more chronic disease care.
• Examples of these sources and impacts include:
• • Population growth: The U.S. Census Bureau projects the population to
• increase by 13 percent between now and 2025.10
• • Population aging: The first baby boomers turn 65 in 2011, and by 2030, 70
• million U.S. residents (20 percent) will be 65 or older.11 A significant impact
• of that trend is that those 65 or older use twice as many physician resources
• as those less than 65.12
• “This [2006-2025 population increase] alone could lead to a substantial
• increase in demand. An aging population virtually assures that increase.”13
• • Chronic disease growth: “By 2030, half the population will have one or more
• chronic conditions, [and studies have shown that patients with chronic
• disease average more than twice as many physician visits per year as
• patients without a chronic condition].”15

Question 61

decreasing supply of health care providers

Answer 61

• Caregiver aging and retiring
• No significant increase in number students
• Increasing school costs and debt
• Declining primary care interest.
• Relatively…
• • Caregiver aging: more than one-third of active physicians were
• 55 or older, and one-fourth were 60 or older;
• 36.4 percent of registered nurses will be 50–64 by 2015;
• the American Dental Association expects dentist retirement (and career change) to outpace growth by 2014;18 and in
• 2008 the ASPH reported that one-quarter of the public sector workforce will be eligible to retire by 2012. The message, of course, is that the industry
• is at risk of losing significant portions of the caregiver population to retirement within the next 5 to 10 years.
• • Flat medical school attendance: From 1980 to 2005 there was no sign of physician supply increase, e.g., the number of graduating medical students
• remained flat (at approximately 16,000 per year).
• • Medical school costs: Undergraduate and medical school educations have become expensive, so much so that the current average educational debt of
• graduating medical school students (more than $155,00020) is becoming an issue for students considering medical school. As noted in a 2007 AAMC
• report on medical school tuition, “… if nothing changes, the outlook for medical education looks bleak.”21
• • Declining primary care interest: What many consider to be the biggest concern about the physician supply is declining interest in primary care
• practice. Between 1950 and 2007, the percentage of U.S. physicians practicing primary care declined from 50 to 30 percent.22 One reason is
• income differentials. “Primary care physicians earn on average half of what their specialty colleagues make, and the gap is widening.”23 For

Question 62

issues affecting supply of primary care providers

Answer 62

• Salaries
• Job dissatisfaction
• Nurse and nurse practitioner faculty shortages
• Regional disparities - “underserved” areas and communities
• per a 2007 American Medical Association (AMA) survey, primary care
• salaries averaged less than $200,000 per year, while neurological surgeons,
• who topped the list, earned more than $580,000.24
• • Physician job dissatisfaction: Another reason for primary care decline is
• job dissatisfaction: “… two key trends negatively affecting the supply of
• primary care physicians: the income/reimbursement gap and growing
• provider dissatisfaction with working conditions …”25 However, dissatisfaction
• is also impacting where physicians practice: “… many doctors have decided
• that the challenges of running their own businesses are simply too great,”
• and are turning away from private practice to employment at hospitals and
• health systems.
• • Nurse and nurse practitioner faculty shortages: According to three-fourths
• of nursing schools surveyed in 2008, faculty shortages accounted for
• refusing admission to almost 50,000 qualified student applicants that year.27
• • Regional disparities: Upon closer examination, a big contributor to
• shortages is often regional disparities (resulting in “underserved” areas
• and communities). “For every new physician that decides to practice an
• underserved area, four will settle in regions of the country with adequate
• numbers of providers.”28 Examples include:
• – 55 vs. 93 primary care physicians per 100,000 residents in rural vs.
• urban areas.29

Question 63

healthcare industry efforts

Answer 63

• Industry efforts prior to health reform have focused on four areas:
  
  • 1. Increasing U.S. medical school enrollment
  • 2. Encouraging primary care residencies and careers
  • 3. Expanding mid-level provider pool (nurse practitioner, physician assistant, nurse mid-wife)
  • 4. Exploring ways to more effectively use caregiver resources.