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INTRODUCTION

In 1989, Frank Hope developed Acquired Immune Deficiency Syndrome (AIDS) and was in and out of the hospital with debilitating infections. Yet he remained hopeful that a scientific breakthrough would give him a chance. By 1995, with the discovery of life-saving protease inhibitors, his wish had come true. In Frank’s mind, these types of scientific discoveries attest to the wonders of the US health care system. Frank’s grandson attends a day care program. Ruby, a 3-year-old girl in the program, was recently hospitalized for a severe asthma attack complicated by pneumococcal pneumonia. She spent 2 weeks in a pediatric intensive care unit, including several days on a respirator. Ruby’s mother works full time as a bus driver while raising three children. She has comprehensive private health insurance through her job but finds it difficult to keep track of all her children’s immunization schedules and to find a physician’s office that offers convenient appointment times. She takes Ruby to an evening-hours urgent care center when Ruby has some wheezing but never sees the same physician twice. Ruby never received all her pneumococcal vaccinations or consistent prescription of a steroid inhaler to prevent a severe asthma attack. Ruby’s mother blames herself for her child’s hospitalization.

People in the United States rightfully take pride in the technologic accomplishments of their health care system. Innovations in biomedical science have almost eradicated such scourges as polio, and measles. Yet for all its successes, the health care system also has its failures. In cases such as Ruby’s, the failure to prevent a severe asthma flare-up is not related to financial barriers, but rather reflects organizational problems, particularly in the delivery of primary care services.

The organizational task facing all health care systems is one of “assuring that the right patient receives the right service at the right time and in the right place” (Rodwin, 1984). An additional criterion could be “… and by the right caregiver.” The fragmented care Ruby received for her asthma is an example of this challenge. Who is responsible for planning and ensuring that every child receives the right services at the right time? Can an urgent care center or an in-store clinic at Walmart designed for episodic needs be held accountable for providing comprehensive care to all patients passing through its doors? Should parents be expected to make appointments for routine visits at medical offices and clinics, or should clinics actively assume the responsibility to ensure that all their patients receive the chronic and preventive services they need when they need them? What is the proper balance between intensive care units that provide life-saving services to critically ill patients and primary care services geared toward less dramatic medical and preventive needs?

The previous chapters have emphasized financial transactions in the health care system. In this chapter and the following one, the organization of the health care system will be the main focus. While ...

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