History of Health Care and Health Professions in the United States

1
History of Health Careand Health Professionsin
the United States

• Chuck Gulas, PT, PhD, GCS

2
Why Study History?

• Why Study the History of Our Profession?

3
Characteristics of a Profession

• ?

4
Characteristics of a ProfessionSociological
Perspective
Value Orientation to Service for the Welfare of
Society
Abstract Knowledge Used, Adaptably
Skillfully, In the Area of Service
Autonomy in Decision-Making Action Relative to
Service
5
History

• Stage in Health Care Development
• Major problems
• Type and quality of services
• Who are providers
• Individual responsibility

6
Stage 1 (1850-1900)

• Institutionalization of Health Care

7
Health Problems
8
Great Sanitary Awakening

• During the end of the 19th Century, improvement
  was made on social and environmental conditions
• Society became dominated by cleanliness and
  comfort

9
Improvement Efforts

• Public Health established
• Governmental action by cities to dispose of
  sewage, purify water, inspect food for safety,
  and monitor housing
• Created the public health policy to give
  guidelines
• Health Departments were increasing in number and
  strength

10
Health Responsibilities

• Severe individualism
• responsible for own health care needs
• Left to own resources to find help
• Most people were in poverty

11
Institutionalization of Health Care

• Health care began to develop into establishments
  to treat the rising number of diseased or injured
  patients of the growing society
• Religious orders out of service
• Brought health care out of the homes and into
  public institutions
• Before this time, physicians would make house
  calls to the persons home (wealthy)

12
Early Hospitals
13
First Large Hospital

• In New York
• NY Bellevue
• Boston
• Mass General

14
Physicians of Early Hospitals
15
Nurses of Early Hospitals

• Not well trained
• First program in Bellevue in 1860s
• Took care of patients

16
Early Forms of Medical Treatments
17
Early Treatments

• Patent Medicines
• Osteopathy
• Chiropractic
• Phlebotomy
• Blistering
• Amputation
• Purging, Puking, Sweating
• Plastering

18
Charitable Organizations
19
Stage II 1900-World War II

• Introduction of the Scientific Method into
  Medicine

20
Scientific Method

• Initial Observations Objectives
• Hypothesis Formulation
• Data Collection
• Analysis of Data
• Summarization of Results
• Discussion of Limitations Conclusions
• Identification of Future Research

21
The First Antibiotic

• Penicillin
• Initially discovered in 1928 by Alexander Fleming
  at St. Marys Hospital in London.
• He found an unusual mold growing in a Petri dish
  containing staph bacteria.
• In 1935 Howard Florey and Ernst Chain began to
  study the Penicillin mold at Oxford University.
• Florey brought the discovery to America and ended
  up in Peoria, Ill. where corn was used to grow
  the Penicillin in mass amounts, just in time for
  the U.S.s entry into WWII.

22
Medical Revolution

• 1906 Wasserman Blood Test for Syphilis.
• 1908 Tuberculin skin test.
• 1910 Ehrlich began chemotherapy with compound
  called arsphenamine which treated Syphilis.

• 1930s Sulfonamide treated Streptococcal
  bacteria.
• 1938 Penicillin is purified.
• 1944 Streptomycin- first antibiotic for
  Tuberculosis.
• 1954 Salk discovers Polio vaccine.

http//encarta.msn.com
23
Private Wings in Hospitals

• Before this time, hospitals had large, open rooms
  filled with patients.
• Medical care began to improve, so patients were
  willing to pay the extra money to receive the
  proper care.
• Private wings were made to offer private rooms to
  individuals who were willing to pay the money.

24
The Flexner Report

• Proposed by Abraham Flexner, in 1910 who was a
  secondary school teacher.
• He published a report call Medical Education in
  the United States and Canada, which is known as
  the Flexner Report.
• It stimulated reforms in standards,
  organizations, and curriculum of North American
  schools.
• The schools of this time were operated for profit
  as opposed to education. The Report caused many
  schools to shut down, and the remaining schools
  conformed to the Flexnerian model.

25
Impact on Development of Health Care

• This school introduced a higher learning and an
  emphasis on supplementing medical lectures with
  bedside teaching.
• The school formed a hospital nearby to teach
  from this was one of the first hospitals.
• The University also assisted in the development
  of neurosurgery, ophthalmology, dermatology, and
  radiology.

26
Primary Health Problems

• Yellow Fever
• Tuberculosis
• Injuries from World War I
• Influenza
• Poliomyelitis

27
Influenza

• In 1918, the United States experienced an
  epidemic of Influenza that killed over 600,000
  people.
• What is Influenza?
• It is a contagious viral infection.
• Characteristics include fever, chills, muscular
  pain, inflammation of the respiratory tract,
  headache, and severe prostration.
• The virus affected those with a weakened immune
  system.

28
Injuries from War

• Many of the people who survived the war needed to
  undergo some type of rehabilitation for their war
  injuries.
• These injuries include the following
• Amputations, gunshot wounds, cuts, scratches,
  shrapnel wounds, and many more

29
Poliomyelitis Basic Description

• Polio or Infantile Paralysis is a viral disease.
• It may affect the central nervous system.
• Some symptoms include fever, vomiting, and muscle
  pain and stiffness in the neck and back.
• Elderly are affected as well.
• Paralysis often times occurs and is most common
  in the legs.
• Source http//www.health.state.ny.us/nysdoh/commu
  nicable_diseases/en/polio.htm

30
Poliomyelitis

• Polio occurs under conditions of poor hygiene.
• Polio is spread through the feces.
• The virus is contracted orally.
• When the virus enters the bloodstream, flu-like
  symptoms occur.
• Source http//www.upnaway.com/poliowa/What20i
  s20Polio.html
• Epidemics
• 1907- nine years long
• In 1916, a Polio epidemic in New York occurred.
  Many hospitals ran out of rooms.
• 1931

31
1890s 1900s

• WWI
• 1894 FIRST POLIO EPIDEMIC IN US-VERMONT

32
1910s -1920s

• Summer 1918 Helen May Bradley attended the
  first PT school
• Jan. 1 1919 Helen May Bradley and the rest of
  the Holy Nine went to Ft. Sam Houston, Texas
• 1919 Hospital Standardization Program

33
(No Transcript)
34
(No Transcript)
35
1910S 1920S...

• 1913 - Pennsylvania become first state to license
  PTs
• 1915 - Mary McMillan graduated college of
  Physical Culture and Corrective Gymnastics in
  Liverpool, England
• 1916 - Subsequent Polio Epidemics in US (27,000
  reported cases)
• 1917 - Physical Reconstruction was established by
  Surgeon Generals office
• Feb 23, 1918 - Mary McMillan was appointed head
  reconstruction aide

36
(No Transcript)
37
1920s 1930s..

• Jan. 1921 Physical therapy formed their first
  professional association, and led by President
  Mary McMillan
• APTAs purpose-
• Categories of APTA-
• - Charter membership
• - Active members
• - Honorary members
• -Associate members

38
1920s 1930s(cont)..

• June nine chapters of AWPTA
• 1922 first annual physiotherapy convention
• -changed name to APA
• -discussed issues about men
• 1927 changed requirements for active members

39
Workmans Compensation

• Definition
• Source The American Heritage Dictionary of
  English Language 4th Edition

40
Blue Cross

• Blue cross was started by Justin Ford Kimball.
• He offered 1,300 school teachers 21 days of
  hospital care for 6.00 a year.
• Baylor University influenced the Blue Cross plan
  because the people that purchased the paid them
  and they were the first place to have this plan.

41
Blue Shield

• Blue Shield started in lumber and mining camps.
• Many injuries and illnesses among people who
  worked in these camps.
• Employers wanted their workers to have medical
  care paid a monthly fee to medical service
  bureaus or the physician that helped them.

42
Blue Cross/Blue Shield

• Both plans were started at the end of the Great
  Depression.
• Hospitals were losing money because people would
  not pay their bills.
• The plans were then designed to help prevent
  hospitals from losing money.

43
Summary of 1900-World War II

• People would now go to hospitals to receive
  medical attention whereas, before they would go
  there to die.
• With the help of Louis Pasteur, Robert Koch, and
  Joseph Lister, diseases became treatable and
  medical advancements were taking place.
• Chronic diseases were introduced and a new type
  of medical field (Physical Therapy) was created.

44
Stage III (WWII-1965)Era Of Expansion
45
Approaches to Rehabilitation

• Victims of WWII
• -physical
• -psychological
• -vocational
• -emotional

46
Resulting Problems

• Gun Shots
• Lacerations
• Amputations
• Extremity Wounds
• Spinal Cord Injuries
• Deep Penetrating Cuts
• Peripheral Nerve Damage

47
NATIONAL INSTITUTE OF HEALTH

• 1946
• A SUCCESSFUL GRANT PROGRAM WAS GIVEN TO THE
  ENTIRE NIH.
• MORE THAN 4 MILLION IN 1947 WAS GRANTED AND BY
  1957 OVER 100 MILLION WAS AVAILABLE IN GRANTS.
• REFERED TO AS
• THE GOLDEN YEARS
• OF
• NIH EXPANSION.

48
The Hill Burton Act

• The Hill Burton Act was created in 1946 by the
  United States Congress
• It is also known as the Hospital Survey and
  Construction Act
• The Hill Burton act allowed for the federal
  government to provide hospitals with extra
  funding and grants to expand the role of the
  hospital

49
The Hill Burton Act

• This act was originally created as a way to
  increase the funding and stability of hospitals
  during the Great Depression and World War Two
• The funding allowed for more hospitals to remain
  open to the public for healthcare and for more
  construction of more hospitals

• Today the Hill Burton Act remains an intricate
  part in the world of healthcare
• The federal funding received by hospitals allows
  for more people to obtain the healthcare that
  they need despite their financial status

50
Role of Hospitals in Era of Expansion

• Societal issues also helped to play a major part
  in expanding hospitals
• Aging Population, Health Promotion, and Disease
  Prevention

• New research of health issues, diseases,
  treatment, and technology caused the role of
  hospitals to expand their reputation and the
  actual building as well

51
Medical Specialties in the Era of Expansion

• The most basic form of a healthcare provider was
  a general physician/practitioner
• Medical specialties began to evolve as more
  knowledge was obtained though research and
  experimentation

52
Medical Specialties in the Era of Expansion

• Medical specialties became more defined during
  the World War Two-1965 era
• The war created a need for health professionals
  to become experts in the rehabilitation field as
  many soldiers were in need of assistance in
  dealing with their war injury or disability
• New scientific and medicinal discoveries were
  made, which created an opening to new areas of
  healthcare
• (EX) The polio vaccine the health risks of
  smoking

53
Labor Shortage on Health Care

• WWII - 1965

54
Problems

• Labor shortage
• Significant
• Need skilled workers
• Companies want to stand out from rival
• Advertised benefits to potential employees
• Benefits
• Healthcare
• Third Party payer

55
Impact

• Companies forced to offer health care
• Lose potential employees
• Railroads, Logging, and mining
• Competition
• Health care plans not wages
• Worry change
• Health care plan vs. danger of workplace

56
Thoughts

• Third Party payer
• Initial needed
• After time undermined workers
• Way to cover up dangers of workplace
• Workers and Unions organize their own
• 200 health care groups
• Labor Health Institute of St. Louis
• The Health Institute of the United Auto Workers

57
Healthcare Costs

• Health care costs during WWII to 1965 increased
  due to
• New Technologies
• New Medical Specialists
• Medications
• Increased Administrative Costs

58
Source Adapted from Health Spending in 1998
Signals of Change, K. Levit et al., Jan/Feb 2000,
Health Affairs, 19(1), p. 125 and National
Health Expenditures, 1995, K.R. Levit, et al.,
Fall 1996, Health Care Financing Review, 18(1),
pp. 175-214
59
Healthcare Costs

• New Technologies
• Simultaneous with the increase in the number of
  physicians, there was an explosion in available
  technology.
• Much of the technology development from the 1960s
  and onward was paid for by the federal
  government, originally for military purposes.

60
Healthcare Costs

• Medications
• Since WWII, the number of new medications
  developed to treat all sorts of diseases, from
  high blood pressure to infections to damaged
  hearts, has been phenomenal.
• The cost of developing these medications is very
  high.

61
National Institute of Health Funding

• Majority of funding to the NIH is by government
  grants
• The NIH and the NIC had a total appropriation of
  2.8 million in 1945
• In 1945 2.7 million of the 2.8 million
  appropriation was for direct NIH operations

62
NIH Funding cont

• In 1950 the size of the research commitment begun
  during WWII rose to 73 million of which 35
  million was distributed through the NIH
• Total federal support for health research and
  development was 448 million and federal support
  of 67 in 1950
• During this time, the NIH consisted of six
  component research institutes

63
The Hill Burton Act

• Since 1946, when it was passed their have been
  many amendments added on to the act
• If hospitals used money from the act, they in
  return had to provide free or low cost health
  care services to people who could not afford it

64
The Hill Burton Act

• The act helped pay for the cost to build new
  hospitals and modernize the existing ones so they
  could better serve the community
• Money was spread equally throughout the United
  States, based on need and population

65
Hospitals, the Center of Health Care

• Hospitals were interested in serving the
  community in the Era of Expansion
• Hospitals had a wide variety of services they
  could offer in one place
• Many offered outpatient facilities, pediatric,
  and family care

66
Hospitals, the Center of Health Care

• In the 1930s, the number of planning agencies
  had increased therefore their was a need for more
  health services
• The hospital and the planning agencies had
  improved working agreements
• The population was increasing in America and
  therefore we had to expand our hospitals

67
1943-1944

• President Roosevelt wanted social insurance from
  the cradle to the grave
• He also stated that people have an economic bill
  of rights includes the right to adequate
  medical care and the opportunity to achieve and
  enjoy good healthPresident Roosevelt
• Nothing was done with this until the following
  year

68
1945

• President Truman wanted National Health Insurance
  to be part of the social security system
• This plan would cover doctor services, hospitals,
  nursing services, laboratory tests, and dental
  services
• A revised Wagner-Murray-Dingell Bill providing
  for National Health Insurance was immediately
  introduced.

69
Stage IV Era on Entitlement

• Health Care as
• a Right
• Not a Privilege

70
Great Society Programs

• War on Poverty

71
This 1960 poster highlights some of the major
provisions of the 1960 Social Security
Amendments
72
1965

• The Social Security Act introduced Medicare and
  Medicaid which was expected to help high bills
• They were signed into law by President Lyndon B.
  Johnson
• Medicare and Medicaid made health care available
  to millions of Americans

73
Medicare

• Retired, permanent injury
• Some funding from federal treasury and some from
  individuals income as payroll tax

74
Medicaid

• Unemployed and low income individuals
• Administered by state
• On average per state 57 of funding from federal
  treasury and 43 of funding from state treasury

75
Increasing Health Care Costs during the Era of
Expansion
76
Reasons for Increasing Health Care Costs
77
Breakthroughs in Medical Treatment

• Medical Technology was improving
• New medicines and vaccines were invented.
• - Vaccines to prevent polio
•      - Penicillin
• - Antibiotics
• Surgical skills were improving.
• - Organ transplant performed

78
Stage V (1980 2000) Era of Cost Control
79
What is meant by making the beneficiary of health
care more responsible for payment?
1
80
Beneficiary responsibilities

• Patient is responsible for assuring that the
  financial obligation of his/her health care are
  fulfilled as promptly as possible

81
Beneficiary responsibilities
82
Cost-Benefit Analysis

• an analysis of the cost effectiveness of
  different alternatives in order to see whether
  the benefits outweigh the costs

83
What fueled the increase in health care costs?
3
84
Factors for Fueling

• Health care costs grew to extreme heights during
  the time between the 1980s through to 2000.
  These increased costs arose from
• More reliance on impatient care and specialized
  mental health care treatment
• Escalating numbers of employees needing abuse and
  mental health services
• The practices and issues of insurance fraud

85
Political Events to Help Control the Costs of
Health Care
4
86
Political Events

• 1983 the amendment to the Medicare of the
  Social Security Act of 1965
• DRGs Diagnostic Related Groups
• Patients put into categories
• Fixed rate for each category based on past cases
• Hospitals paid this rate for every patient
• Actual cost

87
Health CareRight or Privilege?
5
88
Health Care

• 35 million Americans
• Have no health insurance
• Have inadequate coverage
• Homeless
• Drug prices

89
Health Care

• Clintons proposal
• Guaranteed universal coverage
• Control costs of care
• Changes in quality and type of health care
  offered
• Emphasis on health care for children

90
HMOs

• Began in late 1920s
• Elk City, Oklahoma and Los Angeles, California
• Organized by businesses and community groups

91
HMOs

• Grew rapidly in 1960s
• Term HMO developed under Nixon Administration
• By 1978 more than 200 HMOs in over 37 states

92
HMOs

• Immense growth in 1980s
• Mid 1986 nearly 23 million in total enrollment

93
Balanced Budget Act of 1998
7
94
Balanced Budget Act

• Had a huge impact on health plans
• Dealt with Medicare payment
• Changed the Medicare program
• From open-access, fee-for-service program to a
  program that puts the providers at risk

95
Healthcare in the United States Today
96
1. What are the main problems with health care
today in the United States?
97
Access

• Too many Americans without access to healthcare
• Over 45 million people without health insurance
• Language barriers
• Deficient cultural competency
• People with chronic conditions may be excluded
• Under-funded government programs
• Some are unable to afford it
• AMA Healthcare Access, www.workingpeople.org

98
Consequences

• Those without insurance are more likely to
• Receive too little medical care and too late
• Go without screening tests
• Lack regular access to medications
• Receive fewer treatments services after injury
• Imposes costs on healthcare providers
• National Healthcare Agenda for America

99
Plausible Solutions

• Expansion of existing government programs
• Increased and more stable funding for government
  programs
• More affordable health insurance
• Encourage high-risk individuals to get insurance
• National Healthcare Agenda for America

100

• Medicare coverage
• for prescription drugs, and
• the new Drug Discount Cards.

101
Is there parity between mental health services
and other health care coverage?
102
NO

• People with mental health problems are treated
  differently through health care coverage than
  people without mental health problems.

103
FACTS

• 54,000,000 people have mental disorders.
• or
• 1 in 5 adults suffer from a diagnosable mental
  disorder in a given year.

104
TODAY

• 33 states have made into law some form of mental
  health care parity.
• Connecticut, Maryland, Minnesota, and Vermont
  have parity under private insurance plans. 29
  other states have health care limitations,
  exemptions, or no parity at all.

105
SCHIP

• State Childrens Health Insurance Program

106

• SCHIP is a build on the Medicaid program.
• Not a welfare program.
• Designed to support working families who earn too
  much money to be eligible for Medicaid, but not
  enough money to purchase private insurance.

107
SCHIP pays for

• Doctor visits
• Prescription medicines
• Hospitalizations
• Most states cover
• Dental care
• Eye care
• Medical equipment

108
Why is health insurance for children and teens
important?

• Children who have health insurance generally have
  better health throughout their childhood and into
  their teens. They are more likely to
• Receive needed shots that prevent disease
• Get treatment for recurring illnesses such as ear
  infections and asthma
• Get preventative care to keep them well
• Get sick less often and
• Get the treatment they need when they are sick.

109

• How has managed care continued to evolve?

110
Managed Care

• Managed care coordinates and arranges health care
  services and benefits for us.
• Types of managed care
• HMO health maintenance organization
• PPO preferred provider organizations
• EPO exclusive provider organizations

111
25 years ago

• It used to be that people had indemnity insurance
  plans
• This plan allowed patients to visit any doctor
  and then the insurance company and the patient
  would split the bill (the patient would only pay
  20)
• The deductibles for this were paid at the
  beginning of every year

112
Today

• Managed care will make an arrangement with a
  health care professional or a whole hospital and
  that way their clients can go to him/her or the
  hospital and pay less than the patient normally
  would going somewhere else.

113
HMO

• An HMO organizes, controls, pays for, and
  provides almost every aspect of health care that
  a member may need. (Your Guide to Managed Care)
• This may sound like a great deal, but really you
  have no choice in doctors etc.
• An emergency also has to be authorized before you
  are taken care of
• Another good point is there are lower co-pays
  for HMOs

114
PPO

• This group would prefer you use one of their
  chosen doctors/hospitals, but you still have a
  choice.
• You can go to a specialist without your primary
  doctor referring you
• You do have to pay a little more for a doctor not
  in the plan
• Yearly premiums for both PPO and HMOs are fairly
  close in cost

115
Our job is not to do what our forbearers did but
rather what they would do if they were here today

• Superior General Jane Erskine Stuart, RSCJ