health care delivery system. evolution of hcds early 20 th century – prepaid medical plans...
TRANSCRIPT
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Health Care Delivery System
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Evolution of HCDS
• Early 20th Century – Prepaid medical plans –lumber and mining camps
Nursing care still focused in homes• 1920 – American hospitals offered
“Baylor Plan” (later Blue Cross) –• 1935 – Social Security - benefits for
elderly, child welfare, training of healthcare personnel
• WWII – veteran healthcare benefits
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• 1960’s – Medicare and Medicaid health care services for elderly and indigent
• Nursing Training Act (physician and nurse shortage)
• Nurse Practitioners began• Focus moves to health maintenance• 1970’s – HMO Act – primary health care
service for a predetermined fee• Amendments to SS allow nurse practitioners
to be paid directly for service• Rural Health Clinic Service Act
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• 1980’s – Focus on Cost Control• “OBRA” – Omnibus Budget
Reconciliation Act (peer review, quality, restraints, payment to midwives)
• DRG’s (Diagnosis Related Groups)• HMO’s increase• Technology proliferates• AIDS discovered
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• 1990’s – Medicaid and welfare program reforms: welfare to work
• SCHIP – Children’s health insurance program
• UAP’s (unlicensed assistive personnel)
• 2000’s – More telemedicine utilization
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Levels of Health Care
Primary – Health Promotion and Illness Prevention
• Ideal level to enter the health care system
• Teaching, lifestyle modification, referrals, immunization, promote safe environment
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Secondary – Early detection, Diagnosis and Treatment
• Screening, diagnosis• Acute Care• Surgery
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Tertiary – Restorative and Rehabilitation actviities– return to optimal functioning
• Education and retraining• Environmental modifications• Provision of direct care
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Health Care Settings
• Hospitals – General and specialized Proprietary Teaching and Research Public Voluntary
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Health Care Settings
• Ambulatory Services Outpatient departments Physician group practices HMO’s Nursing Care Centers Community Health Clinics Indian Health Service Ambulatory Care Facilities (urgent care centers)
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Health Care Settings
• Long Term Care Facilities Residential care Assisted Living Skilled Care• Public Health Agencies• Home Care Agencies• Adult Day Care• Wellness Centers• Hospice Care – hospital, nursing home,
free-standing hospice, home
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Health Care Team
Guess the professional:
Has completed a 120 hour course in basic life support skills and passed a national test. Provides care in an emergency
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• EMT
• ??? Has a minimum 2 year preparation and performs diagnostic measures involving radiant energy
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• X-ray technician
• ??? A nurse who has studied an additional 2-3 years in an approved school or anesthesiology
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• CRNA (Certified Registered Nurse Anesthetist)
• ???Graduate of a 12-18 month program and passed a certifying exam - provides treatments for breathing
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• Respiratory Therapist
• ???? Provides assistance for mobility and exercises – has completed a 2 year program
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• PTA – Physical Therapy Assistant
• ??? Has completed 4-5 years of education plus an internship regarding nutritional problems and therapeutic diets
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• Dietician
• ??? A graduate of a 4 year or more program who helps patients restore body function through specific tasks and skills related to activities they need to function in their daily lives
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• Occupational Therapist
• ??? A professional who helps the patient solve problems with financial concerns, assist with obtaining services in the community after discharge and has completed a master’s degree.
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• Social Worker (MSW)
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Financing
• Public• Private• Third Party
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Financing Health Care
• Fee for service – physician paid by patient for each service provided
• Capitation – set monthly fee charged by provider for each member of group for a specific set of services
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Fee for Service - Terminology
• Premium• Deductible• Co-Payment• Co-Insurance• Health Care Provider
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Public Financing - Medicare
• Part A – Hospital Insurance Provided free for those who have 40 or more
quarters of Medicare-covered employment
• Deductible ($1024 in 2008)• Coverage: Hospitalization Skilled Care rehabilitation service– 21 days plus 80 days with $124/day deductible May cover Home Health
Services (co-insurance applies) Hospice Care
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Public Financing - Medicare• Part B – Medical Insurance (like major medical
insurance plan)• Funded by monthly fixed-rate premiums
($96.40/mo 2008)• Pays 80% of approved charges Doctor’s services Outpatient hospital services Ambulance transportation Diagnostic tests, lab, mammography Physical , Occupational, Speech Therapy outpatient or in rehab agencyNOT COVERED: prescription drugs, routine
physicals, dental, cosmetic, foot care, hearing aids, vision
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Public Financing - Medicare
• Part D – Prescription Drug• Voluntary participation• “Doughnut Hole” coverage• Monthly premium based on plan
chosen
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Diagnosis Related Groups (DRG)
• A set fee is used , based on illness category, to determine hospital reimbursement
• Medicare and insurance • Hospitals receive flat fee,
regardless of length of stay• Hospital makes money if they
provide service for less than DRG amount
• Goal – care provided in most economical fashion possible
• Prospective-Payment system
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Public Financing - Medicaid
• Medical assistance for low income and disabled
• State establishes services and requirements, including eligibility
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Health Care Financing – Managed Care
HMO – Health Maintenance Organization
• Prepaid fee paid to provider for comprehensive care of the enrollees
• Encourage preventative medicine• Discourage excessive tests and treatments• Patient may not have option of choosing
physician each time treatment is needed• Single point of entry
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Health Care Financing – Managed Care
Preferred Provider Organization (PPO)
• Insurance companies contract with groups (physicians and hospitals) for discounted fees
• Patient may see anyone in the network
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Health Care Financing – Managed Care
• Open Access – individuals may see specialists within network without a referral
• Gatekeeper – usually primary physician – must give referral before patient can see specialist – goal is to keep costs down
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Issues
• US rankings by WHO• #1 – dignity, provider choice,
confidentiality• #37 – performance (outcomes vs
expenditures)• #54 – fairness in financing
Hill, p. 317
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Issues
• Uninsured• Uncompensated care• Aging population• Cost of government health care
programs• Cost of prescription drugs• Quality
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Issues
• Limited resources – how are they allocated, and to whom?
• Private vs National Healthcare
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Nurses’ Response to HCDS Issues
• Cost containment• Quality Improvement
• Health, prevention focus• NP’s providing care• Education
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HCDS Issues in the Workplace
• Use of UAPs• Nurse/Patient Ratios
• Acuity levels• Mandatory Overtime• Unionization
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Assignment• You are the self-employed head of household
for a family of four. Your gross annual family income is $33, 280 (equivalent of $8/hr full time for 2 people).
• Research the cost of a family health insurance policy with a $500 deductible.
• What is the monthly and annual cost of this
policy. What % of your annual income will be spent on health insurance?