The Biggest Changes in Health Care

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Sunday, 10 August 2014
Experts weigh in on the biggest trends that have emerged during the past century.

In years past, the hospital experience included lengthy stays, severe blind spots in prevention and a lack of patient respect, according to medical historians and health care professionals.

"The words that come to mind are 'tightly controlled' and 'paternalistic,'" says Trisha Torrey, founder and director of the Alliance of Professional Health Advocates, a membership organization for patient advocates

The Biggest Changes in Health Care
Because of cultural shifts, policy adjustments, the price of care and technological advances, over the last century hospitals have moved toward a more patient-empowered approach that prioritizes prevention.

"Heath is driven by health care, but it also is driven as much by everything that is not health care – all the social factors, economic factors and demographics," says Maulik Joshi, senior vice president and CEO of the American Hospital Association's Health Research & Educational Trust.

The hospital industry continues to evolve, streamlining and improving patient care, integrating big data and moving from a fee-for-service to a fee-for-outcome payment model. The hospitals of yesterday were quite different from the sprawling health care centers that are common in the United States today. Here's a look at how the industry has changed.

Patient Segregation:

Discrimination based on race, religion and gender was widespread during the early 20th century. Hospitals were segregated by race until the 1960s, says Jennifer Gunn, associate professor and program director for the History of Medicine at the University of Minnesota. According to a 2003 article published in the American Journal of Public Health, some hospitals treated patients of certain races only, while other facilities were segregated by floor or sections, with better amenities provided to white patients.

The segregated facilities were inadequate, but they were the only health care facilities provided for African-Americans in some southern states, says Martin Pernick, history of medicine professor at the University of Michigan. They also provided the only professional training available to black doctors. A series of cases litigated by the National Association for The Advancement of Colored People in the late 1960s helped eliminate racial discrimination in hospitals.

Both staff and patients of faiths or cultures with dietary restrictions did not have their needs met in most hospitals. "The result was that those groups had to found their own independent hospitals," Gunn says. Religious groups started their own hospitals; Catholic hospitals didn't serve meat on Fridays, and Jewish hospitals kept kosher meals, she says.

Long Stays:
It once was common for a woman to spend 10 days in the hospital after giving birth, rather The Biggest Changes in Health Carethan today's more-standard 24-hour turnaround. Other health care services also came with long hospital stays: Dr. Peter Kernahan, a retired physician and medical historian, says when he started his residency in the late 1970s, a patient with a hernia could spend four days in the hospital after an operation. Now, the surgery is performed on an outpatient basis.

Technological advances drove many of these changes. Some patients with kidney disease today can bring home a dialysis machine, for example. Laparoscopic surgery, which uses a high-resolution camera and very small incisions, allows patients to heal faster. "For any operation, what keeps you in the hospital and from going back to work is the incision," says John Cameron, a surgeon at Johns Hopkins Hospital. "It's uncomfortable, painful and takes a while to heal."

Years ago, a patient would have been admitted overnight for a series of tests after complaining of chronic stomach pain, says Dr. Mark Chassin, president and CEO of the Joint Commission, which accredits and certifies hospitals and other health care facilities. Now, even some procedures that required a hospital stay in the past are performed on an outpatient basis today, according to the Ambulatory Surgery Center Association. A few examples include pacemaker implantations, tonsillectomies and cataract extraction.

This trend toward moving patients out of the hospital quickly became important to the bottom line. The industry began putting an emphasis on controlling health costs in the 1980s, Kernahan says. Dr. Don Forrester, a family medicine physician based in Sacramento, California, says it didn't take long for hospital administrators to figure out that shorter stays resulted in higher profit, because hospitals were reimbursed by procedure in what's known as a "fee-for-service" payment model.

Discharging patients sooner tended to be better for the patient as well, Gunn says. Staying in the hospital for a long time can be detrimental to a patient's health, she says, because it increases their exposure to germs and errors. According to a 2013 report in the Journal of Patient Safety, more than 400,000 deaths occur in U.S. hospitals each year because of medical errors.

The Biggest Changes in Health CareNo Option but to See a Doctor:

From the 1920s through the 1940s, some doctors were continually on call, causing states and accreditation councils to place 80-hour limits on residents' workweeks for the first time, Kernahan says. Rules were implemented nationally in 2003, and tightened in 2011. Physicians' paychecks were also high, and the country's emphasis on lower costs prompted more hospitals to create new, lower-paying jobs for people to take on some of the responsibilities that used to fall to doctors alone. Those roles, including that of the nurse practitioner, began to emerge some 45 years ago.  

A nurse practitioner is a registered nurse with a master's or doctoral degree that can diagnose diseases, prescribe medications, and initiate treatment plans, according to the American Academy of Nurse Practitioners. More than 900 million visits to nurse practitioners in hospitals, emergency rooms, clinics and private practices occur each year in all states and the District of Columbia, AANP data show.
"A lot of medicine, quite fairly, is repetitive," Forrester, from Sacramento, says. "A nurse practitioner who is well-trained can do the same job I can."
 Hospital staff members continue to evolve in their roles, allowing for less-expensive care and greater specialization. Hospitalists, or doctors whose primary focus is medical care of hospitalized patients, allows for gaining experience in the unique aspects of a patient's need during a hospital stay, according to the University of California, San Diego's Department of Medicine, and home care providers have allowed patients to have access to skilled care at home.

Smoking in the Hospital:
Oxygen tanks prevent people from smoking in their hospital rooms, but people lit up in plenty of other places. Staff and visitors smoked in cafeterias, men smoked in the waiting room while their wives went into labor, and patients had hospital staff push them outside in a wheelchair for a quick smoke.

Hospital doctors often would ignore the fact that a patient smoked, and instead deal with what they considered to be the "real" problem for which the patient was admitted, says Bronson Frick, associate director for the American for Nonsmokers' Rights. Though separate smoking rooms were later created, a 1986 report by the surgeon general revealed the effects of secondhand smoke on patients, creating what Frick calls the "beginning of the end" of allowing any smoking on hospital campuses. "The evolving mindset is that you have to treat the whole patient," he says.

Mayo Clinic was the first hospital to ban smoking on its entire campus about a decade ago, and hospitals in North Carolina became smoke-free before any other state, Frick says.

Now at least 3,658 U.S. health care facilities, or about 50 percent, are 100 percent smoke-free on campus grounds, according to data collected by Americans for Nonsmokers' Rights.

Patient Empowerment:
Until 1914, a patient who received charitable care from a hospital had no right to deny care or refuse to take part in medical experiments. The Schloendorff v. Society of New York Hospital case changed that, establishing informed consent.

But doctors would still withhold critical information, Kernahan says. If you were a married woman with cancer in the 1950s or '60s, there was a chance you wouldn't be informed of your diagnosis – though your husband likely would be.
Some physicians felt that knowing you could have a potentially negative or life-threatening diagnosis could hurt patients' psychological health, and therefore affect their prognosis, Kernahan says. In other cases, Chassin says, family members themselves might request that a doctor not tell a loved one he or she was dying.
Now, care givers tend to be transparent with patients about diagnostic information, risks and treatments, he says, in order to establish shared decision-making.

The Biggest Changes in Health Care

"In the '60s and early '70s with the bioethics movement, there was a sea change in moving from a paternalistic model to placing a high value on patient autonomy," Kernahan says. Chassin adds that the 1960s fueled a distrust of authority, causing patients to want to know more about their health.

These days, many changes in the hospital industry are driven, not just by social or demographic factors, but by legislation like the Affordable Care Act, which requires hospitals not only to provide efficient care at a lower price, but to aim to keep patients out of the hospital as much as possible. To do so, some hospitals are even engaging in community health initiatives, which Joshi says are growing.

"In some cities hospitals are the largest economic drivers of their communities, and they are also the largest employer, so they are really trying to change the health culture of the whole community," he says. Some hospitals are providing mobile vans for mammography, equipping patients with credible health information through electronic health records, or providing home health resources, he says.

Pernick from the University of Michigan concludes that there is no "type" of hospital when looking at the past or the future. "Hospitals have had
 different purposes and functions over time," he says.

But Joshi,  from the American Hospital Association, says he thinks they will continue moving toward engaging and partnering with patients, which is something patients say they want. "Hospitals are getting into the culture of health," he says. "It's not just health care."

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