Howard S Berliner - Strategic Factors in U.S. Health Care: Human Resources, Capital, and Technology

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Strategic Factors in U.S. Health Care

Strategic Factors in U.S. Health Care

Human Resources, Capital, and Technology

Howard S. Berliner

First published 1987 by Westview Press

Published 2019 by Routledge
52 Vanderbilt Avenue, New York, NY 10017
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN

Routledge is an imprint of the Taylor & Francis Group, an informa business

Copyright 1987 by Conservation of Human Resources, Columbia University

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers.

Notice:
Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe.

Library of Congress Cataloging-in-Publication Data
Berliner, Howard S., 1949
Strategic factors in U.S. health care.
(Conservation of human resources studies in health
policy)
Includes bibliographies and index.
1. Medical careUnited States. 2. Medical
personnelEmploymentUnited States. 3. Medical
careUnited StatesFinance. 4. Medical technology
United States. I. Title. II. Series. [DNLM:
1. Delivery of Health CaretrendsUnited States.
2. Economics, MedicaltrendsUnited States.
3. Forecasting. 4. Health Manpowertrends
United States. W 84 AA1 B4s]
RA395.A3B465 1987 362.1'0973 87-14227

ISBN 13: 978-0-367-28886-0 (hbk)

Contents

Guide

Eli Ginzberg

The Conservation of Human Resources, Columbia University, of which I am the director, has been carrying out over the past three years an inquiry into selected forces that are altering the structure and functioning of the U.S. health care system. The funding for the project was provided by the Robert Wood Johnson Foundation and the principal investigator was Howard Berliner, an Associate Research Scholar on the Conservation staff.

Berliner selected four major themes for detailed evaluation: the potential and limitation of forecasting techniques; the transformation in employment; the capital issue and how it has been changing; and the role of technology. This introduction offers a lengthened perspectivefrom the years immediately following the end of World War II to the mere thirteen years to the end of this centuryto explore the role these four critical elements have played in the alteration of the structure and operation of the U.S. health care system and the clues they provide about the reshaping that lies ahead.

Forecasting

By adopting a broad view of forecasting to include aspirations and achievements, we can distinguish the following themes that dominated the successive periods of development.

1. President Truman tried twice to have Congress pass national health insurance (NHI) and twice was defeated. The American people were willing to give employer-sponsored health insurance more time to see if it could provide adequate coverage for most, if not all, of the public. (It should be noted that the American voter has never been inclined to respond to ideology and analysis and usually has waited until coming face to face with reality before supporting a major deviation from established policies and practices.)

2. With the defeat of NHI, the leitmotiv for the 1950s was the accelerated inflow of resources for new construction, biomedical research, and additions to the physician supply. This enlargement of the resource base resulted in improved access and availability.

3. By the early 1960s most Americans, conservatives as well as liberals, saw that employer-sponsored health insurance, though highly successful in the breadth and depth of its coverage, failed to protect the elderly who had reached retirement age. In 1965 Congress passed Medicare, a tax-based system of social insurance to ensure that the elderly had access to acute care hospitals and physician services. Although the American Medical Association went to great lengths to derail the passage of Medicare, it failed because pragmatic congressmen and the public could find no suitable alternative to a tax-supported system to ensure the elderly's access to modern health care.

4. The 1970s can be characterized as an era of experimentation in bringing steeply rising health care costs under control. These efforts included such diverse approaches as the founding of professional standards review organizations; federal support for the establishment and expansion of health maintenance organizations; creation of a federal-state planning mechanism; and a federal attempt to limit the inflow of new capital into the hospital sector.

5. In the 1980s the dominant approach was a retreat from regulation in favor of competition as the preferred mechanism for ensuring that the health care system could meet the public's needs and desires for quality care at affordable prices.

We can categorize these dominant shifts in health care policy under a forecasting mode of analysis as follows: The vocal minority that was sure NHI was just around the corner were proved wrong not only in the late 1940s but again in the 1970s; congressional support for biomedical research did not eliminate any of the dread diseases that it addressed; the construction of a large number of hospitals in rural America was no guarantee that residents of thinly populated areas would have access to modern health care; the so-called physician shortage led to such a serious overcorrection that the country is now threatened by a growing surplus; employer-sponsored health insurance was unable by itself to provide an effective alternative to NHI; and Medicare, though it met many of the needs of the elderly, also fueled a cost inflation which to date we have been unable to bring under control.

In the face of this record, a great deal of faith in the improved methodology of "futurism" is required to believe that forecasting can contribute useful inputs into health planning and the formulation of health policy. The health care sector and the economy of which it is a part are both too complex and too dynamic to be correctly modeled, especially because most of the important investments, in such areas as biomedical research and the supply of physicians and hospital beds, have long production cycles and large repercussions.

Employment

We are now ready to take a closer look at developments on the employment front, both those that occurred and others that might have been anticipated but failed to occur. During the past four decades the health care sector has undergone very rapid growth: It now accounts for about 8 million employees or roughly one out of every fourteen jobs in the U.S. economy. Furthermore, a high level of specialization has characterized both professional and supporting staffs. At the end of World War II, U.S. physicians were overwhelmingly general practitioners with a small cadre of specialists. Today the balance has been reversed with specialists and subspecialists far outstripping primary care physicians. The period of training for entrance into practice has been lengthened from four years of undergraduate medical school and one year of internship to three to five years of residency training and up to an additional three years for subspecialty qualification. For a variety of reasons, including the rapid growth in the demand for their services and increased third-party financing, physicians enjoyed large absolute and relative increases in their incomes.

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