The most visible aspects of any healthcare system are the facilities and personnel involved in the delivery of healthcare. Centralized systems have attempted to provide greater equality in the distribution of facilities and healthcare workers by focusing on the needs of a community rather than on the autonomy of providers and patients. In some centralized systems the national government may determine how many and which types of physicians, nurses, and other healthcare workers are produced; the location of hospitals and the technology they may purchase; and the location of hospital-based and outpatient-care providers. Care is strongly regionalized, with easily accessible primary care for most common healthcare problems, some specialty care available in regional hospitals, and subspecialty and tertiary care confined to a few large teaching centers.
In contrast to most other countries, the healthcare system in the United States provides little central control. There has been almost complete autonomy for providers, starting with a system of health-professional education with a substantial number of private schools and little or no restriction on specialty choice, practice, or hospital location or on the availability of technology. Because of the prestige and generous payments for new technology nearly all hospitals provide a full array of high-technology services. This complements a strong trend toward subspecialization among health professionals. In the case of physicians the percentage of generalists versus specialists declined from nearly 50 percent in 1961 to the current 28 percent; if OB/GYN and emergency medicine physicians are included in the generalist category, the figures are 32 percent primary care physicians and 68 percent specialists (Bureau of Health Professionals; Council on Graduate Medical Education). The abundance of specialists, especially those who are trained to perform high-technology procedures, is thought to exacerbate the over utilization of some healthcare services. Conversely, the decline in the number of generalists is believed to be a contributing factor in the poor access to healthcare experienced by persons in rural areas and those with low incomes in urban areas.
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