Resources and Organization
The U.S. medical-care system is based on the private
practice of medicine and job-related
health insurance. In 1993 nearly 11 million people were employed in the system, of whom 620,000 were
physicians, 1.9 million registered nurses, 630,000 licensed practical nurses, 24,000 nurse practitioners, 25,000 physician assistants, and 160,000 dentists.
There were 4,856 short-term general hospitals with nearly 1 million beds, of which 592 hospitals were for-profit ("investor- owned"). There were over 20,000 nursing homes, half of them for-profit. These provided nearly 2 million nursing home beds, and a growing number of hospices afforded special facilities for the dying.
Heretofore, U.S. medical
practice was basically entrepreneurial, with physicians earning their income through a variety of reimbursement mechanisms other than salary: fee-for-service, capitation, per-session. This is changing, as more and more physicians are employed by health maintenance organizations and managed care (HMOs). Once called prepaid group practice, these plans offer comprehensive scope of services, including hospitalization, for a fixed premium and lend themselves to control of spending by regulating the doctor's activities and patient complianceÑ"managed care."
These prepaid insurance groups of physicians may be nonprofit or for-profit. Nearly 45 million Americans belong to and receive their care through HMOs, and 55% of that total are enrolled in nonprofit groups. Some groups are owned and managed by the physicians themselves; others are part of corporate entities, local or national. About 35% of U.S. physicians are associated with HMOs full- or part-time.