historical factors that have influenced health care, health management

Running Head: Historical Factors That have Influenced Health Care 1

Historical Factors That Have Influenced How Health Care is Delivered in the U.S.

Ardavan A. Shahroodi

Northeastern University

Professor James J. Ferriter

HMG 6110-The Organization, Administration, Financing and History of Health care in the

U.S.

Friday, April 12, 2013

Historical Factors That Have Influenced Health Care

Introduction

In the U.S., the delivery of health care has been influenced by five major factors. The

first of these factors has been the largely uninterrupted authority of the medical profession in the

organization and delivery of health care related services. The second factor has been the

consideration of health care as a market commodity. The third factor is seen as the limited role

of state and federal authority in the organization and delivery of health care. The fourth factor

may be regarded as the enormous influence of technology in every aspect of the delivery of care

and the fifth factor is the relatively newer effect of medical malpractice litigation. The combined

effect of all these factors have led to the creation of an environment where escalating costs and

lack of access by a substantial minority of the population and citizenry will have serious social

and economic consequences for the present and future generation of Americans.

Analysis of the Five Factors that have Influenced Health Care delivery

According to Barr (2011), at the turn of the 20th century, the field of medicine in the U.S.

was composed of a wide variety of skills, competencies, knowledge and resources at the

individual and organizational/institutional level (p. 16). Barr (2011) maintains that “There were

no standards, either legal or ethical, to maintain a consistent level of quality in the way

physicians practiced medicine” (p. 16). Nevertheless Parsons (as cited in Barr, 2011) brings to

our attention that the ascendancy of science and technology in American society facilitated the

viewing of physicians as “altruistic agents who possessed valuable scientific knowledge and

technical skills” (p. 17). In order to address discrepancies existing in the training and practice of

medicine, a commission of experts was created in order to study and offer solutions that would

bring about consistency and quality to the field of health care. The views of the commission

called the Flexner Report paved the way for state and local governments to depend and rely on


physician associated professional organizations such as the American Medical Association

(AMA) to “guide the restructuring of medical practice” (Barr, 2011, p. 16) in this country.

As a result, the first historical factor that has influenced the practice of health care in the

United States is the ascendancy and power of the medical profession and her representative

organizations to exert substantial authority and direction in the manner by which medicine is

organized, accessed and delivered in this country. Barr (2011) argues that in time physicians

were seen “as agents of reason, worthy of our trust to act autonomously on behalf of patients,

exerted substantial influence over governmental policy toward medical care” (p. 17) and led to

the civil authority “granting sovereignty to the medical profession over the organization and

financing of medical care” (p. 18).

Barr (2001) presents us with two views that analyze the role of physicians in American

society. One view offered by Parsons (as cited by Barr, 2011) sees physicians as “Agents of

Reason” (p. 18) with their authority based on “Specialized knowledge” (Ibid), “Technical skills”

(Ibid), “Professional ethics” (Ibid) in addition to being regarded as “altruistic healers” (Ibid)

“paternalistic” (Ibid) and “unbiased’ (Ibid). The other opinion, maintained by Freidson (as cited

by Barr, 2011) sees physicians as “Agents of Power” (p. 18) with their authority based on

“Control of Knowledge” (Ibid), “Limited entry into profession” (Ibid), “Sovereignty over

system” (Ibid) in addition to being regarded as “self-interested entrepreneurs” (Ibid) with

“conflicting loyalties” (Ibid) who are “imperfect agents for their patients” (Ibid). As much as the

reality of the situation may be somewhere in the midst of both commentaries the fact remains

that as Barr (2011) maintains “for much of the twentieth century, power over the organization

and delivery of health care was concentrated in the medical profession” (p. 50) in order to


“establish standards of education and licensure, guide medical ethics, define financing

mechanisms for care, and control the ways hospitals are used” (Ibid).

A direct outcome of the authority that has been bestowed to the medical profession in

order to organize the health care environment is the historical emergence and promotion of the

“individual physician as self-interested entrepreneur” (Barr, 2011, p. 17). This in turn entails the

consideration of “medical care as a market commodity” (Barr, 2011, p. 17) that may be regarded

as the second factor that has influenced health care where a potential health care provider is in

possession of the “right to charge a separate fee for each service they provided, and to base that

fee on whatever the market would bear” (Ibid). Of course, in recent years the growing state and

federal government programs such as Medicare and Medicaid have altered and ameliorated the

nature of medicine/health care as a “market commodity” (Barr, 2011, p. 50). However, the

significant concept here is embedded in the word “right” (Barr, 2011, p. 17) that health care

providers enjoy in order to practice their profession such as the decision not to see Medicare and

Medicaid insured patients and charge other patients according to “…whatever the market would

bear” (Ibid). As Barr (2011) would observe, the practice of medicine is exercised as a “market

commodity to be distributed according to ability to pay. Other than basic emergency services,

there is no acknowledged right to health care for those under 65 years of age” (p. 50).

A third interrelated and interconnected factor that has influenced how medicine is

practiced and medical services are delivered in the U.S. is the very fact that “Government has

historically had relatively little role in guiding our system of health care” (Barr, 2011, p. 50). As

has already been mentioned governmental authority both at the state and federal level have

depended on the medical profession to set the standards for the delivery, training and the


financing of medical services. All the same, as Barr (2011) maintains “government’s role has

increased in recent years due to its growing role in paying for care” (p. 50).

In this light, the Affordable Care Act (ACA) will aim to increase the “availability of

health insurance” (Barr, 2011, p. 33), “controlling the cost of health care” (Ibid), offer “patient

protections” (Ibid) by addressing the pre-existing conditions matter and introduce other

budgetary, cost saving and qualitative reforms. Once the major ACA initiatives are implemented

beginning in 2014, “health insurance will become available to an estimated 32 million people

who previously were uninsured” (Barr, 2011, p. 33). An additional most significant policy

initiative of the ACA is the introduction of a “national program of comparative effectiveness

research (CER)” (Barr, 2011, p. 68). The ultimate aim of the CER is to “provide

recommendations for the optimal approach to care, but not to create mandates as to how specific

conditions should be approached” (Barr, 2011, p. 69) thereby answer the question “Which of

these alternative treatments works best?” (p. 68).

A fourth historical factor that has influenced how health care is delivered in the U.S. is

the effect of modern technology in the practice of medicine. Barr (2011) argues that the “value

we as a society place on technology and technological advances encourages the development and

use of high-tech medical treatments, even when the added benefit of those treatments is small

compared to their cost” (p. 56). Indeed there exists this almost mystical faith in the ability of

technology to improve our lives and offer cure to our ills. Some of this faith, I have to admit is

well grounded as I and many of my loved ones/family/friends/acquaintances have benefited from

the utilization of technology in helping our recovery from illness during our lives. However,

Barr (2011) argues that we as a society have automatically come to believe that “more


technological a treatment is, the better it is” (p. 57) and that as “patients we have not received

complete treatment unless we receive the most advance technology” (Ibid).

Barr (2011) utilizes a number of examples, cases and scenarios in order to illustrate this

“irrational exuberance” in the automatic enthusiasm that we afford to all new health related

technological and scientific matters. In pages 54-56 of our textbook, Barr (2011) gives us a

number of examples utilizing marginal cost/marginal benefit analysis in order to illustrate how in

many occasions a physical examination in addition to a simple X- ray may be sufficient in the

diagnosis of orthopedic related injuries and conditions. At that level, Barr (2011) proposes the

marginal cost and marginal benefit to the society and the individual are more likely and in most

cases equal. Nevertheless, in the U.S. the cost/benefit analysis in the diagnosis and treatment of

injuries and maladies is rarely utilized and routinely more advanced and expensive technologies

such as MRI imaging are prescribed.

Barr (2011) also discusses the controversy concerning prostate specific antigen (PSA)

tests and how this more high tech and expensive test that is shown to project “false-positive

results” (p. 57) may lead to the unnecessary decision to remove prostate glands with painful and

discomforting side effects. Furthermore, Barr (2011) illustrates how diuretics that were a low

tech and inexpensive medicine available for two decades in order to treat blood pressure where

shown in a “double-blind” (p. 59) (patient and doctor were not told of the contents of the

medicine) study to be “superior in preventing one or more major forms of cardiovascular

disease” (Ibid). In that study diuretics were compared to other more high-tech and expensive

medications. All this infatuation with the desirability of more technologically advanced and

consequently much more expensive medical treatment options, Barr (2011) argues has

exponentially increased our health care related expenditure.


A fifth historical factor that has influenced how health care is delivered is the effect of the

medical malpractice system and environment and its practical and financial consequences for

both patients and their physicians. The specter of medical malpractice suits has forced

physicians and hospitals to purchase insurance policies that would protect them and their practice

from financial liability. This in turn has also convinced physicians and medical

establishments/hospitals that they must exercise “defensive medicine” (Barr, 2011, p. 65) that is

the practice of ordering additional costly and potentially unnecessary diagnostic tests. However

as Brennan et al. have found in a study of “30,000 hospital records in 51 hospitals” (as cited in

Barr, 2011, p. 66) that “Among the patients who received negligent care, only a tiny fraction

(between 1 and 2%) filed a malpractice suit in response to their care” (Ibid).

Conclusion

The above five historical factors have combined to influence the delivery of health care in

the United States in a synergic fashion effecting the practice of medicine by increasing cost in an

exponential manner. The unmitigated role of the medical profession in the organization and

delivery of services, the practice of health care as a market commodity, the limited role of

governmental authority, the unhindered utilization of more technologically advanced solutions in

providing care and the deleterious and demoralizing effects of the medical malpractice

environment have led to an unsustainable state of affairs. This level of unsustainability is

uniquely observed in the uncontrollable expense of maintaining such a financially draining

system and the social costs of having so many of our citizens deprived of the benefits of a

professional and quality laden level of care. I would like to end this first assignment with the

comments of Professor Ferriter that the goal and the challenge must be to “influence the structure

of health care without jeopardizing the quality of the delivery system that exist” (Class 1, Lecture


Outline, p. 7). That would be the most responsible and logical way of addressing our health care

dilemma.


References

Barr, D. A. (2011). Introduction to U.S. health policy: The organization, financing, and delivery

of health care in America (3rd ed.). Baltimore, MD: The John Hopkins University Press.

Brennan, T. A., Leape, L. L., Laird, N. M. et al. (1991). Incidence of adverse events and

negligence in hospitalized patients: Results of the Harvard Medical Practice Study I.

New England Journal of Medicine 324:370-76

Freidson, E. (1970). Profession of medicine: A study of the sociology of applied knowledge.

New York, NY: Dodd, Mead.

Parsons, T. (1951). The social system. New York, NY: Free Press.

Parsons, T. (1975). The sick and the role of the physician revisited. Millbank Memorial Fund

Quarterly 53:257.

historical factors that have influenced health care, health management

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