Delivering Health Care in America: A Systems Approach, ed 2.

Delivering Health Care in America: A Systems Approach, ed 2 Shi L, Singh DA. Gaithersburg, MD 20878, Aspen Publishers Inc, 2001, paperback, 649 pp, illus, ISBN: 0-8342-1764-3, $53.

This book is--as its title describes--a discussion of health care delivery in the United States using a basic systems framework. The authors note that the current edition retains all of the previous chapters and most of the fundamental concepts of the previous edition, with the addition of current data, developments, and research findings.

The book is organized into 5 parts containing 14 chapters, using the systems framework as a conceptual basis for the organization of chapters and parts. The 5 parts are "System Foundations," "System Resources," "System Processes," "System Outcomes," and "System Outlook." The format of the book provides an opportunity for graduate or undergraduate programs to select sections of this book for entire courses or for specific modules within classes. Learning objectives are included at the beginning of each chapter, and each chapter ends with a terminology section, a set of review questions, and a reference list.

At the back of the book, there is a glossary of terms and an appendix that includes selected Web sites. The authors use a "real world" segment at the beginning of each chapter to engage the reader in the learning content. For example, coverage of Healthy People 2010 precedes the chapter on beliefs, values, and health, and the Balanced Budget Act precedes the health services financing chapter. This is a nice touch for readers because it establishes direct links between current health issues and where the reader might fit in or affect the health care system.

Chapter 1 is a stand-alone chapter on health care delivery. The chapter has an array of figures and tables to illustrate the complexity of the system and its many partners and players. There is discussion of the health delivery systems of several countries, and the chapter includes the authors' rationale for using a systems framework approach. They argue that "in the absence of a unifying central agency, the various functional components of health services delivery structure in the United States are at best only loosely coordinated.... The systems model provides a logical framework for understanding the disjointed arrangements and linkages used for delivering health care in America."

Part II, "Systems Foundations," includes chapters on beliefs, values, and health and the evolution of health services in the United States. The beliefs chapter describes the "curative" medical versus holistic model of health and a disease versus health approach, and it incorporates a discussion on why market justice does not work in the United States. This chapter also takes note of measures of health status (mostly quantitative), including holistic categories. The chapter on evolution describes the scientific research and technological developments that have advanced medicine. The physician is used as the focus in discussing medicine in the preindustrial era, postindustrial era, and the past quarter century.

"System Resources" includes chapters on health care services professionals, medical technology, and health care services financing. In the chapter on health care professions, physicians (including a section on international medical graduates), dentists, pharmacists, other doctoral-level providers (optometrists, psychologists, podiatrists, chiropractors), nurses (including advanced practice nurses), non-medical practitioners (physicians assistants, certified nurse midwives), and allied health practitioners are listed. When all of these provider categories are combined, they account for 3% of the total US workforce. Allied health practitioners constitute 60% of the health care workforce. Physical therapists were categorized as key allied health professionals.

Some of the information contained in this section, however, is misleading and erroneous. For example, the authors state that all allied health professions were created because of time constraints on doctors and nurses. In fact, the challenges of the rehabilitation of veterans of World War I and the impact of the polio epidemic required the creation of more specialized health professions such as physical therapy. The authors also list the old degree requirements for physical therapists and mistakenly state that the licensure examination for physical therapists is administered by the American Physical Therapy Association.

Internet applications and the growth of technology and bioethics highlight the chapter on medical technology. The health care services financing chapter, which describes the complexity of health care financing, has received significant updates and restructuring since the first edition. The chapter concludes with a discussion of the current trends and directions that are likely to influence the future of health care finance.

In Part III, "System Processes," there are chapters on outpatient and primary care services, inpatient facilities and services, managed care and integrated organizations, long-term care, and health care services for special populations. Beyond descriptions of the settings themselves, these chapters discuss alternative and complementary medicine, assisted living, compliance by nursing homes for Medicare and Medicaid reimbursement, mental health, public health, and the uninsured and homeless populations.

"System Outcomes" includes a chapter on cost, access, and quality, and one chapter on health care policy. The authors discuss the interactive relationship among cost, access, and quality variables. They talk about rising health care costs, universal access issues, and the ever-growing interest in quality of care. The health care policy chapter describes the development of legislative policy and the critical health care policy issues, including cost-related policies and their impact on health outcomes and quality.

The final part, "System Outlook," addresses the future of health care delivery. The authors speak about a "desired system outcome" and discuss likely trends. Some concepts mentioned were health and wellness, public health, demographics, financing, and managed care configurations.

Overall, this text is logically sequenced, organized, and well illustrated. There is general discussion and historical perspective about a number of subjects that makes the book quite broad in scope. However, it does not discuss any subject area in detail. This book would be an excellent choice for any undergraduate or graduate student in the health professions. It is also a good text for any other health are professional who wants to become familiarized with the many nuances of the system structure and organization. For anyone returning to the United States to practice in a health care profession or for those returning from an absence in practice, this book provides the missing evolutionary pieces that "time away" may have created.

Susan Hanrahan, PT, PhD Arkansas State University Jonesboro, Ark

Dr Hanrahan is Professor of Physical Therapy. She currently serves as the Dean of the College of Nursing and Health Professions. Her research interests include health education, health administration, health behavior, and health policy.