Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 7 The Health Care System

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health Care System Health Care Providers People –Primary health care providers  Initial contact with health care system  Health maintenance  Treatment of illnesses Institutions Organizations

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health Care System (cont.) Health Care Facilities Buildings or locations where health care is provided Hospitals –Provide health care –Are medical education centers –Types of hospitals  Public or private  Classifications  Acute care general, specialty, size, length of stay

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health Care System (cont.) Health Care Facilities (cont.) Patient Care Units –Primary diagnosis –Amount of care needed  Progressive care  Intensive care  Intermediate care  Self-care  Long-term care

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health Care System (cont.) Other Facilities –Nursing homes (SNF, ICF) –Rehabilitation centers –Free-standing surgical centers –Dialysis centers –Doctors’ offices –Local health departments –Industrial health centers –Community mental health centers Health Care Facilities (cont.)

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health Care System (cont.) Health Care Service Describes the actual delivery of health care by health care workers Includes prevention, diagnosis, and treatment of illnesses Includes providing care during an illness

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health Care System (cont.) Health Care Regulation, Approval, Accreditation, and Standards of Excellence Health Care Regulation −Methods designed to control quality of health care and cost −Developed by governmental bodies Health Care Approval −Minimum regulatory standards a facility must meet

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health Care System (cont.) Health Care Accreditation −Process of examining operation of a facility using written standards of excellence −Mandatory if receives federal or state government funds Standards of Excellence –Certificate awarded for exceeding requirements  Magnet status  The Baldrige award

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health Care System (cont.) Regulation and Primary Health Care Providers −Mandatory licensure by each state −Professional codes of ethics Approval and Accreditation of Hospitals −Approval by State Department of Health −Accreditation a voluntary process −Mandatory  Medical educational program sponsor  Receive federal payments

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health Care System (cont.) Approval and Accreditation of Long-Term Care Facilities −State approval and standards for accreditation designed for long-term care facility activities Approval and Accreditation of Home and Community Health Care Organizations −License to operate −CHAP, JCAHO, CMS

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health Care System (cont.) Approval of Other Health Care Facilities −JCAHO, AOA, CHAP, and CMS Regulation of Agencies That Receive Medicare and Medicaid Payments −Intended to help control cost of health care

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health Care System (cont.) Quality Assurance, Peer Review, and Risk Management Programs Ensure patients receive quality care in a safe environment Evaluation and improvement of level of service to patients –Minimally accepted levels of care –Lowest possible cost

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Care Financing Private Insurance Fee-for-service (indemnity) Prepaid (managed care plans) Government Insurance Social Security Act of 1965 –Medicare –Medicaid –SCHIP (1997)

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Controlling Health Care Costs Diagnosis-Related Groups Prospective Payment System (1983) Ensuring profit while providing necessary care Other Cost-Controlling Programs Utilization review Quality management Critical pathways and care maps Pay for performance (P4P)

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Care and the US Government U.S. Department of Health, Education, and Welfare –Department of health and human services –Department of education DHHS –CDC prevents and controls disease, injury, and disability. FDA –Foods, medicines, and cosmetics

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Care and the US Government (cont.) HRSA –Leadership in planning and delivery of health services NIH –Institutes and centers engaged in research IHS –Native American, Indians, and Alaskan CMS –Administered Medicare, Medicaid, SCHIP, HIPAA

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins State and Local Health Departments Administer insurance programs Licensing Educational materials and information Report communicable disease data to CDC Keep vital statistics Manage sanitation Provide safe water supply Provide child and school health services

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Private Organizations that Support the Health Care System Contribute to the health of our society Receive funding through fund drives, individual contributions, business and corporate gifts, and donations –Support research and treatment –People-to-people programs

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Issues and Concerns The Patient Protection and Affordable Care Act—2010 Health Care System –Difficult to navigate Health Care Providers –Shortage of primary care providers –Future role of multipurpose worker Health Care Facilities –Financial challenges

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Issues and Concerns (cont.) Health Care Services –Equal access to health care services for all citizens Health Care Approval, Accreditation, and Standards of Excellence –Cost of accreditation –Cost and maintenance of standards of excellence certificate

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Issues and Concerns (cont.) Health Care Financing Increased number of elderly Medicare costs Expensive treatments Cost of finding cures Lawsuit settlements Investments for advances in technology Cost of creating electronic health records

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Health care services include prevention, diagnosis, and treatment of illness as well and the actual delivery of health care.

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True Rationale: Health care service is a term used to describe the actual delivery of health care by health care workers. Health care service includes the prevention, diagnosis, and treatment of illnesses. It also includes providing care during an illness.

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Cost-controlling measures include: A.Managed care plans B.Utilization review C.Fee-for-service D.Medicare

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Utilization review Rationale: Managed care is a form of private insurance. Fee-for-service is a form of private insurance. Medicare is a form of government insurance.

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Question State and local health departments are responsible for: A.Foods, medicines, and cosmetics B.Engaging in research C.Reporting communicable disease data to CDC D.Administering Medicare and Medicaid

Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Reporting communicable disease data to CDC Rationale: A, B, and D are responsibilities of the U.S. government. The FDA is responsible for foods, medicines, and cosmetics. The NIH is responsible for research. Medicare and Medicaid are administered by the US government.