COMMUNITY HEALTH 173
for public health practice as changing beyond any predictions
and urged support of government for health monitoring sys-
tems and interventions.^3
Private health care has gradually become part of the
greater public health system, largely due to change in fund-
ing and demands from the public and its elected officers
for better quality control of health services. These interests
have led to closer supervision of medical services delivery.
Licensing boards and related quality assurance organizations
have increased their efforts to assure that the profession-
als who provide health care are fully qualified to practice
the disciplines for which they were trained. Terminology
like licenses, certificates, or permits tend to be specific for
each profession even though a general public may use the
names interchangeably. Commonly, physicians and dentists
are licensed, nurses are registered, midwives are certified,
and physician assistants receive permits from specific state
boards.
Each board evaluates the training that its applicants have
received and administers a licensing examination that must
be passed before permission to practice is awarded. Licenses
or certificates can be withdrawn when the specific board has,
always by careful legal action, determined that the holder
of that license has breached its standards for quality perfor-
mance. Sanctions of licensees or permit holders vary and
may include a written admonition or reprimand, suspension
for brief periods, requirement that the professional undergo
special training or medical treatment, or even complete with-
drawal of the permit to practice. Failure to perform in accor-
dance with accepted standards may result in disciplinary
action by hospitals as well, and the results of such decisions
are shared with all agencies that have official public respon-
sibility for quality care, consistent with existing standards of
confidentiality. Categories of other health care practitioners
who must possess licenses vary slightly from state to state
but often include dental hygienists, psychologists, social
workers, physician assistants, chiropractic, physical thera-
pists, and acupuncturists.
Personal health care services, once known as the “pri-
vate practice” of physicians and nurses, are gradually shift-
ing from solo practitioners to corporate or group practices.
Remuneration has also shifted from personal payments by
the patient or a guardian to public payments from sources
like Medicare, Medicaid, and insurance programs. Some of
the new groups of health providers are independent practice
organizations (IPAs) in which physicians are separate pro-
viders but relate to a central management group; preferred
provider organizations (PPOs) where physicians retain inde-
pendence but engage in contractual services; and health
maintenance organizations (HMOs) in which physicians
and other professionals may be contractual employees of a
public or private entrepreneurial organization, rather than
independent professionals.
Free-standing medical centers provide initial care for
relatively minor illnesses or prompt referral of more seri-
ous conditions, sometimes known as “urgicenters,” have
arisen to care for persons who have no regular medical atten-
dant or whose physicians are not immediately available.Free-standing non-governmental medical clinics are often
located at vacation resorts or in busy shopping malls and
are part of a community’s medical resources. These are also
known as walk-in clinics or colloquially as “doc in a box”
services of various complexity and usually meant to suffice
only for short-term care.
Mergers of smaller health care groups create progres-
sively larger corporations which control wide-ranging deliv-
ery sites with well-equipped outpatient clinics for initial care
and specialty consultations of medical and surgical illnesses,
ambulatory surgical centers for one-day surgery, as well as
more complex invasive and diagnostic procedures, similar
to those provided in hospitals. Pharmacies and laboratories
and rehabilitation centers may be part of major health care
groups. Special medical units have been created to provide
general care services for entire families at university medical
centers with their own professional schools, or by major hos-
pital groups or industries whose employees might otherwise
lack quality medical care.
Urban and rural US communities have always had cadres
of health care providers or “healers” who were considered
by traditional licensed physician groups as being less well
trained and to whom medical licensure was denied. Some
of these care givers in remote or isolated communities were
folk medicine healers who had received instruction from
older practitioners or even been self-taught. These indig-
enous healers and a large number of other allied health care
providers have been roughly designated as complementary
or alternative health care.
Complementary and alternative are general terms
applied loosely to more than a hundred or so unrelated
healing methods whose adherents believe each is effective.
Complementary health care refers to those skills or systems
that will support customary medical or surgical care directed
by a licensed physician. Acupuncture is a complementary
system, an insertion of needles in parts of the body in accord
with a complex system to relieve pain or cure ailments.^4 The
practice of chiropractic, also, is increasingly accepted as
complementary to physician directed care. In contrast, alter-
native health care is a term to denote a therapy or system
that is meant to supplant regular medical care of a physician.
Iridology, the diagnosis of human disorders by examining
the ocular iris, and naturopathy are two of many alternative
care systems.
Homeopathy and chiropractic practitioners, for example,
are recognized as healers to be licensed by their own boards
in many states, thus subjecting them to a degree of oversight
and legal responsibility. Several popular journals now exist in
which the various supportive health care modalities are fea-
tured. Meanwhile, any of the other alternative care practitio-
ners may be found in local jurisdictions with little or no official
supervision or control, unless medical licensure laws are vio-
lated or use of a specific method causes harm to a subject under
care.^5 Quiet controversy or open disagreement exists about the
value of any one system in these two fields, but a federal office
has been created in the Department of Health and Human
Services (DHHS) to study and evaluate efficacy and safety in
complementary or alternative health care practice.C003_002_r03.indd 173C003_002_r03.indd 173 11/18/2005 10:17:41 AM11/18/2005 10:17:41 AM