CHAPTER 8 Hospitals and Health Systems Stephen J. Williams and Paul R. Torrens W I L S CHAPTER TOPICS O History of the Hospital N The Scope of the Industry , Structure of Hospitals and Health Systems LEARNING OBJECTIVES Upon completing this chapter, the reader should be able to 1. Understand the role of the hospital in today's health care system. Hospital Organization The Hospital and Medical Staff Key Issues Facing the Hospital Industry 2. Appreciate the historical trends that have shaped the hospital industry. Q U A S H E 3. Understand the types of hospitals, ownership patterns, and differentiating characteristics of various hospitals. 4. Comprehend the development of health systems and the role of hospitals in such systems. 5. Follow the impact of competitive pressures and other developments on the structure and operation of hospitals and health systems. 1 9 9 7 B U 6. Understand the internal organizational structure of hospitals. 182 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems The hospital's role in the nation's health care system has changed dramatically over the years. The hospital originated as an institution for the poor, offering little in the way of therapy, and then evolved into the center of the system and the primary technology focus of health care. Now the hospital is a provider of highly specialized services and the hub of an assortment of other activities. The traditional independence of each hospital has been dramatically altered by horizontal and vertical integration within the health care system such that today few hospitals are truly freestanding entities. The technolW ogy to manage hospitals has likewise changed with an information systems focus and the application of I complex parameters of performance measurement. L Expectations of consumers, providers, and payers have also changed dramatically over the years S with the anticipation of more effective interventions O at more efcient and competitive pricing. Finally, as has always been the case in the past, the hospital inN dustry continues to face immense challenges, op, portunities, and expectations for the future. The hospital has also changed from an island of care to an institutional octopus, with tentacles Q springing out throughout the community, afliatU ing with other institutions and providers, and providing outreach services for consumers. On the A inpatient side, hospitals are increasingly providing S the most complex of care to the most critically ill patients. On the outpatient side, most hospitals are H broadening the array of services that they offer to E better compete. Hospitals face the challenges of sick and dying patients, demanding payers, government ofcials 1 seeking accountability, physicians demanding the availability of the latest equipment and support, 9 and many other crosscurrents. Some hospitals are 9 for-prot entities, while others are not-for-prot. Some hospitals are highly specialized while others 7 offer a broad range of services. Hospitals are often B major employers in their communities and many U provide the bulk of indigent care for low-income and disenfranchised citizens. Through it all, the backbone of hospital management has increasingly adopted the managerial principles of commercial 183 industry, seeking to provide services in an efcient, but cost-effective manner, and to offer competitive pricing to third-party and governmental payers. The challenges of this industry are immense and unlikely to recede in the decades that follow. HISTORY OF THE HOSPITAL Although the hospital today is in the forefront of technology and clinical medicine, the history of the nation's hospitals actually began as facilities for housing the poor and the ill. These institutional warehouses for human suffering were the almshouses, the pest houses, the poor houses, and the workhouses that sheltered the homeless, the poor, the mentally ill, those with serious degenerative diseases, and others for whom there was little to offer in the era before modern medicine. Isolation of individuals during epidemics of cholera and typhoid, among other diseases, also led to the utilization of these institutions. Little medical knowledge was available and few individuals received any signicant treatment. The middle class avoided these institutions and received their care at home. Not until the 1700s and 1800s did hospitals emerge with a mission of providing some form of clinical medical care. Many of these early hospitals were supported by philanthropic efforts and religious organizations. Also during this period, many public hospitals were established in various cities to provide for the social needs of local populations, laying the groundwork for our modern acceptance of local government as the provider of last resort. Finally, by the early 1900s, with the introduction of scientic method in medical practice and the recognition that hospitals and clinical medicine must adhere to a stricter formulation of practice focused on scientic discovery, was the era of the truly modern hospital established. Throughout the twentieth century, the escalating advance of knowledge accelerated the focus of the Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 184 hospital as a center for medical technology. After World War II, the hospital's role as a center of technology and innovation became rmly established. At this point, the practice of medicine itself was increasingly dependent on scientically valid knowledge and training. Finally, over the past 30 years the degree of rigor of clinical practice and the scope of scientic knowledge has escalated greatly, and the hospital has become a center of high standards, scientic applications, and advanced technological capability. At the same time, the increasing shift of services to W an ambulatory care arena facilitated by technological advancement itself has left the hospital with an everI more complex base of patient care, higher acuity, L and higher costs. In addition, pressure from payers, as noted previously, has escalated greatly as has the S expectation of providers and consumers alike. IndusO try consolidation, vertical and horizontal integration, public policy concerns, and quality assessment N and assurance have placed the operation of the na, tion's hospitals under tremendous scrutiny. Yet, through it all, the nation's hospitals have risen to the challenge of providing superlative care overall in a Q high-intensity, stressful atmosphere that has signiU cantly contributed to our improved health status and well-being. This is a remarkable achievement in light A of countervailing nancial and political pressures S that have always buffeted the hospital industry. We owe a great debt of gratitude to the nation's hospitals H and to those dedicated individuals who work within these institutional walls for achieving so much in E an environment that started as a warehouse for the poor and sick, left to die without care and concern. 1 9 9 7 THE SCOPE OF THE INDUSTRY B U Although the hospital industry has seen its share of the nation's health care dollar decline somewhat, hospital systems are still immense segments of the industry and of our nation's economy. (See Table 8.1.) PART THREE Providers of Health Services Table 8.1. Hospital Expenditures by Source of Funds: United States, Selected Years Source of Funds Hospital care expenditures All sources of funds Out-of-pocket payments Private health insurance Other private funds Government Medicaid Medicare 1960 1990 2003 Amount in billions $9.2 $253.9 $515.9 Percent Distribution 100.0 100.0 100.0 20.8 4.4 3.2 35.8 38.3 34.4 1.2 4.1 4.1 42.2 53.2 58.3 10.9 16.9 26.7 30.3 In 2003, the hospital industry alone accounted for more than $500 billion of expenditures. In 1960, the industry counted for only $9.2 billion of economic activity annually. The growth of private health insurance and government entitlement programs, particularly Medicare, has shifted the burden of paying for hospital care to third parties. In 1960, more than 20 percent of the hospital bill was paid by people out of their own pockets; by 2003, this percentage had dropped to 3.2 percent. Private health insurance now accounts for a little more than one-third of all hospital expenditures while government programs account for nearly 60 percent. Medicare alone counts for nearly a third of all hospital expenditures; in many facilities the Medicare program pays about half the bill overall. Certainly, for the nation's seniors, Medicare is a critical source of support for paying for the enormous costs of hospitalization. The number of hospitals in the United States has decreased dramatically. Table 8.2 illustrates this decline with the total number of hospital in 1975 at 7,156 dropping by 2003 to 5,764. A small number of the nation's hospitals are owned and operated by the federal government. These include the Veteran's Administration Hospitals and military facilities. The vast majority of hospitals are nonfederal and are nonprot, for-prot, or owned by state and local governments. The information in this table Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems 185 Table 8.2. Hospital and Beds by Ownership and Hospital Size: United States, Selected Years Type of Ownership and Size of Hospital Hospitals All hospitals Federal Nonfederal Community Nonprot For prot State-local government Bed size 6-24 beds 25-49 beds 50-99 beds 100-199 beds 200-299 beds 300-399 beds 400-499 beds 500 beds or more 1975 W I L S O N , Q reects hospital ownership, and it should be noted U that some hospitals, while owned by one type of entity, may be operated under contract A another by entity, such as a hospital management company. The largest grouping of hospitals in S nation the are nonprot community hospitals. Although their H numbers have declined overall, they remain the priE mary source of hospital care for most Americans. These hospitals are owned by nonprot entities, although they are sometimes operated under con1 tract by for-prot or other nonprot corporations that specialize in managing hospitals and health 9 systems. 9 Nonprot entities, including hospitals, function under special provisions of corporation law in each 7 state, and under federal and state tax provisions that B recognize their community service function. The naU tion has approximately 1 million nonprot entities of various sorts and hospitals have long been a traditional service provider in the nonprot sector. Nonprot entities serve a community service and have special recognition under the law due to 1995 2003 7,156 382 6,774 5,875 3,339 775 1,761 Number 6,291 299 5,992 5,194 3,092 752 1,350 5,764 239 5,525 4,895 2,984 790 1,121 299 1,155 1,481 1,363 678 378 230 291 278 922 1,139 1,324 718 354 195 264 327 965 1,031 1,168 624 349 172 256 their role in our society. Nonprot entities do not have owners and are governed by a communitybased board that has ultimate authority for operation of the entity. Nonprot entities are generally exempt from most taxes at the federal, state, and local levels including income and property taxes. Many nonprot entities have tax exempt status under Section 501C(3) of the federal tax code, allowing individuals to make potentially tax deductible donations to these organizations. Nonprot entities are able to raise funds through donations, retained earnings, and debt obligations, often on favorable terms. Nonprot entities may be \"sponsored\" by various types of organizations. Many hospitals have traditions of religious sponsorship. However, they are not owned by such sponsors. Nonprot entities may also afliate with each other through various organizational arrangements. Most nonprot hospitals operate in a manner similar to other types of hospitals by employing modern management techniques, sophisticated information systems, and other Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 186 principles of twenty-rst-century management. Nonprot entities are generally expected to provide some indigent care and serve the community in a variety of ways as well. A much smaller percentage of the nation's hospitals are operated as for-prot businesses. Forprot entities have owners and issue stock to those owners to reect their equity position. For-prot entities, including hospitals, may be publicly or privately held. Publicly held for-prot entities have stock that is available for purchase by anyone, typically through the nation's various stock exchanges. W A variety of accountability and registration rules and regulations affect publicly owned for-prot I entities, generally administered by the Securities L and Exchange Commission at the federal level and similar entities at the state level. Privately held S for-prot entities also issue stock, but that stock is O not available to the general public for purchase. Accountability and other regulatory oversight are N much less for privately held entities. , For-prot hospitals may be independent and historically in this country and throughout the world today many for-prot hospitals have been owned Q by the physicians who practiced in them. Today, however, due to the tremendous capital costs U of building, maintaining, and operating a hospital, A most hospitals in the United States that are for prot are part of large multihospital chains, mostS of which are publicly traded. For-prot hospitals are H not just accountable to the community but must E also provide a return on investment to the shareholders; therefore they expect to generate a prot to pay a return to the equity investors for their cap1 ital. For-prot hospital companies may also manage not-for-prot and governmental hospitals as a 9 separate line of business. 9 The third category of ownership in Table 8.2 is state and local government hospitals. These are 7 hospitals that are owned by state or local governB ments, but again, may be managed under contract U by other entities, either for-prot or not-for-prot management companies. Many local government hospitals are owned by counties or other local government units. They are often the providers of last PART THREE Providers of Health Services resort, bearing the burden of indigent care in their communities. In the western United States, hospital districts were created much like water districts to provide infrastructure for communities as populations moved West. These local taxing districts were responsible for the construction and operation of hospitals for their communities. In recent years the taxing authority of these districts has accounted for a very small percentage of total hospital operational costs. As reected in Table 8.2, the majority of the nation's hospitals are relatively modest in size as measured by licensed hospital beds. The very large institutions are typically teaching hospitals, often associated with medical schools, and have a range of residency programs for postgraduate medical education. The small hospitals are typically in rural areas, raising particularly complex issues regarding nancial viability. Broadly speaking, large hospitals are more prevalent in the East as the trend over time has been to build smaller rather than larger facilities. Signicant numbers of smaller hospitals, particularly in urban areas, have closed over the past 25 years due to nancial and competitive pressures, and to the difculty of efciently operating a small number of hospital beds. Specifying the optimal side of a hospital is particularly difcult given the complexity of services now offered on an inpatient basis. Most likely, the very small and very large hospitals are the least efcient. As reected in Table 8.3, the total number of hospital beds has dropped from just under 1.5 million to just less than 1 million since 1975. This trend reects a combination of closures and reductions in operating licensed beds among those hospitals still in operation. Large hospitals, because of their size, account for a disproportionate share of the total number of hospital beds. About 70 percent of the nation's hospital beds are in nonprot facilities. As reected in Table 8.4, there are approximately 36 million admissions to the nation's hospitals every year, of which 25 million are to nonprot hospitals. The number of admissions has been remarkably Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems 187 Table 8.3. Hospital Beds by Ownership and Hospital Size: United States, Selected Years Type of Ownership and Size of Hospital Beds by Ownership All hospitals Federal Nonfederal Community Nonprot For prot State-local government Bed size 6-24 beds 25-49 beds 50-99 beds 100-199 beds 200-299 beds 300-399 beds 400-499 beds 500 beds or more 1975 W I L S O N , 1995 2003 1,465,828 131,946 1,333,882 941,844 658,195 73,495 210,154 Number 1,080,601 77,079 1,003,522 872,736 609,729 105,737 157,270 965,256 47,456 917,800 813,307 574,587 109,671 129,049 5,615 41,783 106,776 192,438 164,405 127,728 101,278 201,821 5,085 34,352 82,024 187,381 175,240 121,136 86,459 181,059 5,635 33,613 74,025 167,451 152,487 119,903 76,333 183,860 Table 8.4. Hospital Admissions by Q Ownership and Hospital Size: United States, Selected Years Type of Ownership and Size of Hospital Beds by Ownership All hospitals Federal Nonfederal Community Nonprot For prot State-local government By hospital bed size 6-24 beds 25-49 beds 50-99 beds 100-199 beds 200-299 beds 300-399 beds 400-499 beds 500 beds or more U A S H E 1 9 9 7 B U 1975 1995 2003 36,157 1,913 34,243 33,435 23,722 2,646 7,067 Number in thousands 33,282 1,559 31,723 30,945 22,557 3,428 4,961 36,611 973 35,637 34,783 25,668 4,481 4,634 174 1,431 3,675 7,017 6,174 4,739 3,689 6,537 124 944 2,299 6,288 6,495 4,693 3,413 6,690 162 1,098 2,464 6,817 6,887 5,590 3,591 8,174 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART THREE Providers of Health Services 188 stable over the years, but the total number of hospital days has declined dramatically due to sharp reductions in the average length of stay. A relatively small proportion of admissions to hospitals are accounted for by the smaller hospitals. Examining hospital utilization based on population data illustrates a significant decline in discharges per thousand U.S. population as reflected in Table 8.5. Overall explanation of this trend lies in changes in the number of Americans, which Table 8.5. Discharges and Days of Care, Nonfederal Short-Stay Hospitals: United States, Selected Years Characteristic Total Age Under 18 years 18-44 years 45-54 years 55-64 years 65 years and over Sex Male Female Geographic Region Northeast Midwest South West Total Age Under 18 years 18-44 years 45-54 years 55-64 years 65 years and over Sex Male Female Geographic Region Northeast Midwest South West 1980 W I L S O N , Q U A S H E 1 9 9 7 B U 2003 Discharges per 1,000 population 173.4 119.5 75.6 155.3 174.8 215.4 383.7 43.6 91.3 99.5 145.7 367.9 153.2 195.0 104.4 135.1 162.0 192.1 179.7 150.5 127.6 117.1 125.8 103.9 Days of care per 1,000 population 1,297.0 574.6 341.4 818.6 1,314.9 1,889.4 4,098.3 195.5 339.7 477.2 735.9 2,088.3 1,239.7 1,365.2 546.7 605.2 1,400.6 1,484.8 1,262.3 956.9 694.4 507.9 609.8 476.4 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems 189 has led to a larger denominator. Declines in discharges are much more moderate for higher-age individuals. Overall, changes in technological innovation combined with nancial pressures from payers has led to an increasing proportion of medical care being provided on an ambulatory basis, and to much shorter lengths of stay for equivalent diagnoses for those patients who are admitted to the hospital. The impact of these trends is to yield a much higher intensity or complexity of care for hospitalized patients. W Table 8.6 presents hospital occupancy rates since 1975 for the nation's hospitals. IEven with shorter lengths of stay, the closure of many hospiL tals, and an overall reduction in the number of hospital beds, occupancy rates remain on the decline. S On average, today, only about two-thirds of the O nation's hospital beds are lled with patients each night. This trend is evident in virtually every category of hospital ownership. In the days since September 11, 2001, and more recently since various epidemics and natural disasters, the issue of ideal targets for hospital occupancy rates has become much more complex. How much capacity should be maintained for potential utilization in emergency situations is a complex policy issue. Maintaining unused capacity costs money. As a result, the industry has some reluctance to do so. On the other hand, operating at a more efcient level of occupancy, say 85 or 90 percent, not only restrains the ability to respond to normal uctuations in utilization but also signicantly impacts the ability of hospitals to respond to a critical community emergency situation. Alternatives for providing reserve back-up capacity for community-based emergencies have become an important priority as communities prepare for N , Table 8.6. Hospital Occupancy Rates by Ownership and Hospital Size: United States, Selected Years Type of Ownership and Size of Hospital Occupancy Rates by Ownership All hospitals Federal Nonfederal Community Nonprot For prot State-local government By hospital size 6-24 beds 25-49 beds 50-99 beds 100-199 beds 200-299 beds 300-399 beds 400-499 beds 500 beds or more Q U A S H E 1 9 9 7 B U 1975 1995 2003 76.7 80.7 76.3 75.0 77.5 65.9 70.4 Percent 65.7 72.6 65.1 62.8 64.5 51.8 63.7 68.1 64.8 68.3 66.2 67.7 59.6 65.3 48.0 56.7 64.7 71.2 77.1 79.7 81.1 80.9 36.9 42.6 54.1 58.8 63.1 64.8 68.1 71.4 31.9 44.6 57.2 62.6 67.0 68.5 70.7 74.2 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART THREE Providers of Health Services 190 unforeseen events without signicantly impacting hospital cost structures. STRUCTURE OF HOSPITAL AND HEALTH SYSTEMS Although technological advancement and reimbursement policy are among the key factors affecting the development of the hospital industry over W the past half century, other dramatic changes in the corporate environment of health care and particuI larly of the hospital sector have served a prominent L role in affecting hospital management. Horizontal and vertical integration and the afliation of hospiS tals with each other and with other sectors of the O health care system have been extremely important developments in the organizational structure N in governance and in the operational management of , the hospital industry. These changes in the legal and organizational environment have profoundly affected how the hospital industry is structured and Q lines of accountability. The introduction of an inU creasingly typical corporate environment for the hospital industry has, to an extent, changed the A roles for the key players, affected the organizational S design, and facilitated other related changes within the industry such as closures and consolidations. H Horizontal and Vertical Integration E 1 The development of organizational and nancial efciency in the hospital industry has been most ac9 celerated by both vertical and horizontal integra9 tion. Because both of these forms of integration have been occurring, it is certainly fair to say that 7 this is an industry in transition still seeking a level B of equilibrium that can respond to changes in the U health care marketplace and pricing as well as providing an adequate response to the invested community. Along with horizontal and vertical integration, the industry has experienced a tremendous phase of closures and consolidations, particularly affecting smaller institutions. The dramatic changes in the number of operating hospital beds and hospitals in the United States are a result of this process as the industry seeks to provide more competitive products and pricing, an increasingly market-driven health care economy dictated by such payers as the government programs and various forms of managed care. Both horizontal and vertical integration have experienced ebbs and ows over the past decades. The objectives of integration of resources have also varied depending on the participants involved and local market conditions. National integration of various types, particularly for horizontal integration, has also been driven in part by the behavior of for-prot entities. To this day, the success of both vertical and horizontal integration varies tremendously across the country, and changing economic and market conditions suggest that such integration is a dynamic rather than static process with players possibly assessing their assets and adding and subtracting from their portfolios. In horizontal integration, similar units of production afliate with each other. For example, for-prot and not-for-prot chains of hospitals under common ownership operating in different geographic locations all providing similar hospital-based services would be a horizontally integrated system. Horizontal integration occurs in the for-prot and not-for-prot sectors and can involve various levels of organizational afliation from direct ownership to looser afliation arrangements. Horizontal integration, designed to provide an enhanced level of efciency of scale across multiple institutions and in related geographic areas, may serve to reduce duplication of services and marketplace competition. In a form of horizontal integration associated with regionalization of health services, smaller hospitals may feed into larger tertiary care facilities. Horizontal integration may also facilitate operational efciency such as purchasing, information systems, quality assurance, and management capacity. Horizontally integrated multihospital networks may establish contractual arrangements with other types of Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems health care providers and participate in larger health care delivery systems. Vertical integration implies the establishment of integrated health care delivery systems that incorporate all or most aspects of the health care process. In this form of integration, inpatient hospital services, ambulatory care services, mental health, long-term care services, and other related health care products are incorporated into a comprehensive delivery system. Vertical integration, in many respects, is more complicated than horizontal integration because it involves a range of highly diverse W and not always easily integrated services.Vertical integration was prompted by the objective of negotiI ating with insurers and managed-care providers L such that the full range of services could be provided in a contractual arrangement. In addition, S vertical integration provides for feeding patient O ows into hospital inpatient services and other critical delivery components to ensure the nancial N viability of these institutions. Vertical integration al, lows for greater capture of patients within integrated systems and a more established institutionally based relationship with physicians. Vertically Q integrated systems in managed-care settings typiU cally contract for a broad range of services rather than just for inpatient or other discrete A care. Vertically integrated services provide a delivery chain for S a range of health services rather than specializing in only one product.Vertically integrated systems have H greater capture of premium dollars but at the same E time, assume a greater degree of nancial risk. This increased risk has represented a signicant challenge in recent years. Some vertically integrated sys1 tems have also established their own health plans independently or in conjunction with insurance en9 tities. However, this trend has faced signicant 9 challenges from nancial and legal perspectives and they increase the risk to the institutional 7 provider. B Both horizontally and vertically integrated sysU tems of care need to align physician interests with institutional objectives. This has always been a challenge in health care and continues to be so, particularly with today's more competitive markets and 191 pricing pressures. Vertically integrated systems may have a greater likelihood of success in this regard because they can control a broader range of delivery systems and capture more of the health care dollar. Physician ownership initiatives such as for ambulatory, surgery centers, or even specialty hospitals are an additional threat to hospital delivery systems. HOSPITAL ORGANIZATION The traditional organization of hospitals is centered around three sources of power. These are the governing entity, the medical staff, and the administration. Traditional hospital governance was predicated on independent institutions each with its own corporate-style board. Legally and structurally, the governing body has ultimate authority for all activities and decision making within the organization, delegating certain tasks among administration and the medical staff. Among nonprot entities, these boards were historically composed of well-to-do individuals who could provide a platform for fundraising. Over time demands for accountability resulted in substantially ramped-up professional representation on these governing bodies. Physicians, accountants, attorneys, and others with a knowledge base relevant to institutional governance were elected to membership. Although frequently a volunteer activity with minimal, at least by corporate standards, pay and fringe benets, public service was the key motivation. For-prot entities have typically been components of larger corporations with advisory rather than legally binding governing boards. Hospital governing entities have delegated dayto-day management of the institution to hospital administration and the clinical medical affairs to the medical staff, which itself is typically formally organized with by-laws, elected ofcials, and specic duties and responsibilities. Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 192 In recent years, considerable effort has been directed toward educating members of governing entities and hospitals to better understand the principals and legal responsibilities of hospital management and to more critically assess decision-making activities, particularly pertaining to large capital investments, organizational mission, the role and management of medical staff, and contractual arrangements with other entities. With both horizontal and vertical integration, the ultimate governance responsibility is typically shifted to the highest level of organizational strucW ture. Depending on corporation status of components within the larger organization separate I boards may exist with statutory authority or may L serve primarily in an advisory capacity. In the forprot sector, a parent organization governing S board serves a corporate role analogous to that of O any public or privately held for-prot corporation. In the publicly held environment, the corporate N board has an additional legal responsibility at, tributable to securities; regulation and corporate governance are dened by state and federal laws. For all governing entities, specic duties and reQ sponsibilities are specied in the legal charter or U other documents creating the organization and dening the duties, responsibilities, and memberA ship of the board. With increased accountability for S individual and collective acts of governance, board members must assume that they do have personal H and professional liability to perform their corporate E duties in an appropriate duciary manner. Hospital administration has also changed appreciably over the years moving toward a more tradi1 tional corporate operational approach. In addition, hospital management increasingly incorporates the 9 delegation of responsibility to an array of other 9 managers including, on the front lines, departmental administrators. Specic technical expertise 7 is typically incorporated into the management B structure in such areas as information systems, U nance, legal environment, quality assurance, marketing, and contracting. Traditional roles such as patient care, including the hotel function, physical plant, admissions, discharge, other operational PART THREE Providers of Health Services responsibilities, and various other key functions, are also represented. Today's hospital administrators are often dened by traditional corporate titles and attractive pay packages. In the not-for-prot sector, seniorlevel hospital managers typically earn from the $100,000s to more than $500,000 per year. In the for-prot sector, these managers may also receive stock and stock options and other equity-related benets. In both nonprot and for-prot sectors, managers typically receive valuable benet packages and in some instances, pay for performance and other types of bonuses. Hospital administrators usually have a management-related background or have clinical training and have worked their way into a management position or some combination of both. Hospital managers, like their employees, work in a relatively high-stress and demanding environment, answering not only to their formal bosses, but also to the public, consumers, physicians, and other constituencies. THE HOSPITAL AND MEDICAL STAFF With authority delegated from the governing entity, the hospital medical staff has specic responsibilities related to the clinical care provided in the facility and regulation of those individuals who practice clinically. Hospital and medical staffs are typically organized with elected ofcials, various committees, and with a leadership role represented by the president of the medical staff. State medical practice laws generally prohibit direct employment of physicians by hospitals. As a consequence, and due to historical independence of physician practices, physicians and other health care professionals have afliated with institutions such as hospitals in a variety of other ways. Historically, these afliations have primarily been through membership in hospital medical staffs. More recently, hospitals and physicians have afliated Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems through joint ventures such as physician/hospital organizations, indirect employment of practitioners in other contractual arrangements, hospital purchases of group practices, and a variety of other models. Hospital medical staff membership has generally followed a model whereby physicians apply for hospital privileges in their area of specialty and are vetted by a committee of the hospital medical staff supported by administration. If found to be of good character and having a reputable clinical reputation, physicians are granted privileges, which is, W in essence, the ability to admit and discharge patients, provide care within the hospital facilities, I and serve as a participating member of the medical L staff. Although the governing entity is ultimately responsible for granting privileges, this responsibility S is usually delegated to the medical staff in recogniO tion of their knowledge of clinical practice and ability to assess professional skills. The evaluation of N individuals for the granting of privileges is one of , the key and most important roles of the medical staff. Physicians, for example, are evaluated on their medical and specialty residency training, their Q track record of clinical care as reected in medical malpractice and other quality assurance U indicators, and their reputation in other respects. A When a physician is granted privileges, he or she S remains subject to surveillance by the medical staff to ensure continued maintenance of aH minimum level of quality of care. This surveillance typically E consists of monitoring cases to assess any instances for patterns of poor quality of care as well as other indicators of difculty such as being associated with a physician impaired with alcohol 1 drug or or other abuse. Hospitals and their medical staffs also 9 serve a regulatory role in reporting violations of 9 clinical practice standards by physicians and other practitioners to state licensing agencies7 and other entities. B Physicians, as members of the medical staff, may U participate in various committee assignments and historically were expected to provide some level of indigent care although this requirement in many instances has largely dissipated. In most hospitals 193 physicians are also expected to utilize their clinical privileges only in those areas in which they have proper training and credentialing. Physicians and other professionals who are less frequently utilizing a specic hospital may be granted a separate category of privileges for occasional use with less expected participation and fewer responsibilities. Physicians who are interested in clinical leadership positions may assume responsibility for medical staff committees or seek to be a leader in the medical staff hierarchy. Increasingly, physicians who are interested in managerial roles may also be employed for that purpose by the hospital on the administration side, typically a position such as vice president for medical affairs. In addition to credentialing physicians for hospital privileges, the medical staff is typically responsible for ensuring the quality of care provided in the hospital under delegated authority from the governing entity. Various committees may be formed for this purpose, including a quality assurance committee or other peer review committee. The medical staff will seek to provide feedback to physicians and other clinicians who are not meeting expected standards of the quality of care in their clinical practices within the institution. This feedback can take many forms, including quantitative data assessment comparing each individual to the norms of other practitioners in their specialties, or even informal feedback from the medical staff president or a clinical department chief. Ultimately, hospital privileges may be revoked in extreme situations where clinical standards are clearly not met. In this instance, appropriate due process must be followed utilizing specied procedures as outlined in the medical staff bylaws. The increasing utilization of computerized information systems and a more interested younger generation of clinicians have greatly accelerated the attention to data-based assessments of quality of care. National voluntary organizations have worked hard to promote these efforts so as to elevate the overall quality of care provided in the nation's hospitals. Voluntary accrediting agencies, in particular, have also increasingly pressured institutional Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART THREE Providers of Health Services 194 providers to incorporate quality assurance mechanisms in their ongoing production methods. Many types of approaches have been developed in this regard, including a range of processes designed to encourage the use of clinical approaches that are validated from scientic and evidence-based research. Many clinical quality assurance and quality improvement techniques have been adapted from the corporate environment, particularly industrial settings as well. Payers are also demanding enhanced quality surveillance and improvement. In contrast to a typical corporate environment, W hospitals do not directly employ most physicians, who are key decision makers and decide resource I allocation and utilization. Thus, the medical staff L serves an important role in aligning physician behavior and objectives with institutional needs. S Medical leadership is particularly important in O today's complex environment to facilitate this relationship. Ultimately, the traditional hospital strucN ture, particularly with regard to the medical staff, is , inconsistent with managing an organization that faces numerous competitive and pricing pressures. Some medical staff organizations, such as those Q in group practice, model HMOs that directly own U all resources in their systems, and certain governmental entities such as the military and veteran's A administration hospitals, have more direct control S over the medical staff. H E KEY ISSUES FACING THE HOSPITAL INDUSTRY 1 9 The hospital industry almost continuously faces key 9 critical issues that challenge its structure, viability, 7 and roles in health care. This section discusses many of these issues. B U Specialty Hospitals In recent years, the development of highly specialized hospitals has gained considerable traction. Although not a new concept by any means, the more rapid recent development of these specialty hospitals poses a threat to community general hospitals to a much greater extent than in past years. The new specialty hospitals include those focused on cancer and heart disease and other highly discrete areas of practice in lucrative elds such as orthopedic surgery. To further complicate the controversy over specialty hospitals, these institutions are increasingly partially owned by the physicians who practice within them. Ironically, in the early days of the modern development of hospitals, physician ownership was not unusual. However, the popularity of physician-owned proprietary hospitals today has been challenged by two ramications. The rst is that these hospitals draw protable patients from community hospitals, and the second potential conict of interest is represented by physicians admitting patients to hospitals in which they have an ownership interest. Of course, our quality of care data suggest that high volumes of discrete services can enhance quality. From some perspectives, highly specialized institutions may in fact provide the best care. On the other hand, many of these specialty hospitals may siphon off insured and relatively healthier patients, leaving the less protable and more complicated cases to community general hospitals. Physician ownership of specialty hospitals raises concerns that nancial incentives will affect the treatment decisions, such as the use of specialty and diagnostic services. In addition to providing care to the less complex and more protable cases, these hospitals may also leave the uninsured and underinsured to community and public hospitals for treatment. The combination of adverse selection and less private insurance and public coverage for community general hospitals and government facilities does raise signicant policy concerns. Federal policy development has been slow to respond to this trend. Medicare has complex rules regarding physician ownership of health care resources and potential conicts of interest. And both the Medicare and Medicaid programs have a valid Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems concern with respect to the distribution of health care costs across all facilities and patient groups. The impact of specialty hospitals on community general hospitals and governmental hospitals has yet to be fully assessed, but this development is potentially signicant clinically and nancially. Changes in Technology The hospital industry is all about technology. Although the hotel function of a hospital is in a way primary to its purpose, it is the provision of techW nology that is its true mission. Technology has shaped the physical and operational structures of I hospitals, has affected the lives of patients and famL ilies, and has provided a delivery vehicle for physicians in clinical practice. S From its earliest days as a modern institution, the O availability of technological resources has dened the services provided in hospitals. The discovery of N anesthesia and of antisepsis clearly established the , early stages of the provision of surgical care. The vast array of imaging technologies has had tremendous impact on effective intervention for patients Q seeking care in the hospital setting. Laboratory, diU agnostic, and other technological innovations have also greatly facilitated clinical medicine.A Successful intervention is dependent on the technology of inS novative therapies including pharmacological interventions and surgical techniques. H More recently, the huge range of technological E advancements that have vaulted to the forefront of the tertiary care role of inpatient services within hospitals have included organ transplantation, a 1 vast array of minimally invasive surgical technologies, advanced cardiac treatments, primarily through 9 a variety of surgical interventions, an impressive 9 range of successes in advanced emergency and trauma care, and vast improvements in the underly7 ing technologies related to information systems, B medical records, and other aspects of hospital and health care operations to facilitate the U delivery of services to patients. Technological advances have affected obstetric patients, pediatric care needs, patients with terminal illnesses, and a range of other 195 problems that present to the inpatient side of hospital operations. Technological advancement has led to the development of increased specialization and clinical practice, expansion of specialized services, new medical and surgical specialties, and treatments for many diseases for which little curative or other care could be provided in the past. Advanced technologies including the many applications of lasers, the use of ultrasonic technology for treatment, and more recently, the development of automated surgical assistant or robot technologies have all been revolutionary. Hospitals operate in competitive markets and the pressure to provide a full range of technology, and to keep that technology current, yields signicant cost pressures and even potential conicts with medical staff members. Insurers and employers as well as government entities seek to pay for the latest technologies, but at efcient pricing. The continuing advancement of technology is a double-edged sword providing us with tremendous new capabilities, but at the same time, many challenges. The hospital, perhaps more than any other sector of the health care system, faces these opportunities and challenges in the most dramatic ways. And, ultimately, it is their customers, their patients, and their physicians who utilize these hospitals and health care systems, who have the highest expectations and often the least sensitivity about costs. Clinical Practice Patterns Hospital design and operations are signicantly affected by accepted clinical patterns of practice. The increasing attention to best practices and practice norms of various types, particularly under quality assurance programs, requires institutional adherence to various protocols and guidelines. Information systems and other operational requirements must also be compliant with the need to provide evaluative information to assess and report on physician clinical patterns of practice. Medicare and many managed-care contracts require such Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 196 reporting. Accreditation by the Joint Commission for Accreditation of Health Care Organizations and other specialty accreditation bodies also requires the availability and interpretation of data. In addition to the availability of appropriate information to monitor and evaluate clinical protocols and practice guidelines, institutions are increasingly expected to offer a governance structure that assigns responsibility for these activities. Typically, in most community hospitals, that responsibility is delegated from the governing body to the medical staff. The governing board and institutional W administration, however, retain responsibility for successful compliance with these requirements. I Individual practitioners are likewise increasingly L being held accountable for their practice patterns and behavior through a variety of monitoring and S feedback mechanisms. O The complexity of integrating all the requirements pertaining to clinical practice is of itself a sigN nicant burden on institutional operations. Legal , and ethical expectations, combined with reporting requirements contained in various contractual arrangements, further enhance the depth and comQ plexity of this obligation. Physician independence U has been signicantly weakened by the introduction of various external regulatory requirements. A S H Hospitals and hospital systems are heavily conE strained by the reimbursement mechanisms that Reimbursement Mechanisms pay their bills. The most signicant source of funds for most hospitals is the federal Medicare 1 program. As discussed elsewhere in detail in this book, nancial mechanisms for reimbursement 9 under the Medicare program have become increasingly complex. Medicare has moved 9 to reward efciency and specialization while increas7 ingly squeezing institutional cash ow. Medicare, B being a federal program, also has signicant regulatory and force of law powers unknown to thirdU party insurers in the private sector. Medicare has imposed an array of requirements to reduce fraud and abuse, but these efforts have had secondary PART THREE Providers of Health Services effects in complicating organizational administration and nancial arrangements. Nongovernmental sources of payment, primarily from managed-care organizations, have themselves become fraught with complexity and cost pressures. Most payers now seek a competitive market advantage in pricing in an attempt to drive down the cost of health care, while at the same time shifting an increased burden of cost to the consumer. The negotiated per diem rates are heavily discounted and many insurers exclude a range of reimbursements for various specic services. Many third parties also require reporting from institutional providers on utilization patterns, use of resources and services, and other parameters of the care process. Hospitals are generally expected by payers to provide extensive oversight of practitioners through aggressive credentialing efforts and other responsibilities. All these developments have resulted in pressure to improve efciency, reduce waste and duplication, and provide care as quickly as possible and at the lowest possible cost. While payers are increasingly squeezing payments to all providers, hospitals in particular are susceptible to nancial pressures. Hospitals provide services that require a high degree of capital investment, have limited control over the cost of many of their products due to such considerations as shortages of nursing and other specialized personnel and the high cost of innovative products, and nally, the expectations on the part of both consumers and individual practitioners for reasonable ambience and excellent outcomes. Academic Medical Centers Academic medical centers typically consist of medical schools and their primary teaching hospitals. Academic medical centers provide tertiary, secondary, and primary care but have a principal focus on biomedical research, teaching of medical residents and medical students, and often an array of other professional training, research, and service activities. These organizations are highly complex Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 8 Hospitals and Health Systems with a multitude of power structures, funding sources, and sometimes conicting missions. Hospitals that are part of academic medical centers are operationally constrained by the demands of the teaching mission, particularly with regard to medical students and postgraduate medical education, and a mandate to conduct both basic biomedical and applied clinical research. Financial efciency and consumer satisfaction are not typically the top priorities. Physicians and researchers place considerable demands on these organizations to provide the latest technology and stafng and to W allow for teaching and clinical investigation. The success of academic medical Icenters in achieving their missions should be a national priL ority. The long-term strengths and successes of our health care system depend on this. Although not S necessarily widely acknowledged, nancial efO ciency in fact should probably not be a top priority from a national health policy perspective. UnfortuN nately reimbursement policies by Medicare and , other government and private payers typically do not overtly allow enough latitude for academic medical centers. In addition, academic medical centers Q are frequently the providers of last resort, further reU straining cash ows and viability. Local government and, to an extent, private insurers through cost A shifting, pick up part of the tab. S A lot of attention has been directed toward academic medical centers in recent years. The chalH lenge is to reconcile the needs for medical education E and research with the scal realities of available resources in a manner that will meet our nation's educational and clinical needs. This remains a huge 1 challenge for the nation's health care system. 9 9 SUMMARY 7 The hospital industry has faced numerous chalB lenges over the years and will continue to do so in the future. Markets have changed, pricing presU sures have increased, and consumer and payer expectations have evolved. Yet, through it all, our nation's hospitals have continued to provide the best hospital-based care in the world, delivering a 197 technology that is second to none with top-notch staff dedicated to patient care. REVIEW QUESTIONS 1. Describe the historical development of hospitals in the United States. 2. Describe the differences between nonprot and for-prot hospitals. 3. List the major trends that have occurred within the hospital sector. 4. What is horizontal integration, and why is it used? 5. What is vertical integration, and why is it used? 6. Describe the internal organization of community hospitals. 7. Describe the key issues facing the hospital industry. REFERENCES & ADDITIONAL READINGS Birkmeyer, J. D., Siewers, A. E., Finlayson, E. V. A., Stukel, T. A., Lucas, F. L., Batista, I., Welch, H. G., & Wennberg, D. E. (2002). Hospital volume and surgical mortality in the United States. New England Journal of Medicine, 346, 1137-1144. Davis, M., & Heineke, J. (2003). Managing services: Using technology to create value. Boston: McGrawHill/Irwin. Gapenski, L. (2004). Healthcare nance: An introduction to accounting and nancial management (3rd ed.). Chicago: AUPHA Press/Health Administration Press. Halm, E. A., Lee, C., & Chassin, M. R. (2000). How is volume related to quality in health care? A systematic review of the research literature. Prepared for National Academy of Sciences, Interpreting the volume-outcome relationship in the context of health care quality workshop. Washington, DC. Kelly, D. L. (2003). Applying quality management in healthcare: A process for Improvement. Chicago: AUPHA/Health Administration Press. Martin, L. L., & Sage, R. (Eds.). (1993). Total quality management in human service organizations. New York: Sage Publications. Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 9 The Continuum of Long-Term Care Connie J. Evashwick CHAPTER TOPICS Denition of Long-Term Care Clients of Long-Term Care How Long-Term Care Is Organized W I L S O N , LEARNING OBJECTIVES Upon completing this chapter, the reader should be able to 1. Describe who uses long-term care and under what circumstances. Service Categories Integrating Mechanisms Long-Term Care Policy 2. Explain the role and scope of services included in long-term care. Q U A S H E 3. Articulate how long-term care services are organized, operated, nanced, and integrated. 4. Evaluate model delivery system approaches to long-term care for the future. 5. Articulate national policy issues pertinent to long-term care. 1 9 9 7 B U 198 Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 9 The Continuum of Long-Term Care WHAT IS LONG-TERM CARE? A child with cerebral palsy attends a special needs classroom in a public school, with therapy available on-site, and her parents care for her when she is at home. An 85-year old recovering from a broken hip receives meals on wheels during the week and relies on her daughter for mealsW over the weekend. I A young man with schizophrenia lives in shelL tered housing, with nancial assistance provided through a public housing voucher program and S medication or counseling assistance available from an on-site staff when needed. O An elderly couple, one of whom is blind from N advanced glaucoma and one of whom is , crippled with severe arthritis, uses a moneymanagement service from a local community agency to pay their bills, since neither can write Q a check. U A middle-aged woman with multiple sclerosis has a live-in attendant to assist her with the A activities of daily living. S All these are examples of long-term care proH vided by formal or informal sources. Long-term E care is defined as health, mental health, residential or social support provided to a person with functional disabilities on an informal or formal 1 basis over an extended period of time with the goal of maximizing the person's independence. 9 Services change over time as the person's and 9 caregivers' needs change. The goal of long-term care is to help people 7 achieve functional independence, in contrast to the B goal of acute care, which is to cure. People of all U ages and a wide range of clinical diagnoses need long-term care. The vast majority of long-term care (80 to 90 percent) is provided by friends and family. However, formal services are essential to enable 199 the informal system to be sustained. The formal services that provide long-term care are described in this chapter using a conceptual framework referred to as \"the continuum of long-term care.\" The ideal is an integrated set of services that provides continuity of care over time and across settings. In reality, services are highly fragmented due to nancial drivers, local community variation, and a lack of uniform federal and state policies. This chapter provides an overview of the ideal continuum of care juxtaposed with the reality of existing services, structure, and policies. WHO NEEDS LONG-TERM CARE? The clients of long-term care are growing rapidly. They represent a mosaic of population segments of those with functional disabilities. Three intersecting concepts warrant explanation to understand the users of long-term care. The fundamental reason that a person needs long-term care is because they suffer from one or more functional disabilities. Functional ability is a person's ability to perform the basic activities of daily living (ADLs) or instrumental activities of daily living (IADLs). ADLs include the ability to bathe, dress, perform personal care and grooming, walk, transfer from bed to chair, maintain bowel and bladder continence, and eat. ADLs were initially dened by Katz and colleagues through research (Katz et al., 1963), and years of study have produced commonly accepted measures and scales of functioning. ADLs tend to involve large motor skills, and they are lost in a predictable order. IADLs are more loosely dened (Lawton & Brody, 1969) but typically involve cognitive reasoning and ner motor skills. IADLs include telephoning, managing money, taking medications, grocery shopping, housekeeping, doing chores, and using transportation. The conditions that underlie the need for longterm care may be physical health, mental health, Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART THREE Providers of Health Services 200 57.6% 80 73.6% 38% 57.7% 28.3% 70 -74 46.6% 30.7% 44.9% 24.2% 55- 64 35.7% 13.9% 22.6% W 13.4% I 5.3% L 10.7% S 3.8% Under 15 7.8% O 0 20 N Figure 9.1. D i s a b i l i t y P re v a l e n c e b y A g e , 1 9 9 7, 25- 44 8.1% Severe Disability Any Disability 40 60 80 SOURCE: From Health, United States, 2005 (Special Excerpt), Trend Tables on 65 and Older Population (DHHS Pub. No. 2006-0152) (Table 58, p. 243), National Center for Health Statistics. Q U or a combination, as well as family situation and environmental context. Of the 288 million people A in the United States in 2005, more than 12 percent, S or more than 35 million people suffered from some type of disability that limited their ability to perH form basic activities of daily living (National Center E for Health Statistics, 2005). Limitations in functional ability affect people of all ages but increase with age and the concomitant chronic conditions 1 that accumulate with aging. Figure 9.1 shows the estimated number of people with disabilities. How 9 a person manages a functional disability depends 9 on several factors, including other health conditions, age, family and social support, economic sta7 tus, housing, and personal preference. B Chronic is dened by the National Health InterU view Survey as any condition that lasts 3 months (or 90 days) or more (National Center for Health Statistics, 2007). Chronic conditions may derive from physical or mental conditions. Over the progression of a disease, both may occur. Chronic conditions may be as life-threatening as coronary artery disease or as harmless as mild arthritis. In 2005, an estimated 133 million people had some type of chronic condition (Hoffman, Rice, & Sung, 1996). Chronic conditions often (although not always) result in functional disabilities. An impairment as used by the National Health Interview Survey is dened as \"a chronic or permanent defect, usually static in nature, that results from disease, injury, or congenital malformation. It often represents a decrease in or loss of ability to perform various functions.\" Permanent impairments, such as limb amputation or blindness, may require an initial adjustment and are then more or less stable. People may attain a level of independence by learning special skills to overcome the disability or by using adaptive devices. For example, a person with myopia can have their vision corrected by wearing glasses or contact lenses and thus suffer Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 9 The Continuum of Long-Term Care no disability as a result of their impairment. Nonetheless, impairments are closely associated with functional disability. Impairment, chronic condition, and functional ability are intertwined. For example, a person who is blind, who lives with a supportive family, learns Braille, and masters the immediate environment, may achieve a fair degree of independence on a daily basis. However, if that person ages and becomes cognitively diminished, he or she may no longer be able to remember the environment, and without the ability to use the visual clues (or just W simple notes or lists) that a person with sight can use to help overcome cognitive weaknesses, is less I able to function independently. If that person then L slips and breaks a hip, suffers a permanent impairment, and has to use a walker, they willS lose more functional ability than a sighted person or a person O without cognitive impairment who is able to understand rehabilitation routines. N In addition to a person's health and mental , health, social situation, finances, housing, and community context all affect the extent to which a person can perform ADLs and IADLs indepenQ dently and the type of assistance they may need. U Contrast a male veteran in a wheelchair who lives with a spouse, can afford a personal caregiver, reA sides in a one-story home, and lives in a large S urban community served by a community-based agency coordinating services for the disabled and H a Veterans Affairs hospital that provides a full range of health care for people with E disabilities with an elderly widow who breaks her hip, has no family nearby, has no income except Social Security, resides in a two-story walk-up in a 1 small rural town, and must travel 30 miles to reach9 hospital a with an orthopedic service. The man will main9 tain his independence by working with a multifaceted support system; the older woman will 7 most likely end up moving to a relative's home or B an assisted living facility for those with low income and be forced to move awayU from her friendship network. The United States makes no single, constant, ro