A specially trained trauma team at Bellevue Hospital in New York City treats a patient injured in a drug-related fall. Blood vessels between the membranes surrounding his brain have ruptured, causing an increase in pressure inside the skull that may kill him if not treated immediately. Teams like this one must diagnose and treat many such unconscious and critically injured patients every day. Modern hospitals include CT scanners and X-ray and emergency surgery facilities to make this possible. They may also have access to equipment such as helicopter “life flight” ambulances that increase chances of survival even more.
A sick or injured person can obtain medical care in several different places. These include provider practices such as medical offices and clinics, hospitals, nursing homes, and home care.
There are about 200,000 medical offices, clinics, and other provider practices in the United States. Earlier in the 20th century most physicians were solo practitioners working in their own offices or in partnership with another doctor. Patients visited the office, received an examination or other service, and paid a fee. This traditional solo, fee-for-service medicine has been declining. Many physicians now practice in groups where they share the same offices and equipment with other doctors. Group practices may combine primary care physicians, several kinds of specialists, laboratories, and equipment for diagnosing disease. Physicians who practice in a group reduce their own expenses and provide patients with a wider range of services.
Many doctors are joining with hospitals, insurance companies, and industrial employers to provide managed care for groups of patients. Physicians may work as employees of health maintenance organizations (HMOs) or other health care alliances. These plans oversee, or manage, care for patients, to avoid unnecessary services and reduce costs. Rather than taking a fee from each patient, managed care physicians may receive an annual salary from the HMO or a fixed sum for each patient.
Patients who are too sick for care in a doctor's office go to a hospital. Hospitals offer patients 24-hour care from a staff of health professionals. They provide services not available elsewhere, such as major surgery, child birth, and intensive care for the critically ill. The United States has about 6,020 hospitals including more than 1 million beds. Several kinds of hospitals exist, including general hospitals, specialized hospitals that care for specific diseases, small community hospitals, and large academic medical centers that train new doctors. Hospitals also provide many outpatient services to patients being treated in doctors' offices and clinics. These include laboratory tests, computerized imaging scans, X rays, and other diagnostic tests for people who do not require admission to the hospital.
Hospital care is the most expensive form of health care. Efforts to control health care costs have emphasized reducing the number of patients admitted to hospitals and their length of stay. During the 1980s and 1990s, these efforts led to the closing of more than 600 hospitals, which eliminated almost 200,000 beds. Physicians also try to treat more people on a nonhospital, or outpatient, basis, and these cost-control efforts have led to fast growth in outpatient treatment centers. These include ambulatory surgery centers, where patients undergo operations once available only in hospitals and return home the same day.
Patients who need long-term medical care because of advanced age or chronic illness may stay in a nursing home. The United States has about 17,000 nursing homes with about 1.8 million patients. The number of nursing homes has doubled since 1960 because there are more older people in the population. Changing lifestyles, in which adult children and parents often live far apart, also contributed to the need for more nursing homes. About 85 percent of nursing home patients are age 65 and over. Many stay for a few weeks while recovering from an acute illness. They receive medical care and help with everyday activities like eating, bathing, and using the bathroom. Then they return home and care for themselves, often with the help of family or other caregivers. Other patients stay longer.
Some patients need regular medical care and other assistance, but are not sick enough for a hospital or nursing home. Home health care allows them to receive skilled nursing and other care in their own homes. Home care services are the fastest-growing sector of the health care industry, increasing about 30 percent per year in the 1990s. This growth is largely because home care is less expensive than hospital or nursing home care. Home care also is very popular with patients because most people prefer staying at home, rather than entering a hospital or nursing home. About 15,000 home health agencies provide most home care services in the United States. Many agencies are privately owned. Hospitals, public health departments, and other organizations also offer home care.
Hospices are special health care facilities that provide care for dying patients in the final stages of a terminal illness. A hospice staff is focused on making the last days of a dying patient pain free and comfortable. Many patients choose hospice services in their homes.