UNIVERSITY OF FLORIDA

COLLEGE OF PUBLIC HEALTH AND HEALTH PROFESSIONS

HSA 6114 – INTRODUCTION TO THE U.S. HEALTH CARE SYSTEM

COURSE SYLLABUS

INSTRUCTOR: Allyson Hall, PhD

Room: HPNP 4137
Phone: 352 273 5129
Email: [email protected]

CO-INSTRUCTOR: Eric Jamoom, M.S.

Email: [email protected]

CLASS MEETINGS: Mondays: Periods 7 - 9

1:55 - 4:55 Room G101
ON OCT 20 EXAM 1 WILL BE HELD IN C1-9

OFFICE HOURS: Monday 12:00-1:45 pm (Dr. Hall)

Tuesday from 11am -12 pm (Mr. Jamoom)
Or by Appointment

COURSE DESCRIPTION

This course is designed to familiarize students with some of the basic concepts and ideas concerning
the distribution of health and illness, the organization of the health care system, and the relationship
of one to the other. Definitions of health and illness, as well as the historical context for
developments of our health care system are discussed and debated. The course concludes with a
discussion on trends that could impact the health care system in the future.

Students should come to class ready to discuss and debate the major themes related to health and
distribution of disease, the ability of the US health care system to meet the needs of the population,
as well as the policy environment that influences access to health care services.

COURSE OBJECTIVES

At the conclusion of the course students are expected to be able to describe:

• The dynamics of the health care system and the interaction of providers (hospitals,
physicians, etc), patients, and sources of health care financing (Medicaid, private health
insurance etc)
• The historical development of the health care system
• The determinants of health and how these determinates are related to the distribution of
disease in populations (demand for health care)
• The financing and delivery of health care services
• The role of government in the delivery of health care services
• How the US health care system compares to systems in other developed nations
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 • Current health policy and management issues, and options related to the delivery, financing,
quality, and access of health care services

The course is organized into FOUR parts:

• The Distribution Of Health And Disease And Public Health

• Access, Financing, and the Role of Government
• Infrastructure of the US Health Care System
• Quality Of Care In Health Care Delivery

COURSE READINGS AND MATERIALS

One textbook is required.

• Kovner AR, Knickman JR. Jonas and Kovner’s Health Care Delivery in the United
States (9th edition), Springer Pub Company (2008).

• In addition to the test, there are supplemental readings listed in the syllabus. These readings
are available on the course website. To adhere to copyright requirements some readings
may only be available the week the reading is assigned.

• We have also made suggestions for additional readings for certain lectures

• You should also sign up for the Kaiser Family Foundation’s Daily Online Reports. The
reports serve as a tremendous source of information on health care related news stories and
links to original articles. You can sign up on:
http://www.kaisernetwork.org/daily_reports/rep_index.cfm

• From time to time additional readings may be assigned or suggested

***********
PowerPoint presentations will be available on the course website either immediately before or
immediately after the lecture. POWERPOINT PRESENTATIONS WILL NOT ALWAYS BE
AVAILABLE PRIOR TO CLASS. These presentations are provided as a courtesy to students.
Students should not assume that all material presented in class will be included in the PowerPoint
slides. Therefore, students should be prepared to read assigned materials and to take notes in class.

I expect you to attend and be prepared to participate in all class sessions. Personal issues with
respect to class attendance or fulfillment of course requirements will be handled on an individual
basis. Only under the most extenuating circumstances will changes to class requirements be made.

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GRADE DISTRIBUTION

A 90-100
B+ 85-89.9
B 80-84.9
C+ 75-79.9
C 70-74.9
D 65-69.9

Use of cell phones, pagers or laptop computers are not permitted in class!

Students with Disabilities: Students requesting classroom accommodation must first register with
the Dean of Students Office, which will provide documentation to the student. The student should
then provide this documentation to me.

STATEMENT OF UNIVERSITY’S HONESTY POLICY (CHEATING AND USE OF

COPYRIGHTED MATERIALS)

Students are expected to act in accordance with the University of Florida policy on academic
integrity (see Graduate Student Handbook for details). Cheating or plagiarism in any form is
unacceptable and inexcusable behavior.

We, the members of the University of Florida community,

pledge to hold ourselves and our peers to the
highest standards of honesty and integrity.

***Instructions to access articles from WebCT

Go to the e-Learning Support Services web site at http://lss.at.ufl.edu. Log in with your GatorLink
ID.

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 COURSE REQUIREMENTS

Exam 1 Designed to test your knowledge of key concepts 20% October 20

covered in class. Format will be primarily short
answer. Exams will be returned to students no
later than November 3

Exam 2 Designed to test your knowledge of key concepts 20% December 17

covered in class. Format will be primarily short
answer.

Midterm Designed for you to apply key concepts covered in 20% PowerPoint presentation + notes are due
Project Section 2. Power point (10-12 slides) on 3 US November 3
Heal System issues plus accompanying notes.

Critique of Select, read, and provide a 2 page review of three 15% At the beginning of the semester, students
three articles articles drawn from the peer-review literature or (5% will select three lectures for which they
popular press that pertain to the lecture you have each) will submit article critiques.
signed up for. The review should include three
components: Critiques are due at the BEGINNING of
• A brief summary or overview of the the class period and will be incorporated
article (not more than a paragraph) into class discussion.
• Your reaction to the piece (what
interested you? Did anything shock or See Attached list for possible article
surprise you? Is their anything you sources
disagree with?)
• Relevance to the topic or lecture (i.e
implications for health care policy,
delivery, or management)

Case Studies Case studies are designed to foster group 20% Case 1 –Summary due Sept 22
discussion on a critical issue. Students will be (10% Case 2 – Summary due October 27
divided into groups. Group discussion will focus each)
on a particular topic, for which case study
materials will be distributed ahead of time.
Students are expected to have read the material
and be prepared to contribute meaningfully to the
discussion. At the end of the class period, a
spokesperson for each group will summarize the
group discussion. Individual students are to
summarize their own thoughts on the case in a
2 page paper.

Class Students are required to read assigned 5% Instructor reserves the right to have
participation chapters/articles prior to coming to class and unannounced quizzes
& Quizzes participate in class discussion. I take this
component very seriously. If your grade is on a
cutoff point, this 5% can make the difference in
the assignment of a final grade.

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 Sources for Article Summaries/Reviews

Foundations and Think Tanks

The Kaiser Family Foundation www.kff.org

(sign up for their e-mail alerts – provides daily or weekly updates on various aspects of health care delivery and policy –
latest reports and journal articles are included in the updates)

Commonwealth Fund www.cmwf.org

The Robert Wood Johnson Foundation www.rwjf.org

The Urban Institute www.urban.org

The Heritage Foundation http://www.heritage.org

(click on the health link)
Families USA www.familiesusa.org

Center for Studying Health System Change http://www.hschange.org

AcademyHealth http://www.academyhealth.org
(Click on the publications link)
Peer-Reviewed Journals

Health Affairs
These journals occasionally run articles about
JAMA
health care delivery and policy
NEJM

American Journal of Public Health

PubMed is the primary search engine for
Healthcare Management Review
peer-reviewed literature. The link can be
Medical Care found on the Health Science’s Library’s
home page under databases.
Medical Care Research and Review

Journal of Health and Social Behavior

Health Services Research

Newspapers and Trade Magazines

New York Times (The Gainesville Sun is owned by the New York Times – so occasionally you can find NYT articles
in the Sun)

Wall Street Journal

Washington Post

Healthcare Executive

Hospitals and Health Networks

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HSA 6114: Article Critical Reaction Guidelines

Each student will sign up for three lectures that they are interested in. For each of these three class
meetings, the student will select a pertinent article to read and analyze. The written response will
be turned in at the beginning of class, along with a printout of the article you selected.

Your analysis should be no more than 1-2 pages. The response should briefly summarize the article
and include your overall reaction to the piece in a well thought out critique. (What interested you?
Did anything shock or surprise you? Is their anything you disagree with? Why or why not?)
Students are encouraged to incorporate outside knowledge and ideas into the response.

For example, one student might provide an opinion piece while another student ties her article to
readings she has done in another course. Most importantly, the response must be brief, well thought
out, and expand upon what the author has said. Remember, a summary of the article is not sufficient
– this is not an exercise in reading comprehension.

Students will be graded on the relevance of the article they chose to review (does it pertain to that
week’s lecture?), the content and thoroughness of the write-up, the depth of their analysis, and their
ability to draw the article into class discussion. Provide proper citations. For help in finding an
appropriate article, use the source list provided on the first day of class. If you have any doubts
about the relevance of your article, please ask.

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COURSE OUTLINE

INTRODUCTION

1 August 25 DR. HALL

Course Overview: Demand and Supply of Medical Care Services
• Discussion of course readings and requirements
• Definitions of health and illness
• Measuring Health
• Cultural values and health care delivery
• Health Services Research

Readings:

• Kovner and Knickman: Chapter 1

• Kovner and Knickman: Chapter 2

• In Conrad P editor The Sociology of Health and Illness, 7th edition

Callahan D. Rationing Medical Progress: The Way to Affordable Health
Care page 458-461

• In Conrad P editor The Sociology of Health and Illness, 7th edition

Relman AS. The Trouble with Rationing page 462-464.

• Peter Conrad & Valerie Leiter (2004). Medicalization, markets and

consumers. Journal of Health and Social Behavior, 45, Extra Issue:
Health and Health Care in the United States: Origins and Dynamics,
158-176.

• In Iezzoni, LI. Risk Adjustment for measuring Health Care Outcomes. 3rd
Ed. Chicago, IL: Health Administration Press; 2003 Chapters 2(27-31)
and 3 (33-70).

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 September 1 LABOR DAY—NO CLASS

PART ONE: DISTRIBUTION OF HEALTH AND DISEASE & PUBLIC

HEALTH

2. September 8 DR. HALL

Social Determinants of Health and Disease
• How do factors such as age, gender, race, poverty, and occupation relate to morbidity
and mortality?

Readings:

• Kovner and Knickman: Chapter 2

• In Conrad P editor The Sociology of Health and Illness, 7th edition Syme
SL and Berkman LF Social Class, Susceptibility, and Sickness page 24-
30.

• In Conrad P editor The Sociology of Health and Illness, 7th edition

McCord C and Freeman HP Excess Mortality in Harlem page 30-39.

• In Conrad P editor The Sociology of Health and Illness, 7th edition Fuchs
V A Tale of Two States page 55-57.

• In Conrad P editor The Sociology of Health and Illness, 7th edition

Rodwin VG and Croce-Galis MJ Population Health in Utah and Nevada:
An Update of Victor Fuchs’ Tale of Two States page 57-62.

• Kaiser Family Foundation Key Facts: Race and Ethnicity and Medical
Care, January 2007

• Kaiser Permanente, Institute for Health Policy. Issue Brief: Racial and
Ethnic Health Disparities

• Kilbourne AS, Switzer G et al “Advancing Health Disparities Research

Within the Health Care System: A Conceptual Framework” American
Journal of Public Health 2006 96(12):2113-2121.

Additional Readings:
• The environment of health model (Planning for Health Developmental
Application of Social Change Theory (Blum)

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 • WHO Achieving Health Equity: from root causes to fair outcomes:
Commision on the social determinants of health:
http://whqlibdoc.who.int/publications/2007/interim_statement_eng.pdf
ƒ IOM Reading: Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care (2002) via web:
http://www.nap.edu/catalog.php?record_id=10260#toc

ƒ Mechanic, D. (2000). Book Review Essay: Rediscovering the Social

Determinants of Health. Health Affairs, May – June.

3. September 15 DR. HALL/MR. BRYANT

Individual Health Behavior & the Role of Public Health and Health
Promotion
ƒ Relationship between health behavior/health beliefs on health care and health
ƒ Theoretical underpinnings of public health
ƒ Core public health areas
ƒ Organization of public health in the United States
ƒ Public health achievements
ƒ Health Promotion and prevention
ƒ Case Study 1: combating the obesity epidemic: see WebCT for additional materials
related to the case study

Readings:
ƒ Kovner and Knickman: Chapter 4

ƒ Kovner and Knickman: Chapter 10

ƒ Gostin LO, Boufford JI, Martinez RM “The Future of Public’s Health:

Vision, Values, and Strategies. Health Affairs July/August 2004 vol 23
(4):96-107.

ƒ Brandt AM, Gardner (2000) Antagonism and accommodation:

Interpreting the relationship between public health and medicine in the
United States during the 20th Century. American Journal of Public
Health, 90(5):707-715.

Additional Readings:
ƒ Brownson, RC, Bright, FS (2004). Chronic Disease Control in Public
Health Practice: Looking Back and Moving Forward. Public Health
Reports, 119:230-238.

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 ƒ Mullan, F. (2000) Don Quixote, Machiavelli, and Robin Hood: Public
Health practice, past and present. American Journal of Public Health,
90(5):702-706.

PART TWO: ACCESS, FINANCING, AND THE ROLE OF GOVERNMENT

4. September 22 DR. HALL/MR. JAMOOM

Historical Context of US Health System, US Health Care

Financing/Health Care Costs, and the Policy Making Process

ƒ History, trends and characteristics—what are the social ,medical, and technological
factors that have led to the health care system as we know it today?
ƒ Health Care costs
ƒ The Policy Making Process
ƒ Government as provider, purchaser, and payer
ƒ Regulatory activities

Readings:
ƒ Kovner and Knickman: Chapter 3

ƒ Kovner and Knickman: Chapter 5

ƒ Kovner and Knickman: Chapter 14

ƒ Kovner and Knickman: Chapter 17

ƒ In Williams SJ and Torrens PR Introduction to Health Services Torrens

RP Chapter 1: Historical Evolution and Overview of Health Services in
the United States pages 2-17.

ƒ Kaiser Family Foundation Health Care Costs. A Primer. Key Information

on Health Care Costs and Their Impact. August 2007

Additional Readings:
ƒ Paul Starr, The transformation of American Medicine (Basic Books, NY,
1983 (pages 3-144). Historical context of Health and Disease/Public
Health in US.

ƒ Nichols LM, Ginsburg PB, et al. 2004. Are Market Forces Strong Enough
to Deliver Efficient Health Care Systems? Confidence Is Waining.”
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 Health Affairs 23(2):8-21 and associated perspectives (Butler, SM . 22-24
and Entoven 25-27)

5. September 29 DR. HALL

Concepts in Access and Health Insurance (Part I)

ƒ Economic and non-economic barriers to care
ƒ How barriers can impede access to and utilization of heath care
ƒ Relationship between access and health status and health outcomes
ƒ History and trends in health insurance
ƒ Key characteristics and elements of health insurance
ƒ Why does the US not have national health care?
ƒ Relationship between health insurance and access to care

Readings:
• Kovner and Knickman: Chapter 16

• In Conrad P editor The Sociology of Health and Illness, 7th edition

Rothman DJ A Century of Failure: Health Care Reform in America
pages 292-300.

• Hadley J “Insurance Coverage, Medical Care Use, and Short-term health

Changes Following an Unintentional Injury or the Onset of a Chronic
Condition” JAMA 297(10):1073-1084.

• Penchansky R, Thomas JW. The Concept of Access: Definition and

Relationship to Consumer Satisfaction. Medical Care. 1981;19(2):127–
40.

• Andersen R. Revisiting the Behavioral Model and Access to Medical

Care: Does it Matter? Journal of Health and Social Behavior. 1995;36
(1):1–10.

• Kaiser Family Foundation Medicaid: A Primer:

http://www.kff.org/medicaid/upload/Medicaid-A-Primer-pdf.pdf

• Kaiser Family Foundation Medicare: A Primer:

http://www.kff.org/medicare/upload/7615.pdf

Additional Readings:
• Wyszewianski, L . Access to Care: Remembering Old Lessons. Health
Serv Res. 2002; 37(6): 1441–1443.

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6. October 6 DR. HALL

Health Insurance (Part II) & the Evolving Nature of Managed Care
ƒ Types of Insurance: Medicaid, Medicare, employer-based, small group market
ƒ History of Managed Care
ƒ Organizational Structures in Managed Care
ƒ Reimbursement mechanisms under managed care
ƒ Consumerism and choice

Readings:
• Kaiser Family Foundation, Who are the Uninsured? A Consistent Profile
Across National Surveys August 2006.

• Employment Policies Institute Comparing the Effects of Health Insurance

Reform Proposals: Employer Mandates, Medicaid Expansions, and Tax
Credits. February 2007.

• In Williams SJ and Torrens PR Introduction to Health Services, 6th

Edition Torrens PR and Williams SJ Chapter 6: Managed Care
Restructuring the System pages 124-139.

• In Shi L and Singh DA. Delivering Health Care in America: A Systems

Approach, 3rd edition. Chapter 9: Managed Care and Integrated
Organizations pages 323-365 Jones & Bartlett Publishers, 2003.

• Robinson JC “Managed Consumerism in Health Care” Health Affairs

November/December 2005, 24(6):1478-1489.

• Robinson, R. (2000). Managed Care in the US: A dilemma for evidence-

based policy? Health Economics. 9:1-7.

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7. October 13 DR. HALL/MR. JAMOOM

Election and Health Care Reform & The Uninsured

• The Uninsured
• National, State, and Local strategies for Reform
• The 2008 Election Comparison of Obama and McCain health proposals
• CASE STUDY 2: Covering The Uninsured

Readings:
• Kaiser Family Foundation(KFF): Five Basic Facts on the Uninsured.
(August, 2008) http://www.kff.org/uninsured/upload/7806.pdf

• KFF: States moving toward comprehensive reforms:

http://www.kff.org/uninsured/upload/State%20Health%20Reform.pdf

• Barr, DA. Introduction to US Health Policy: The organization, financing,

and delivery of health care in America. Chapter 13, 2nd Edition. 2007.
Baltimore: Johns Hopkins University Press.

• Kaiser Family Foundation: Health Information on Election 2008

http://www.health08.org/

• Bristol, N (2008) Obama vs McCain on global health. The

Lancet.2008;372:521-522

• Kaiser Family Foundation: 2008 Presidential Candidate Health Care

Proposals:Side-by-side Summary:
http://www.health08.org/FINAL%202%20CANDIDATES%20Side-By-
Side%20July%2022.pdf

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8. October 20 EXAM 1
NOTE: ROOM CHANGE FOR THIS DAY ONLY. THE EXAM WILL
BE HELD IN THE COMMUNICORE BUILDING – C1-9

9. October 27 DR. HALL

Comparative International Examples
• Models of health insurance and health care delivery in other developed nations
• International Health Care spending comparisons
• Pros and Cons of other approaches to health care delivery

Readings:
ƒ Kovner and Knickman: Chapter 6

ƒ Sanmartin C, Berthelot JM, Ng E et al “Comparing Health and Health Care

Use in Canada and the United States” Health Affairs, 23(4):1133-1141.

ƒ Blendon RJ, Schoen C et al. Common Concerns Amid Diverse Systems:

Health Care Experiences in Five Countries. Health Affairs, May/June 2003,
22(3):106-121.

ƒ Yip W, Mahal A. The Health Care Systems of China And India: Performance
And Future Challenges. Health Affairs. 2008; 27(4):921-932

ƒ Prologue: China and India: Reform goes global. Health Affairs.

2008;27(4):920.

ƒ Bloom G, Kanjilal B, Peters DH. Regulating Health Care Markets in China.

Health Affairs. 2008;27:952-963.

Additional Readings:
ƒ Lynn Payer (Medicine and Culture: Varieties of Treatment in the United
States, England, West Germany and France

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PART THREE: HEALTH CARE SYSTEM INFRASTRUCTURE

10. November 3 DR. HALL

Hospitals, Ambulatory, and Primary Care
• History of hospital care in the US
• Types of Hospitals; organization of hospitals
• Comparisons between solo and group practices
• Ambulatory care, safety net, and community health centers
• Definition of primary care
• Primary vs. Specialty care
• Managing chronic care
• MIDTERM PROJECT DUE at the beginning of class

Readings:
ƒ Kovner and Knickman: Chapter 7

ƒ Kovner and Knickman: Chapter 8

ƒ In Williams SJ and Torrens PR Introduction to Health Services, 6th Edition

Williams SJ Chapter 9 : Ambulatory Health Care Services page 177-201.

Additional Readings:
ƒ Feldstein, PJ. Does Competition among Hospitals Raise or Lower Costs? In
Health Policy Issues: An Economic Perspective on Health Reform. 2nd Ed.
(Chicago: Health Administration press, 1999) 149-159.

11. November 10 DR. HALL/DR. LIPOWSKI

Long-term/Mental Health Care & the Pharmaceutical Industry

• Changing health care needs and their impact on the health care system
• Discussion of the growing need for long-term care and its alternative modes of delivery.
• Trends in mental health
• Growth of the pharmaceutical industry
• Pharmaceutical Industry regulation
• Key challenges in the pharmaceutical industry

Readings:
ƒ Williams and Torrens Introduction to Health Services, 6th Edition Chapter
11: The Continuum of Long-Term Care.

ƒ Williams and Torrens Introduction to Health Services, 6th Edition Chapter

12: Mental Health Services.

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 ƒ Kovner and Knickman: Chapter 9

ƒ Kovner and Knickman: Chapter 11

ƒ Additional Pharmacy reading: TBD

12. November 17 DR. HALL/MR. JAMOOM

Health Workforce: Dentists, Physicians, Nurses, and other health care
professionals
• History of medicine as a profession
• Challenges facing these professions and the allied workforce
• Demographic and geographic trends in the health workforce
• Trends in health care and public health administration

Readings:
ƒ Kovner and Knickman: Chapter 12

ƒ Williams and Torrens Introduction to Health Services, 6th Edition Chapter

14:Health Care Professionals

ƒ Cooper RA, Getzen TE, McKee HJ, Laud P “Economic and Demographic
Trends Signal and Impending Physician Shortage Health Affairs
January/February 2002 21(1):141-154. (

ƒ Mertz E and O’Neil E “The Growing Challenge of Providing Oral Health

Care Services to All Americans” Health Affairs September/October 2002
21(5): 65-77

ƒ Aiken LH “US Nurse Labor Market Dynamics are Key to Global Nurse
Sufficiency” Health Services Research June 2007 42(3 part 2):1299-1320

• LDI Issue Brief Medical Migration to the U.S.: Trends and Impact,
April/May 2007.

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PART FOUR: QUALITY OF CARE IN HEALTH CARE DELIVERY

13. November 24 DR. HALL

Quality of Care and Cultural Competency

• Definition of cultural competency
• Need for culturally competent care
• Examples of best practices and programs in the public and private sectors
• Movie: Worlds-Apart: Thinking about Cross-Cultural Health Care

Readings:
• Kovner and Knickman: Chapter 15

• Betancourt, Green, Carrillo, Park, “Cultural Competence and Health Care

Disparities: Key Perspectives and Trends” Health Affairs March/April 2005

• Rosenthal M, Frank R. What is the Empirical Basis for Paying for Quality in
Health Care? Medicial Care Research and Review. 2006; 63:135-157.

Alternative Readings:
• The Spirit Catches You and You Fall Down. A Hmong Child, Her American
Doctors, and The Collision of Two Cultures by Anne Fadiman.

14. December 1 DR. HALL/MR. BRYANT

Patients’ Rights, Privacy, and Ethical Issues

• Ethical theories
• Patient rights – including the right to privacy
• HIPPA

Readings:
• Williams and Torrens Introduction to Health Services, 6th Edition Chapter 17: Ethical
Issues in Public Health and Health Services.

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15. December 8 DR. HALL

Information Technology and the Future of Health Care

• Rationing revisited
• Cost Containment
• Increasing role of medical technology
• Privacy challenges

Readings:
ƒ Kovner and Knickman: Chapter 13

ƒ Kovner and Knickman: Chapter 18

ƒ Berwick D Escape Fire: Lessons for the Future of Health Care

16. December 17 EXAM 2

HAPPY HOLIDAYS!!!!

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