(422 E2) healthcare systems & economics Flashcards
structures of the US health care system
-private
-public
-philanthropic
philanthropic health care systems
generally, addresses health of individuals with specific disorders via funding mechanisms (ex. American Heart Association, Planned Parenthood, cancer Association)
philanthropy
refers to funded activities to promote the welfare of others
private health care system
Focus = individual health
- Cure, rehabilitation, custodial care
- Prevention, early detection, and treatment of disease more recently considered
Nonprofit and for-profit agencies
Individual care provided by physicians and other health professionals on a fee-for-service basis (ex. OB GYN office)
-usually based on managed care or capitated payments such as HMOs
public health care system
Refers to the efforts organized by society to protect, promote, and restore people’s health (ex. state health departments)
Mandated by the U.S. Constitution
Public health care is organized into multiple levels: federal, state, and local
Coordination of services under the U.S. Department of Health and Human Services (DHHS)
focus of population health
disease prevention, health promotion and rehabilitation (broad scope)
current DHHS strategic plan
transform: transform health care
advance: advance scientific knowledge and innovation + health, safety & well being
increase: efficiency, transparency & accountability of DHHS
strengthen: the nation’s health and human services infrastructure and workforce
local health department subsystems are responsible for
-Direct care delivery of public health services and protection of the health of citizens (ex. flu shots)
-Community health services
-Environmental health services
-Personal health services (limited)
-Mental health services
how are philanthropic health care systems funded
donations and fundraising
focus of philanthropic health care systems
-finance research
-provide direct care
-provide supportive care
US health system: phase 1
1800-1900
-Health concerns relating to social and public health issues
-Family and friends provided most health care in home
-People avoided hospital
US health system: phase 2
1900 - 1945
Focus on controlling acute infectious diseases
Growth of hospitals and health departments
Water purity, sanitary sewage disposal, housing
New medications:
1922 = insulin
1932 = sulfa drugs
US health system: phase 3
1945-1984
-Shift away from acute infectious health problems towards chronic health problems
-Major technological advances
-Birth of nurse practitioners and certified nurse midwives
-Increased role of insurance companies
-Start of community-based clinics for primary care
US health system: phase 4
1984 - present
-Limited resources
-Emphasis on containing costs, restricting growth in health care industry, and reorganizing care delivery
-Computers and internet more knowledgeable society
-Hospitals = sicker patients, shorter stays, more intensive care
health economics: financing of US health care
-private pay
-health insurance
-federal & state coverage
third party reimbursement
(patient gets treatment and insurance company pays provider) encouraged growth of the healthcare industry
health insurance: individual & employer
indemnity plans: people choose there providers and pay a set amount of charges incurred for the service
managed care plans: HMO, PPO, POS
self insured plan
managed care plans: HMO
-prepaid health plan
-Members have fixed monthly payment for health care services and co-payments when services are used
-Plans are fairly comprehensive and include preventive care
-Requires gatekeeper to oversee care (designated primary care provider who then refer if needed for specialties)
-Fixed fee when use providers in network
-providers contract w/ HMO
-Decreased flexibility and greater expense for services outside the plan
managed care plans: PPO
-similar to HMO but more expensive & no gate keepers
-Payment is on a fee-for-service basis
-Is based on arrangements between doctors, hospitals, and insurance companies (discounted rate if it is “in network”)
-Providers are guaranteed increases in the number of consumers
managed care plans: POS
-Contain elements of both HMOs and PPOs
-Resemble HMOs for in-network services:
Both require co-payments
Both require a primary care physician who
serves as a “gatekeeper”
-Resemble PPOs:
Services can be received outside of the
network but are usually reimbursed on a
higher fee-for-service basis
health insurance government plans
medicare
medicaid
military (VA & TriCare)
other
medicare
-age 65 + or permanent disability
-100% Federally Funded except for elective supplemental parts which are privately funded
-Recipients often purchase supplemental insurance
-Hospitals are reimbursed based on diagnosis
-No dental or vision coverage
medicare: part A
Covers hospital and facilities: some home health, some hospice, and some skilled nursing care
-Has a deductible
-Funded by federal payroll taxes
medicare: part B
Covers outpatient care, home health, equipment and supplies, lab, ambulance, preventative services
-Elective supplemental purchase
-Supported by general tax revenue and a small
income-based premium from enrollees
medicare: part C
“Advantage Plan”
-Expands options for Medicare recipients
-Advantage plans like HMOs and PPOs
medicare: part D
Provides prescription drug coverage
-Has premiums, deductibles, and co-payments
-There are a variety of plans.
-Higher earners have to pay higher premiums
for part D under the ACA
medicare: accountable care organization (ACO)
Part of the Affordable Care Act to reduce costs and improve quality of care through cooperation and coordination among providers
ACOs consist of groups of physicians and other providers that work together to manage and coordinate care for Medicare fee-for-service beneficiaries
“Shared savings” programs: ACOs receive a portion of the shared savings if they sufficiently reduce costs and simultaneously improve quality.
medicaid
-joint funded by federal and state governments
-expanded to include Children’s Health Insurance Program
CHIP
Health care coverage for low-income children generally those in households with income below 200% of the federal poverty level (FPL) who did not qualify for Medicaid and would otherwise be uninsured
medicaid eligibility
Varies by state, designed for the very poor, families with children, blind, disabled, pregnant people below poverty line, very poor older adults, state programs for children, SSI. (Those considered ‘blameless’ in their poverty.)
Overlaps with Medicare as a supplement with some populations (Dual eligibility)
medicaid covers
Hospital, physician/provider services, dentist, home health, pregnancy related services, supplies, glasses, hearing aids
tricare
-Uniformed services and dependents and retirees
-Covers hospital, medical, dental, and prescription services
veterans administration
-Medical benefits for veterans
-Services at any VA Medical Center
-The 2003 income threshold for enrollment was relaxed in June 2009
Indian health services
Comprehensive health service delivery system for approximately 2 million of the nation’s estimated 3.4 million American Indians and Alaska Natives
Must live on or near a reservation, some reimbursement for residents of urban areas
American Indian Tribes and Alaska Native corporations administer care to 16 hospitals, 258 health centers, 74 health stations, and 166 Alaska village clinics
Outcomes have improved since its inception, but many disparities still exist
new and innovative health care approaches
-Cost sharing
-Health alliances
-Self-insurance
-Flexible spending accounts
-Health promotion and disease prevention
nurse’s role in health care economics: researcher
Investigate efficient, cost-effective care, culturally sensitive treatment modalities, health education, disease prevention, and factors to change behaviors
Investigate, develop, and evaluate the effectiveness of health promotion and disease prevention
nurse’s role in health care economics: educator
Health education is the foundation of public/community health nursing practice
Understand that knowledge empowers clients to actively participate in their health care
Demonstrate the effectiveness and value of health education
Outcome measures for health education need to be established
nurse’s role in health care economics: provider
Care must be appropriate, necessary, and cost effective.
Judicious application of the nursing process is imperative.
Serve as program service provider, health education provider, and health program participant
Participate in grant proposal process, program design, and evaluation of these programs
Participate in statistical information–gathering process as basis for determining needs
nurse’s role in health care economics: advocator
Become more involved in the economics of health care
Increase knowledge of health care funding and policy making
Use political power to influence health care funding
Advocate for increase in health promotion/disease prevention funding
Plan programs, seek funding, and evaluate program effectiveness through outcome measures
