Hospitals and insurance companies go hand in hand to increase the cost of our Health Care. I have one questgion for you to consider. Just what exactly does an insurance company provide in the way of improved health care? The answer: Nothing! They just suck money from the system and give nothing in return! Think about it: Do we need them? We are the only western civilized country with hundreds of these leeches just sucking us dry and providing nothing in return!
I INTRODUCTION Hospital, institution that provides a broad range of medical services to sick, injured, or pregnant patients. Hospitals employ medical, nursing, and support staff to provide inpatient care to people who require close medical monitoring and outpatient care to people who need treatment but not constant medical attention. Hospitals provide diagnosis and medical treatment of physical and mental health problems, surgery, rehabilitation, health education programs, and nursing and physician training. Many hospitals also serve as centers for innovative research and medical technology. Today the United States is home to 6241 hospitals that contain over 1 million hospital beds. U.S. hospitals annually admit more than 33 million patients who are assigned a bed and receive medical or surgical treatment as inpatients. Hospitals also provide outpatient treatment in clinics or other walk-in, or ambulatory, settings for an additional 483 million patients every year.
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II TYPES OF HOSPITALS Hospitals in the United States are classified by the services they provide (general or specialized), the length of stay they offer patients (short stay or long-term care), and by their ownership (not-for-profit, proprietary, or government owned). Although most U.S. hospitals are classified as not-for-profit, any one hospital will fall into several of the above categories. For example, Methodist Hospital in Houston, Texas, with more than 300,000 sq m (3 million sq ft) of space, is one of the largest short-stay, not-for-profit, general hospitals in the country.
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A Services Provided by Hospitals
General hospitals, regardless of their size, provide patients with a wide range of services, including emergency treatment, surgery, and medical and nursing care. Specialized hospitals, in contrast, may concentrate on a particular group of patients, such as children, or a disease, such as cancer. Some specialized hospitals combine treatment and research. For instance, Roswell Park Cancer Institute in Buffalo, New York, offers 37 specialized cancer treatment centers, including centers for acquired immune deficiency syndrome (AIDS)-related cancers, brain tumors, and ovarian cancer, and provides state-of-the-art treatments for these cancers that are not generally available in other hospitals. The institute also conducts research on new cancer drugs and procedures, such as photodynamic therapy, which uses a laser to activate cancer-killing chemicals inside tumors. Some general and specialized hospitals also function as tertiary care centers, treating the most difficult and complex cases or the most seriously ill patients. These may include patients who need heart, lung, or liver transplants (see Transplantation, Medical). Many hospitals that serve as teaching institutions train residents (medical school graduates who are doing postgraduate training) in general medicine or specialty areas. Teaching hospitals also train others interested in a health care career, including nurses and laboratory specialists. Although some of these hospitals are relatively small and train only a few doctors in teaching programs that are affiliated with medical schools, approximately 300 hospitals are university-based academic medical centers that offer both medical training and opportunities for medical research. Academic medical centers are usually massive urban hospitals linked closely with major medical schools. Although academic medical centers represent only 6 percent of all U.S. hospitals, they care for about 20 percent of all patients nationwide because they serve as referral centers for specialized consultation or for advanced diagnostic and therapeutic procedures for patients in wide regional areas. The Medical Center of the University of California at San Francisco, annually admits almost 27,000 patients and treats about 340,000 outpatients in its clinics and 53,000 patients in its emergency room and trauma center.
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B Length of Stay The American Hospital Association (AHA), a national organization that promotes organizational and legislative issues of interest to hospitals, classifies hospitals by the length of stay they offer patients. AHA categorizes hospitals as short-stay or acute-care centers if their patients receive 30 days or less of inpatient treatment. In contrast, AHA classifies hospitals as long-term care institutions if their patients require more than 30 days of treatment, as is available in rehabilitation facilities or nursing homes. AHA makes the distinction between short-stay and long-term care facilities to reflect not only the difference in length of stay but also the scope and intensity of services provided by an institution. Short-stay hospitals are geared for quick intervention and constant monitoring of serious, often life-threatening illnesses. These hospitals provide immediate attention until a patient is stabilized enough to be treated at home or in a health care setting that can provide a longer stay. Long-term care institutions treat physical diseases or injuries that are debilitating and require prolonged medical intervention or physical therapy and regular skilled nursing care. Some long-term care facilities are psychiatric institutions for the mentally ill who cannot be cared for at home.
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C Ownership of Hospitals Not-for-profit, or voluntary, hospitals, which represent about 84 percent of the hospitals in the United States, are charitable institutions that exist to serve the best interests of their communities. Although not-for-profit hospitals do not receive funding from tax dollars, they are exempt from local, state, and federal taxation. Many not-for-profit hospitals were founded and continue to be run by religious groups, such as members of the Catholic Church, Presbyterian or Methodist ministries, or Jewish organizations. A small number of private charitable hospitals were spearheaded by individuals. Probably the best known of these is the Mayo Clinic in Rochester, Minnesota, established by American physician William Mayo and his two physician sons (see Mayo [family]). Most not-for-profit hospitals, however, were established by members of their local community and continue to be governed by community representatives. Proprietary, or for-profit, hospitals are owned by corporations and their shareholders. Although only about 700 U.S. hospitals are for-profit institutions, these hospitals are typically part of large investor-owned hospital chains. For instance, Columbia/Hospital Corporation of America (HCA), the largest for-profit hospital chain, has more than 350 hospitals in its network. Columbia/HCA is listed on the New York Stock Exchange, just as any other for-profit company; company executives seek to reward shareholders who invest in the company by applying standard corporate management techniques, likely to yield corporate profits, to hospital administration. A health maintenance organization (HMO) pays for and provides medical care to enrolled patients. For a fixed payment, HMOs deliver health services by establishing panels of doctors and hospitals that provide all the treatment their members require. The first HMO in the country, not-for-profit Kaiser Permanente of Oakland, California, has operated ten hospitals in California since the late 1980s. Although some HMOs, like Kaiser, purchase the hospitals they use, other HMOs only contract with hospitals to treat HMO patients. When a hospital contracts to meet the health care needs of an HMO's patients, it retains its ownership status. Cities, counties, states, and the federal government also own hospitals. About 1000 public hospitals are owned by their cities or counties and are supported by local tax dollars. The vast majority of city hospitals are in small or moderate-size communities, and they offer services that are similar to those provided in small, general, not-for-profit hospitals. About 150 municipal or county hospitals are found in major cities, such as Cook County Hospital in Chicago, Illinois. These large, urban, public institutions provide most of the care for the poor in their communities. They also often offer comprehensive, high-tech care for certain categories of gravely ill patients, such as trauma and burn victims, as well as intensive care for newborns who are premature or who have severe birth defects. In contrast to the many city and county hospitals in the United States, only a small number of hospitals are run by state governments, and most of these are long-term psychiatric or chronic care institutions. Federal hospitals care for specific types of government program beneficiaries, such as the hospitals on reservations that care for Native Americans. Walter Reed Army Medical Center, in Washington, D.C., and other military hospitals provide treatment for military personnel and high-ranking members of the government, including the president of the United States. Hospitals run by the Department of Veterans Affairs are located throughout the United States and treat illnesses of military veterans and their dependents. | Back to Top |
III LICENSING AND ACCREDITING HOSPITALS
Each hospital, regardless of its classification, must be licensed by the state in which it operates, a procedure that assesses a hospital's compliance with public health standards governing, for example, cleanliness and overcrowding. In addition to being licensed, hospitals seek accreditation from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a private quality-measurement organization. JCAHO sets 700 national standards for hospitals covering every area of their operation, such as clinical care, social services, administration, and financial services. Teams of inspectors evaluate a hospital's compliance with these standards once every three years. JCAHO has established several categories of accreditation, including full accreditation for institutions that meet the vast majority of its standards and provisional accreditation for institutions that must correct specific lapses before they can be accredited. Only about 5 percent of all hospitals surveyed by JCAHO are accredited with commendation for meeting top levels of achievement in all 28 areas of measurement. One such hospital is the University of Washington Medical Center in Seattle, Washington, a 390-bed teaching hospital that also has specialty centers for research on Alzheimer's disease, women's health, and diabetes, and offers 80 outpatient clinics. | Back to Top |
IV HOSPITAL ORGANIZATION AND STAFF
A hospital is a complex institution that coordinates the skills of doctors, nurses, and support care personnel to provide health services. A hospital also has administrative departments to ensure the efficient and financially sound operation of the institution. Large not-for-profit general hospitals, the most common hospital type, have several levels of organization that include a board of trustees, chief administrative officer, chief of the medical staff, administrative and medical department heads, and a director of nursing. A hospital's board of trustees oversees the operation of the hospital by evaluating its financial health and its strategic growth and development. One of the board's major responsibilities is to hire and assess the performance of the hospital's chief administrative officer; another is to approve the appointment and retention of the hospital's physicians. Board members also participate in fund-raising and other philanthropic activities and in community outreach activities that seek to improve the health of the community. Not-for-profit hospitals are charitable institutions that are expected to meet the needs of their communities and their boards of trustees are typically made up of representatives from local businesses and community groups. The chief administrator of a not-for-profit general hospital is known as the chief executive officer, president, or administrator, depending on the size and complexity of the hospital's organization. As the hospital's top executive, the chief administrator plans for the ongoing financial health of the institution, considering such issues as whether the hospital should remain independent or merge with another institution; expand or reduce specific health services, such as high-cost trauma care; develop relationships with groups of physicians, HMOs, or clinics; or create satellite facilities in nearby cities or towns. The chief of the medical staff is a physician appointed to direct the work of all the doctors who treat patients in the hospital and to supervise the procedures for adding doctors to the hospital staff. Also called privileges, these procedures define the qualifications needed by doctors and the specific treatments each doctor may perform in the hospital. The chief of the medical staff takes disciplinary action against doctors who do not follow the rules and regulations of the hospital, and reviews the work of committees of doctors who evaluate the quality of medical care in the hospital and the use of hospital resources. Vice presidents, sometimes called directors, of administrative departments are responsible for the daily operation of a hospital. The vice president of finance directs the work of a hospital's admissions, budget, and cashier's offices, overseeing the general accounting and internal auditing of the hospital's finances. Although responsibilities vary in individual institutions, the vice president of materials management usually buys, stores, and maintains supplies, while the vice president of clinical engineering buys and maintains hospital equipment, including high-tech instruments and machines. The vice president of environmental services supervises the laundry, power plant, and the hospital at large and ensures the safety and security of all staff and patients. A physician heads each of the many medical departments found within most not-for-profit general hospitals. Most hospitals have separate departments organized by medical specialties, including internal medicine, surgery, pediatrics, obstetrics and gynecology, radiology and diagnostic testing, pathology, anesthesiology, and sometimes psychiatry or neurology. The director of nursing supervises the work of nurses, the hospital's largest group of health care providers, to ensure the quality and efficiency of the care they provide patients. Nurses provide round-the-clock care that includes giving patients medication, monitoring health status, and maintaining personal hygiene. Nurses also care for hospital outpatients in the emergency department, ambulatory surgery center, and clinics. They provide specialized services in intensive care units, surgical suites, and trauma units. In addition to medical, surgical, and nursing care, a hospital also provides many other professional services, all of which have a department head who reports to the hospital's chief administrator. Dietary or nutrition staff ensure that hospitalized patients receive food or dietary supplements that maintain and improve health. The pharmacy dispenses the medications that are ordered by doctors and advises doctors on alternative drug regimens for individual patients. The social services department links patients with agencies and professionals inside and outside the hospital that can provide patients with financial help, counseling, long-term care, or assistance in the home. Educational outreach programs not only acquaint community members with the direct services offered by the hospital, they also teach individuals about disease prevention and health maintenance.
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V HOSPITAL DEPARTMENTS
Hospitals are typically organized into medical departments, or units, such as an emergency room, surgical suites, intensive care units (ICUs), pediatric and maternity wards, and departments of radiology, anesthesiology, pathology, and rehabilitative medicine. A hospital's emergency department is staffed 24 hours a day by doctors and nurses who have been trained to diagnose health problems quickly. These doctors and nurses perform medical or surgical treatments that stabilize a patient's condition so that the patient can be moved to another part of the hospital for additional care. When the emergency room is crowded with patients, emergency department staff identify and respond immediately to the most seriously ill or injured patients, a medical approach called triage. The surgical suites include the actual operating rooms, where surgical procedures are performed, and postoperative recovery rooms. All operating rooms have an operating table that can be adjusted to accommodate the surgical procedure and facilitate the use of sophisticated monitoring equipment. Instruments and equipment, such as lasers or television screens, are brought into the operating room as needed. After surgery, patients are taken to the postoperative recovery room, adjacent to the operating room, so they can be monitored as they awaken from anesthesia. Many hospitals offer two types of ICUs-one for patients who have had surgery and one for patients with dangerous medical conditions, usually involving the heart. Some hospitals also have ICUs for newborns or burn patients. Intensive care units use monitoring equipment that transmits data on a patient's condition directly to the nurses' station. ICUs also have on hand technology and medications that are specific to the medical needs of the patients they serve. For example, newborn ICUs have equipment that is specifically designed to deliver oxygen to tiny babies, while burn units have special ventilation systems to reduce the chance that patients will be exposed to infection. The pediatric unit admits only children and is equipped with instruments and machines that are suitable for the small size of its patients. Hospitals often prepare children for a hospital stay by allowing them to visit before being admitted so that the surroundings will seem less frightening during their stay. Some hospitals allow a parent to stay in the child's room during a hospital stay. Pediatric wards often have playrooms for their young patients and organize special activities such as parties to cheer children who are hospitalized during the holidays. The maternity ward, also found in many hospitals, offers homelike labor and delivery rooms where a pregnant woman and her family can gather for the birth of her baby. It also may have a separate surgical area for difficult deliveries requiring a cesarean section, sometimes needed when the baby is not in the normal head-down position or when there are multiple babies. Most maternity wards have a central area where newborns spend most of their time until they are ready to be released from the hospital with their mother. Hospitals also have departments that assist in the treatment of patients but that are not involved in their day-to-day care. The department of radiology provides internal images of the body to diagnose and treat disease; the anesthesiology department works with physicians to provide the safest type of anesthesia for a patient during surgery and pain relief after surgery; and the pathology department examines body tissues in a laboratory to diagnose disease. Some hospitals help patients in their recovery by providing the services of a department of rehabilitative medicine, which is often headed by a doctor and staffed by physical and occupational therapists. These professionals help patients regain normal physical function following surgery and relearn muscular control and coordination in resuming everyday task.
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VI COST ISSUES HOSPITALS FACE
Hospital costs have increased steadily over the last 30 years, largely because of the way health care is paid for in the United States. For many years, both private health insurance companies and government agencies, referred to as payers, paid more for treating insured patients in hospitals than in outpatient settings. In response to this reimbursement strategy, many hospitals expanded their facilities and added the latest in high-tech equipment, spreading the cost of these expensive improvements to every hospitalized patient. Since the mid-1980s, however, private and public payers have tried to reduce the skyrocketing costs of hospital care that resulted from the facility improvements of the preceding two decades. The federal government has cut the budgets for both Medicare, which covers health costs for people over age 65, and Medicaid, which provides similar coverage to the poor (see Medicare and Medicaid). Further, both public and private payers increasingly are opting for an approach to the delivery of health care called managed care, which controls not only the cost but the number of services patients receive. As a result of these trends, hospitals are receiving less money from government programs and have had to reduce their own spending because of the cost-control activities imposed by managed care. Despite tighter budgets, hospitals continue to provide treatment to an increasing number of uninsured Americans, whose ranks swelled from 33.5 million to 41 million between 1988 and 1995. These changes have affected some hospitals more dramatically than others. Public hospitals, which treat large percentages of Medicaid patients and uninsured individuals, have been hit the hardest, often receiving no payment for roughly 13 percent of the care they provide. Because many city and state governments have cut taxes, public hospitals do not receive adequate tax dollars to cover their deficits. The financial constraints facing public hospitals have forced some to close their doors, such as the 112-bed Polk County Florida Hospital, and others to downsize, including the District of Columbia General Hospital, which eliminated 160 of its 410 beds and laid off 260 employees in 1995. The financial health of private, not-for-profit hospitals has largely depended on their location. Hospitals in areas where much of the population is enrolled in managed care plans have had to cut their costs by examining and redefining the most efficient ways of treating patients while ensuring the best medical results. A program at Boston's Massachusetts General Hospital ensuring that patients receive prompt physical therapy, for example, has decreased by 22 percent the average length of stay for patients having hip or knee replacements. The cost of such surgeries has been decreased by 17 percent; the result of this program is not only cost reduction, but also faster recovery for patients and earlier release to home or to a health care setting for further rehabilitation. Another cost-cutting strategy is to merge not-for-profit hospitals with other hospitals to become part of multihospital systems, some of which are for-profit companies. In 1994, 251 of the 308 nonprofit hospitals that changed hands were acquired by for-profit hospital chains. Canadian hospitals also are facing financial challenges, although their challenges differ from those that U.S. hospitals must address. Whereas the number of uninsured Americans is increasing each year, Canada has no uninsured individuals because it provides all citizens with health insurance. However, this health insurance is financed through taxes that provincial governments are reluctant to increase, despite the increased demand for medical services among Canada's aging population. In addition to making tax decisions that affect the financial health of many of Canada's hospitals, provincial governments also make decisions that govern how hospitals operate, even if a hospital is not in the public sector. Examples of decisions made by provincial governments in their efforts to minimize health care costs include prohibiting hospitals from acquiring new technology and rationing nonemergency services by placing patients on long waiting lists for treatment. It is not unusual for Canadian patients to wait as long as three months for a hip replacement and eight months for gall bladder surgery. In contrast, elective surgery in the United States is delayed by only the days, or at most weeks, required for an insurer or managed care company to approve the requested surgical procedure. | Back to Top |
VII HISTORY OF HOSPITALS
The term hospital derives from the Latin word hospitalis, which relates to guests and their treatment. The word reflects the early use of these institutions not merely as places of healing but as havens for the poor or for weary travelers. Hospitals first appeared in Greece as aesculapia, named after the Greek god of medicine, Aesculapius. For many centuries they developed in association with religious institutions, such as the Hindu hospitals opened in Sri Lanka in the 5th century BC and the monastery-based European hospitals of the Middle Ages (5th century to 15th century). The Hôtel Dieu in Paris, a monastic hospital founded in AD 660, is still in operation today. The first hospital established in the United States was Pennsylvania Hospital in Philadelphia, which was chartered in 1751 with the support of Benjamin Franklin. Although other U.S. hospitals were created in the 1700s, most people were treated for their illnesses by neighbors and friends in their homes well into the 1800s. Hospitals changed radically after the Civil War-in the early years of the war no hospitals were available to treat the thousands of soldiers who were wounded or became ill, but by the war's end in 1865, 200 hospitals with more than 137,000 beds had opened in the northern states. In addition to the military hospitals that emerged during the Civil War, many voluntary and public hospitals appeared in the 1850s. Throughout the 1850s and 1860s it was far more dangerous to receive care in a hospital than at home because of poor sanitation. As many as 25 percent of patients died after surgery because hospitals of that era were overcrowded, poorly ventilated, and inadequately cleaned. The introduction of antiseptic techniques by British surgeon Joseph Lister in 1865 marked a turning point in the safety of hospitalization. Patient care also improved as a result of the formal training of nurses at the first U.S. nursing schools, which were founded independently in 1873 by Bellevue Hospital in New York, New Haven Hospital in Connecticut, and Boston's Massachusetts General Hospital. The development of X rays and the clinical laboratory in the 1890s further improved the quality of care available to patients and prompted the opening of many new hospitals, including religious hospitals and hospitals that specialized in the treatment of women or children. The number of for-profit hospitals owned by doctors also increased between 1890 and 1920. As a result of federal legislation and funding to encourage the development of small rural hospitals, the 1940s were witness to the greatest period of growth in U.S. hospitals. Moreover, the increasing presence of health insurance, which began with the Blue Cross system in 1929, ensured that hospital services would be paid. Private insurance paid by employers expanded during the 1940s, and Medicare and Medicaid were established in the 1960s. In the 1980s, in an effort to rein in health care costs, some payers established a program to limit reimbursements to hospitals by determining flat fees for specific diseases or procedures, known as diagnosis-related groups (DRGs). HMOs introduced patient copayments, in which a fee is charged directly to patients for physician visits or prescription medications. Paralleling the increased availability of hospital services throughout the 20th century has been the transformation in the quality of care afforded by medical innovation. The introduction of sulfa drugs in 1935 and penicillin in the early 1940s greatly reduced the postsurgical infection rate. Advances in storing blood allowed for the ready availability of a blood transfusion, if needed. Diagnosis of medical conditions has been enhanced by ultrasound, computerized axial tomography (CAT, or CT) and positron emission tomography (PET) scans, magnetic resonance imaging (MRI), and the endoscope, which doubles as a highly precise, less invasive surgical instrument. New medical equipment developed in the latter part of this century has revolutionized the treatment of organ transplants, kidney failure, and cancer.
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Contributed By: Karen Samdrick
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