Second, physicians are increasingly practicing in groups as opposed to solo practices. Foremost in this trend are groups of physicians practicing as specialists. Between 1969 and 1980, the number of group practices increased by more than two-thirds while the number of physicians practicing in groups more than doubled. By 1980, there were almost 11,000 group practices comprised of more than 88,000 physicians or approximately 25 percent of all actively practicing non-federal physicians.4 By 1984, the number of group practices had increased to nearly 15,500.5 Third, an increasing number of certain physicians are becoming salaried employees of hospitals. For example, about 30 percent of pathologists and 18 percent of radiologists are currently full-time hospital employees. Further, many physicians, who are not actually employed by hospitals, have become economically integrated with hospitals through contractual arrangements. For example, it was reported in 1983 that about 78 percent of pathologists and 58 percent of radiologists had financial contracts with hospitals to provide services. 6 Fourth, an increasing number of physicians are beginning to provide care on a prepaid basis, such as in health maintenance organizations. In 1980, the American Medical Association (AMA) identified more than 20,000 physicians representing about 6 percent of all active, nonfederal patient care physicians who provided care on such a basis.7 In addition, more than 8 percent of physicians have entered into positions outside of an office-based practice, such as biomedical research or teaching programs, where they are generally salaried. gearch Also, physicians are, to an increasing extent, providing care in ambulatory or outpatient settings. For example, according to the National Health Policy Forum, there are 2,300 ambulatory care centers in the United States, which handled 22.1 million patient visits in 1984. visits in 1984. The National Association for Ambulatory Care expects them to number 5,500 and provide nearly 112 million patient visits by 1990, although others predict a slower rate of growth.S 9 WHAT CHANGES HAVE OCCURRED The role of hospitals has undergone profound changes during this century. The first American hospitals were built in colonial times. Until the twentieth century, these institutions were primitive, and their primary role was to serve the dying. Hospitals furnished little medical care as physicians treated patients in either their offices or in the patient's home. Patients furnished little financial support for the care they received in hospitals and neither did government.10 Scientific developments beginning in the late 19th century made it more feasible to treat patients in a hospital setting. For example, the use of antisepsis reduced the spread of infection, making surgery safer. Furthermore, breakthroughs in disease diagnosis and therapeutic intervention expanded the science and art of medicine. As a result, physicians began to depend more on hospital-based equipment and services to provide medical care to their patients. The role of the hospital continues to evolve resulting primarily from the --growth of technology, --development of hospital emergency departments, and --emergence of teaching hospitals. Modern hospitals have developed into vast organizations that employ specialized equipment and personnel and in which physicians perform "miracles" on a seemingly routine basis. 12 Growth of technology In New techniques and new technologies have caused significant changes in hospital practice over the last several decades. addition to the development of antisepsis, the discovery of antibiotics and the introduction of modern surgical techniques and equipment has made surgery safer for the patient. Moreover, the increasing amounts of knowledge acquired by the surgeon and the availability of highly sophisticated medical and surgical equipment has made possible surgical procedures not previously considered. The development of intensive care units (ICUs) and other technologies, such as CT scanners and nuclear magnetic resonance imagers, and life sustaining procedures for critically ill patients are examples of what hospitals can provide and what the public expects. ICUS An ICU is an area of the hospital that is set aside for care of the most seriously ill. ICUS contain ICUS contain an array of electronic monitoring devices and life-support machinery, such as mechanical ventilators and defibrillators. Also, ICUS have a high concentration of nursing and support personnel. The nurse-to-patient ratio varies from one nurse to one patient to one nurse to three patients. 13 American Hospital Association surveys have found that by 1976 nearly all community hospitals having 200 or more beds had an ICU, about 90 percent with 100 to 199 beds had such units, and almost 50 percent of those hospitals with less than 100 beds had an ICU.14 Although there were fewer than 1,000 ICU beds in the United States 25 years ago, 15 by 1983 there were over 80,800.16 Renal transplantation Transplantation is a surgical procedure which involves the implantation of healthy organs obtained from either living donors or cadavers. Kidney transplantation is reportedly a lower cost alternative to renal dialysis in the treatment of kidney diseases and is the preferred method of treating end-stage renal disease. Transplantation frees patients from the inconvenience of undergoing continuous dialysis treatments, imparts a sense of good health, and improves their overall quality of life.17 One of the problems in renal transplantation involves a lack of a sufficient number of organs needed for available recipients. It has been estimated that about 7,000 people are usually awaiting kidney transplants. The increased use of cyclosporine--a new immuno suppressant drug--could increase this number. 18 The shortage of potential organs for transplant may be complicated by an inefficient system of procuring and matching 19 organs. Legislation enacted in October 1984 (the National Organ Transplant Act, Public Law 98-507) provides federal grants to organizations totalling $25 million in fiscal years 1985 through 1987 to coordinate the procurement and distribution of organs, including kidneys.20 Development of life-sustaining procedures for critically ill patients The nation's health care delivery system has the ability to delay the moment of death for almost any life-threatening condition.21 As a result of resuscitation techniques (including reversal of cardiac arrest), the development of respirators, and intravenous feeding, medicine has been able to do more for critically ill patients than ever before.22 For patients suffering a permanent loss of consciousness, intensive and aggressive therapies are given in an attempt to reverse unconsciousness and overcome any other medical conditions. 23 For seriously ill newborns, substantial advances have been made in neonatal care, which make it possible to sustain the lives of many ill infants who, only one or two decades ago, would have died shortly after birth. One major advance has been the development of neonatal intensive care units, which were first established in the 1960's and are widely used today. In 1983, there were about 550 neonatal intensive care units and over 8,000 beds in the United States. 24 As a result of this and other advances between 1970 and 1980, the neonatal death rate was reduced by nearly 50 percent. This was the greatest proportional decrease in neonatal mortality in any decade since national birth statistics were first gathered in 1915. These aggressive efforts, however, cannot save all seriously ill newborns. Some do not survive for long, while others suffer severe impairments. 26 Development of hospital emergency departments Traditionally, an emergency department has been a hospital facility providing services to those requiring immediate medical or surgical care. Today, concerns have been raised as to whether or not emergency departments are being appropriately used because they may have become substitutes for other ambulatory care facilities or primary care services. For instance, many patients with uncomplicated problems may receive care in emergency departments.27 An important factor encouraging the use of emergency departments is that they are usually open 7 days a week, 24 hours a day. 28 29 Today, an increasing number of patients seen in emergency departments are not true "emergencies." For example, the Department of Health and Human Services estimated that for the first 6 months of 1980, only about 14 percent of emergency department visits resulted from life-threatening conditions. On the other hand, almost 65 percent of the visits resulted from patients considering the emergency room as the best place for them to receive care or because medical care was not available elsewhere.30 J As the use of emergency departments increased, hospitals found that they needed to provide increased medical coverage to a large number of patients, particularly low-income individuals, who viewed the emergency department as their usual source of A 1978 study pointed out, however, that while emergency rooms are more accessible than physicians' offices and clinics, they are neither cost-effective primary care providers nor desirable in terms of the quality of care provided, since a continuous relationship with one provider is not established. 31 According to the AHA, there were nearly 66 million visits to hospital emergency rooms in 1973. By 1978, this number of units had increased to nearly 83 million visits.32 However, since that time the number of visits has declined to about 77.5 million visits in 1983.33 Emergence of teaching programs in hospitals Educational reform at the turn of the century encouraged relationships between hospitals and medical schools. Notably, a 1910 report recommended that medical students be exposed to clinical practice in the wards of hospitals.34 By 1984, the AHA reported that 1,161 hospitals in the United States were affiliated with medical schools, and 1,229 hospitals were approved to participate in residency training by the Accreditation Council for Graduate Medical Education.35 Changes in the ownership and structure of hospitals A major change is occurring in the ownership, management, and institutional structure of U.S. hospitals. According to some, the health care industry may eventually be dominated by large health care corporations which consolidate ownership, integrate decentralized hospital systems, and diversify into other health care businesses. 36 Four separate dimensions in the growth toward corporate medicine have been identified as follows: --Changes in ownership and control of hospitals from nonprofit and governmental organizations to for-profit companies. --A pattern of "horizontal integration" demonstrated by the emergence of multi-institutional systems and a resultant shift to regional and national health care corporations. --Greater "vertical integration" demonstrated by a shift to health care organizations that provide various phases and levels of care, such as in health maintenance organizations. --Increasing industry concentration in the ownership and control of health services, in which nearly three quarters of the beds in for-profit multi-hospital systems were operated by three companies in 1981.37 During the past decade, the number of hospital beds operated by investor-owned community hospitals has increased at a much higher rate than beds operated by nonprofit hospitals or state and local government hospitals. In 1983, for instance, investor-owned community hospitals operated 94,000 beds in the United States, up 65 percent over the 57,000 beds they operated in 1972. Such growth was significant when compared to nonprofit hospitals and state and local hospitals, which increased their beds by 16.4 percent and 1.0 percent, respectively, during the same period.38 As of April 1985, 20 percent of all non-federal hospitals were owned or operated by investor-owned firms.39 |