healthcare systems and economics Flashcards
structure of US hc system
private: non profit and for profit sectors
public: address health of pop at federal, state, local level
philanthropic: address health of individuals with specific d/o via funding mechanisms, funded activities to promote welfare of others
AHA, planned parenthood
private
focus = individual health
cure, rehab, custodial care
prevent, early detect, tm more recently considered
individual care provided by physicians and other health professionals on fee for service basis -> usually based on managed care or capitalized payments like HMOs
public
efforts organized by society to protect, promote, restore health
mandated by constitution -> gov must promote welfare
multiple levels: fed policies and practices influence local and state gov
coordination of services under US dep of health and human services, surgeon general as well
public: federal system
focus on pop health: disease prevent, health promo, rehab
broadscope
converned with health pop and env
target general pop, special pop, international health -> many resources directed toward program dev
est laws, rules, regulations to protect public
public: federal system - current strategic plan
transform hc, advance science and innovation, advance health, safety, wellbeing of citizens
increase efficiency, transparency, accountability
strengthen nations health and human services infrastructure and workforce (that can improve health)
public: state level
central authorities in public hc system
dependent on fed level for guidance and resources
est own state laws
public: local law
not every country, may be regional
responsible for: direct care delivery of PH services and protection of health of citizens, comm health services, env health services, personal (limited), mental
STI testing, needle exchange
philanthropic
focus: finance research, provide direct care, supportive care
no legislative power, power of public -> donations and fundraising
global health
phases of us health system: 1st
1800 - 1900
health concerns r/t social and public health issues -> overcrowding, sanitization, running H2O
fam and friends provided most of hc in home
people avoid hospital
phases of us health system: 2nd
1900 - 1945
focus on controlling acute infectious disease -> case finding, quarantine
growth of hospitals and health departments
water purity, sanitary sewage, housing
new meds: insulin, sulfa
phases of us health system: 3rd
1945 - 1984
shift away from acute infectious to chronic
major tech advance
NPs and midwives
increased role of insurance companies
comm based clinics -> primary care
phases of us health system: 4th
1984 - present
limited resources
emphasis on containing cost, restrict growth in hc industry, reorganize care delivery
computers and internet (global) -> society more knowledgeable and aware
hospitals = sicker, shorter stays, more intense care -> more resources: equip, supplies, staff
phases of us health system: 5th
?
ACA and more reform
financing of US hc
private pay: out of pocket -> dont reimburse; aesthetics, mobile IV, plastic sx
HI
fed and state coverage
HI historical factors
<1930: private payment was predominant
plans est in 1930s
WW2 (1939 - 1945): employers offered HI as fringe benefit
3rd party reimbursement -> encouraged growth of hc industry; tm, insurance pays provider
1960s: incresaed focus on social justice -> universal hc coverage
1965: title 18 (medicare) and 19 (medicaid) of social security act
HI individual and employer
indemnity = fee for service plan -> choose provider, pay set amount of charges, more flexibility and services
managed care plan: HMO, PPO, POS
self insured employe plans
HMO
prepaid -> fixed monthly payment for services and copayments when services used (premiums)
plans fairly comprehensive and include preventative care
req gatekeeper to oversee care -> designated primary care provider, referrals
fixed fee when use providers network, contract wiht HMO
less flexibility, more $ for services outside plan
PPO
like HMO but: more $ (higher premiums and deductibles), consumer has more options, no gatekeeper
payment on fee for service basis
based on arrangements btw dr, hospitals, insurance companies
providers deliver services to enrollees for discounted rate negotiated with insurance company (in network)
can go out of service but no discounted rate
providers guaranteed increase in # of consumers
POS
contain elements of both
HMO for in network services: req copayments, req primary care physician
“gatekeeper”
PPO: outsdie services but reimbursed on higher fee for service
medicare
> 65, permanent disability
100% fed funded except supplemental -> privately funded
recipients often purchase supplemental
hospitals reimbursed based on dx
no dental or vision
deductibles, capos -> in pt stay L
medicare: A
covers hospital and facilities, some home health, some hospice, some skilled nc
deductible, funded by fed payroll taxes
medicare: B
out pt care, home health, equip and supplies, lab, ambulance, preventatitve services
elective supplemental purchase
supported by general tax revenue and small income based premium for enrollees
medicare: C
advantage plan
expand options, HMOs or PPOs
medicare: D
Rx drug coverage
premiums, deductibles, co payments
variety of plans, higher earners pay higher premiums
medicare: accountable care organization
part of ACA
decrease cost, increase quality of care through coop and coordination among providers
group of physicians and other providers that work together to manage and coordinate care for medicare fee for service beneficiaries
shared shavings: receive portion of shared savings if they sufficiently decrease costs and increase qual
medicaid
funded by joint fed and state gov
expanded to include CHIP -> children 200% FPL and w/o medicaid who would otherwise be uninsured
medicaid: eligibility
varies by state, designed for v poor fam with kids, blind, disabled, preg below poverty line, v poor OA, state programs for kids, SSI, blameless poverty
dual: overlap with medicare as supplement with some pops
medicaid: services
hospital, physicial/provider services, dentist, home health, preg, supplies, glasses, hearing aids
medicaid: update
income limits set by state (unconstitutional <133% FPL), vary by pop groups
military: tricare
uniformed services and dependents and retirees
hospital, med, dental, rx
military: VA
vets, services at any VA center, income threshold relaxed for enrollment
indian health services
must live on or near reservation, some reimbursement for urban areas
outcomes have improved but disparities still exist
hc financing reform
US spends more on health, worse outcomes
current gen expected to have lower lifespan than parents, fewer healthy yrs
lack of insurance is major factor associated with lack of access
dilema = acceptable and affordable
trends in hc finance
new and innovative approaches: cost share, health alliances, self insure (companies or individuals), flexible spending accounts (money from compant for you to spend on hc), health promo and disease prevention
nurse role in hc economics: researcher
investigate efficient, cost effective care, culturall sensitive tm, health edu, disease prevent, factors to change behaviors
investigate, dev, eval effectiveness of health promo and disease prevent
nurse role in hc economics: educator
empowers clients to participate in own care
est outcome measures
nurse role in hc economics: provider
appropriate, necessary, cost effective
grant proposal, program design, eval
start gathering -> determine needs
nurse role in hc economics: advocate
funding and policy, promo and prevent
