¶ … structure of the American Healthcare System has long been a topic of much debate. The purpose of this discussion is to trace the evolution of the structure of the American system delivery service. We will begin with a timeline of the healthcare system. We will then examine the evolution of the structure of the healthcare delivery system. Timeline

According to a timeline created by PBS the evolution of healthcare delivery services has been dramatic. At the start of the 20th century the American medical Association becomes a very important organization for doctors. In the ten years between 1900 and 1910 the membership of the American Medical Association goes from 8,000 to 70,000. It is during this time frame that the AMA gained a tremendous amount of respect and physicians focused on ways to deliver organized medicine to Americans. ("Healthcare Crisis: Healthcare crisis")

During the ten-year span between 1900 and 1910, Surgeries to remove tonsils and tumors were common. It was during this time that many surgeries were being perfected by physicians. This allowed doctors all over the country and around the world to better understand the human body and doctors could share their expertise with other physicians. ("Healthcare Crisis: Healthcare crisis")

The most significant development of the time was that doctors were allowed to charge patients in hospitals a fee for the care that they received. Prior to that time physicians performed the work for free. Compensation for physicians was a milestone in the medical world at that time and ultimately physicians would become some of the highest paid professionals in the country. ("Healthcare Crisis: Healthcare crisis")

Compensation for physicians also led to some of the first employer sponsored medical programs for workers. According to the PBS timeline, the Railroad industry was among the first to implement comprehensive employee medical benefits. ("Healthcare Crisis: Healthcare crisis") Medical benefits allowed workers to receive healthcare with very little out of pocket expense. The development of health benefits was beneficial to the railroads because the cost associated with losing an employee to illness was greater than the cost of providing the workers with healthcare benefit. So then the implementation of such benefits was beneficial to both the employee and the employer.

During the 1920's the cost of healthcare rose sharply and affected the middle class in ways that had never been seen before. The rise in expenses associated with the delivery of healthcare services was compounded by the fact that the federal government was not attempting to stabilize the cost of healthcare. However, employers were attempting to aid employees with healthcare expenses and General Motors teams up with Metropolitan Life to ensure that 180,000 employees had the proper medical coverage.("Healthcare Crisis: Healthcare crisis")

By the 1950's healthcare expenditures compose 4.5% of GDP. Many working Americans had private insurance and the poor were granted healthcare through welfare programs. ("Healthcare Crisis: Healthcare crisis")

The 1970's saw the advent of Health Management Organizations (HMO). Richard Nixon implemented HMO's which are susceptible to certain government regulations and government assistance. Also during this time,

Healthcare costs are escalating rapidly, partially due to unexpectedly high Medicare expenditures, rapid inflation in the economy, expansion of hospital expenses and profits, and changes in medical care including greater use of technology, medications, and conservative approaches to treatment. American medicine is now seen as in crisis." ("Healthcare Crisis: Healthcare Timeline")

During the 80's and 90's the structure of the hospital system begins to become more centralized because corporations begin to consolidate the system. During the 80's the structure of Medicare also changes and begins to grant payment by diagnosis. In the 90's the cost of healthcare increased to twice the rate of inflation and managed care was expanded. By the year 2000, sixteen percent of America's citizens did not have any healthcare coverage.

As you can see the American healthcare system changed drastically during the twentieth century. Much of this change was due in part to the industrial revolution and the increase in the number of women that joined the workforce. The industrial revolution caused such changes in the healthcare system because production became essential to the American way of life. Business owners understood that the productivity of employees was essential to the prosperity and success of the business. Employers wanted to make sure that employees had access to medical care so that absenteeism would be minimized because absenteeism leads to a reduction in productivity.

The increase in the number of women joining the workforce also had an impact on the changes in the healthcare system. Businesses found...

To accomplish this business had to offer the women health benefits and maternity leave. In addition, during the 80's and 90's there was an increase in the number of single mothers. Business owners recognized that healthcare benefits needed to be extended to these women and their children.
Now that we have discussed the societal influences that led to many of the changes in the healthcare system during the twentieth century, let's discuss the technical side of the evolution. The technical aspects of the evolution have to do with the institutions that make up the healthcare system and the logistical changes these institutions have undergone and a result of the information age.

Evolution of the Structure of the Healthcare Systems service delivery

An article in Health Services Research magazine describes the various aspects of this evolution. The article breaks the evolution down and explains the challenges faced by the institutions that make up the system, which are: health plans, hospitals and physicians. The article concedes that hospitals and health plans are more advanced than the medical profession.

The author describes the evolution of hospitals as changing from a cottage industry to a highly consolidated enterprise. It is estimated that 72% of all the hospitals in America are a part of a network. The article also states that "hospitals are developing a considerable database and information-processing capacity." (Shortell)

The evolution of hospitals is critical to the quality of care that individuals receive. Advances in information technology have made networking and database management feasible and attractive to hospitals.

This evolution has also allowed for the introduction of state of the art facilities and technology to better meet the needs of patients.

Health plans have also done a great deal to consolidate and along the way these insurance companies have worked to develop fair premiums for employers and those that are self-employed. The article asserts that health plans have also made great strides in the processing of claims and marketing their services. (Shortell)

Although health plans have developed well in terms of logistics, many complain that health insurance is too expensive and that the government must do something about it. In recent years, the problem of high health insurance premiums has caused many small businesses to stop offering health benefits to employees.

Unlike hospitals and health plans the evolution of the medical profession has been slow. The article in Health Services Research explains, "While most of the nation was coming "off the farms" and capturing the advantages of economies of scale and scope in the manufacturing and service sectors, medicine largely remained a solo or small partnership enterprise."(Shortell) The article notes that at the present time most of the medical groups in the country employ less than nine physicians. The article also reports that only 45% of doctors practice in a group at all. (Shortell)

Shortell asserts that as a result of the various levels of evolution within the healthcare institutions the healthcare system is broken. Shortell explains, as we enter the electronic/information age, an important and sizable component of the U.S. health system has not yet fully entered the industrial age. Thus, efforts to significantly change healthcare in local markets reflect the challenge of dealing with institutions that are at radically different places in their current stage of evolution. Many physicians not only lack the financial and volume incentives to manage care differently; they also lack the information technology, organizational know-how, and sense of a team-oriented culture to do so. (Shortell)

The assertions made in this article would lead one to believe that the evolution of the health care system is not yet complete. It seems apparent that the institutions that make up the healthcare system are striving to change so that the delivery of healthcare services will be more efficient. The hospitals and health plans have already made strides to accomplish this goal. Both of these institutions understand the purpose behind networking and the need to develop an infrastructure that has information technology at the core.

Health plans and hospitals also understand the benefits of careful planning and teamwork and they know how to "manage" healthcare and not just "provide" healthcare.

The physicians must charge forth and decide to implement changes that will benefit the public and the profession. Much of this could be accomplished if doctors had access to the information technology and the logistics training that is needed. In addition, physicians must get out of their comfort zones and try different strategies of providing healthcare.

In any case the problems in the American healthcare…