The Demography of Health and Health Care Second Edition The Plenum Series on Demographic Methods and Population Analysis Series Editor: Kenneth C. Land, Duke University, Durham, North Carolina ADVANCED TECHNIQUES OF POPULATION ANALYSIS Shiva S. Halli and K. Vaninadhu Rao ANALYTICAL THEORY OF BIOLOGICAL POPULATIONS Alfred J. Lotka CONTINUITIES IN SOCIOLOGICAL HUMAN ECOLOGY Edited by Michael Micklin and Dudley L. Poston, Jr. CURBING POPULATION GROWTH: An Insider’s Perspective on the Population Movement Oscar Harkavy THE DEMOGRAPHY OF HEALTH AND HEALTH CARE Second Edition Louis G. Pol and Richard K. Thomas FORMAL DEMOGRAPHY David P. Smith HOUSEHOLD COMPOSITION IN LATIN AMERICA Susan M. De Vos HOUSEHOLD DEMOGRAPHY AND HOUSEHOLD MODELING Edited by Evert van Imhoff, Anton Kuijsten, Pieter Hooimeijer, and Leo J. G. van Wissen MODELING MULTIGROUP POPULATIONS Robert Schoen POPULATION ISSUES: An Interdisciplinary Focus Edited by Leo J. G. van Wissen and Pearl L. Dykstra THE POPULATION OF MODERN CHINA Edited by Dudley L. Poston, Jr., and David Yaukey A PRIMER OF POPULATION DYNAMICS Krishnan Namboodiri A Continuation Order Plan is available for this series. A continuation order will bring delivery of each new volume immediately upon publication. Volumes are billed only upon actual shipment. For further information please contact the publisher. The Demography of Health and Health Care Second Edition Louis G. Pol University of Nebraska at Omaha Omaha, Nebraska and Richard K. Thomas Medical Services Research Group Memphis, Tennessee Kluwer Academic Publishers New York Boston Dordrecht London Moscow eBook ISBN: 0-306-47376-3 Print ISBN: 0-306-46336-9 ©2002 Kluwer Academic Publishers New York, Boston, Dordrecht, London, Moscow Print ©2001 Kluwer Academic / Plenum Publishers New York All rights reserved No part of this eBook may be reproduced or transmitted in any form or by any means, electronic, mechanical, recording, or otherwise, without written consent from the Publisher Created in the United States of America Visit Kluwer Online at: http://kluweronline.com and Kluwer's eBookstore at: http://ebooks.kluweronline.com Preface When health demography began to emerge as an applied subdiscipline within demography during the 1980s, few anticipated the developments that would occur in health care to influence its direction. While a distinct body of research cate- gorized under this heading has yet to be formally recognized, the impact of health demography is clearly being felt in the field. The number of health professionals who are using the materials of health demography—perhaps without even realiz- ing it—continues to grow. In fact, most of those involved with health demography are not demographers but sociologists, economists, epidemiologists, and health professionals who are applying the concepts and techniques of health demography to concrete problems in the delivery of health care. The boundaries of this sub- discipline are becoming increasingly visible within demography and the implica- tions of health demography increasingly obvious outside of demography. The US health care system is poised, in fact, to enter the twenty-first century riding on the shoulders of health demography. Many factors have contributed to the emergence of this new field. The developments affecting the health care industry during the 1980s and 1990s have served to transform a diverse collection of charitable institutions and ‘‘mom-and- pop’’ operations into an industry increasingly dominated by for-profit conglome- rates. During the 1980s the industry became market driven and consumer oriented, resulting in an explosion in the demand for both demographic data and health statistics. The need to integrate and interpret data from these two fields has provided a major impetus for the development of health demography. At the same time, the significance of health demography has been confirmed through the reconceptualization of ‘‘health’’ and the growing emphasis on a population-based health care perspective. Now the revolutionary impact of managed care can be added to the list of developments that make the materials and methods of health demography invaluable to the health care industry. The emergence of health demography as a distinct field has been fostered by v vi PREFACE several technological advances. These include the development of a microcompu- ter technology that allows for the processing of large data sets, the development of software that can integrate data from disparate sources, the availability of detailed incidence and utilization rates, and access to heretofore unavailable data on various aspects of health and health care. The maturing of the field is evidenced by the content of presentations at professional demography meetings and, slowly but surely, by articles in the demo- graphic literature. Not only are demographers demonstrating increasing sophis- tication with regard to health issues, but they are beginning to approach health- related data as insiders bent on solving concrete problems in health care delivery, not as isolated academicians applying sterile methodologies to distant health issues. The maturing of the field is further evidenced by the increasing variety of constituents for the ‘‘products’’ of health demographers. Once of interest only to selected researchers and funding agencies, the products of health demographers are now demanded by government policymakers, health planners, health care consultants, health care marketers, and other professionals involved in planning, administering, and marketing health services. The ‘‘corporatization’’ of the health care industry has introduced a new magnitude of demand for health data products and the interest in data generated as a by-product of health demography is growing even among parties outside of health care. This volume has been written for an audience of health care practitioners, academic and private sector demographers, and students in demography and the various health care professions. In fact, the material is of interest to anyone who wants to know more about how and why demographic conditions (and changes in those conditions) affect the supply of and demand for health care and conversely how and why changing health care conditions affect demographic structure. It makes use of data from a variety of sources, using research results, models, theories, and case studies to demonstrate the health care–demography connection from both theoretical and applied perspectives. At the theoretical level, the vol- ume conveys the general principles that serve as the basis for health demography. At the applied level, it demonstrates how the merging of demography and health care has a positive impact on the planning processes of hospitals, physicians’ groups, clinics, nursing homes, and other health care organizations. In producing this work, we have borrowed heavily from disciplines closely related to health care and demography such as social epidemiology, medical sociology, and medical economics. Theories and perspectives from these fields have allowed us to make a more thorough assessment of the origins of the connec- tion between demography and health care. Analytical techniques from these and other fields have contributed to our understanding of current conditions and emerging trends in health care. Finally, our work in this evolving field has exposed us to the problems and opportunities that require a health demography perspective for their resolution. vii PREFACE It is these real-world applications, which appear as examples in the book, that reflect the dynamic nature of health demography. ACKNOWLEDGMENTS Like all authors, we are indebted to several persons who were instrumental in formulating and producing both the first and second editions of this work. First, to Jacqueline Lynch in the College of Business Administration at the University of Nebraska at Omaha whose tireless efforts and seemingly endless patience in the word-processing and rewrite stages of production enabled us to complete our task. We express our deepest appreciation to Virginia McCoy for her valuable sugges- tions regarding changes in this edition. We also would like to thank our colleagues who revised the first edition for their insights and constructive comments, as well as those who have adopted the work as a text and subsequently ‘‘field-tested’’ it. Their comments have certainly contributed to the improvements in this second edition. As with the first edition, the encouragement received from our fellow members of the Business Demography Interest Group of the Population Associa- tion of America, particularly Walt Terrie and Hallie Kintner, helped keep us on course. We also wish to thank our students for the feedback and ideas that they have given us in shaping this work. Any errors of omission or commission, of course, are our own. LOUIS G. POL RICHARD K. THOMAS Contents 1. Health Demography: An Evolving Discipline ............ 1 Introduction ............................................. 1 The Origins of Health Demography ......................... 2 Demographic Roots .................................... 2 Historical Demography .................................. 2 Applied Demography ................................... 3 Epidemiological Roots .................................. 3 Social Science Origins .................................. 4 Major Trends Affecting the Development of Health Demography 6 Changing Population Characteristics ....................... 6 The Changing Nature of Health Problems .................. 8 Changing Perceptions of Health and Illness ................. 8 Overview of the Volume .................................. 9 Objectives ............................................ 9 The Audience ......................................... 13 Organization of the Volume ................................ 15 Additional Resources ..................................... 16 2. Health and Health Care: An Introduction ................ 19 Introduction ............................................. 19 The Relationship among Health, Health Care, and Demography ... 21 Twentieth-Century Trends ................................. 23 The Societal Context of Health and Health Care ............... 28 The Institutional Framework ............................. 28 The Cultural Framework ................................ 30 The Structure of Health Care Systems ....................... 31 ix x CONTENTS Medical Care and Health Care ............................ 31 The Organization of US Health Care ...................... 33 The Vertical Dimension of the Health Care System ........... 35 The Horizontal Dimension of the Health Care System ........ 41 Health Care Personnel .................................. 42 Control in the System ................................... 47 Financing Health Care .................................. 49 Additional Function of the Health Care System ................ 53 Public Health .......................................... 53 Health Care Research ................................... 54 Education ............................................. 55 Planning and Regulation ................................. 55 Medical Supplies–Equipment–Pharmaceuticals .............. 56 References .............................................. 56 Additional Resources ..................................... 57 3. The Language of Health Care ........................... 59 Introduction ............................................. 59 Health, Sickness, and Disease .............................. 59 Illness and Sickness .................................... 62 Disease .............................................. 63 Physical Illness and Mental Illness .......................... 64 The Classification of Physical Illness ........................ 65 International Classification of Diseases ..................... 66 Current Procedural Terminology .......................... 68 Diagnostic-Related Groups ............................... 69 Ambulatory Patient Groups .............................. 72 The Classification of Mental Illness ......................... 73 Alternative Mental Disorder Classification .................. 73 Key Concepts from Epidemiology and Health Care ............. 76 Acute and Chronic Conditions ............................ 76 Incidence and Prevalence ................................ 80 Case Finding .......................................... 81 References .............................................. 85 Additional Resources ..................................... 86 4. Population Size, Concentration, and Distribution ......... 87 Introduction ............................................. 87 Conceptual and Measurement Issues ......................... 88 Population Size ........................................ 88 Concentration and Distribution ........................... 97 xi CONTENTS Rates of Change ....................................... 99 Trends in Population Size, Concentration, and Distribution ....... 101 Census Divisions ....................................... 102 States ................................................ 103 Counties .............................................. 106 Measuring the Supply of Health Services ..................... 108 National Patterns ....................................... 108 State Patterns .......................................... 108 County Patterns ........................................ 110 Implications for Health Care Delivery ........................ 110 General Issues ......................................... 110 Population Thresholds for Health Services .................. 111 References .............................................. 113 Additional Resources ..................................... 114 5. Population Composition ................................ 115 Introduction ............................................. 115 Compositional Measures ................................... 116 Biosocial Factors ....................................... 117 Sociocultural Factors ................................... 119 Measures of Compositional Variation ........................ 121 Population Pyramids .................................... 123 Dependency Ratios ..................................... 124 Sex Ratios ............................................ 126 Cohort Analysis ....................................... 126 Standardization ........................................ 128 Compositional Characteristics and Trends for the US Population .. 131 Age ................................................. 131 Sex .................................................. 133 Race–Ethnicity ........................................ 134 Marital Status, Living Arrangements, and Family Structure .... 136 Education, Income, and the Labor Force .................... 138 Changing Population Characteristics: Implications for Health Care 139 Compositional Shifts .................................... 139 Health Care Needs ..................................... 141 References .............................................. 142 Additional Resources ..................................... 143 6. Fertility ................................................ 145 Introduction ............................................. 145 Concepts, Measures, and Trends ............................ 147