Understanding Health Care Systems 2 Understanding Health Care Systems Section 2.1 Health Care Providers Section 2.2 Health Care Systems

Section 2.1: Health Care Providers

Vocabulary Key Terms Facilities Diagnostic Chronic Psychiatric Geriatric Convalescence Ambulatory Prosthetics communicable endowments Managed care obstetrics Therapeutic Maternal Podiatry Outpatient

Objectives Research a volunteer agency Define managed care and ambulatory care Understand the role of government agencies in providing healthcare Six types of outpatient care and the type of treatments Define wellness and preventive care Be able to use and read an organizational chart Explain chain of command Know major healthcare services Know departments in each major service

Types of care What experiences have you had at different types of providers?

Health Care Providers Business organizations some are for profit some are non profit Name a business organization. Is it for profit or nonprofit, sole proprietor, owned by shareholders or public/private?

Types of Health Care Providers There are several facilities and agencies that provide medical care. General hospitals do not specialize in any one type of medical treatment; they provide a wide range of diagnostic, medical, surgical, and emergency care services. Specialty hospitals provide inpatient continuity of care for clients with persistent, recurring diseases or complex medical conditions that require long-term stays (often over a month) in an acute care environment. Section 2.1: Health Care Providers

Types of Health Care Providers, continued Convalescent care (e.g., nursing home, long-term care) facilities generally engage in geriatric care—care for elderly people needing nursing services and assistance with personal care and daily living activities. Extended care facilities are designed to care for those who need assistance with activities of daily living or with medical needs. For older individuals with an active lifestyle, independent living offers the opportunity to remain independent in a home of their own that’s typically located on a campus with health care professionals on staff and facilities/activities designed specifically for older individuals. Section 2.1: Health Care Providers

Types of Health Care Providers, continued Assisted living bridges the gap between independent living and extended care or nursing homes. Ambulatory care/clinics offer medical care—including diagnosis, observation, treatment, and rehabilitation—that does not require an overnight admission to a hospital or other health care facility. Physician and dental facilities provide care that promotes wellness and diagnosis of illness. Rehabilitation centers provide outpatient care for clients who require physical or occupational therapy, recreational therapy, hydrotherapy, and other therapies (such as speech or hearing therapy) for loss of function in mobility or the activities of daily living. Section 2.1: Health Care Providers

Types of Health Care Providers, continued Industrial health care centers are located in large companies and industrial facilities. School health services are found in educational institutions. Health maintenance organizations (HMOs) are a type of managed care organization. Essential community providers (ECPs) provide services to predominately low-income, medically under-served individuals. Home health care agencies provide care in the home for patients/clients who need health services but not hospitalization. Section 2.1: Health Care Providers

Types of Health Care Providers, continued Tele-health care offers medical services through the use of electronic information and telecommunications technologies. Senior day care provides for elderly people who are able to live at home with their families but need care when the family is away. Hospices provide end-of-life care to those patients expected to live six months or less. Section 2.1: Health Care Providers

Section 2.1: Health Care Providers Government Agencies In the United States, the federal, state, and local governments provide health services; these services are funded by taxes. The World Health Organization (WHO) is concerned with world health problems and publishes health information, compiles statistics, and investigates serious health problems. Veterans Administration hospitals are federally supported and provide care for veterans who served in the armed forces. The U.S. Public Health Service is a federal agency whose mission is to protect, promote, and advance the health and safety of the nation. Section 2.1: Health Care Providers

Government Agencies, continued State psychiatric hospitals serve the mentally ill. State university medical centers provide training for health workers, give medical care, and conduct medical research. State public health services provide health education materials. The U.S. Department of Health and Human Services (USDHHS) protects the health of all Americans by providing vital human services, especially to those least able to help themselves. The National Institute of Health (NIH) is the world’s leading agency for conducting and supporting medical research. Section 2.1: Health Care Providers

Government Agencies, continued The Centers for Disease Control and Prevention (CDC) monitors and works to prevent disease outbreaks, including influenza, Ebola, and bioterrorism. The Food and Drug Administration (FDA) assures the safety of foods, cosmetics, pharmaceuticals, biological products, and medical devices. The Occupational Safety and Health Administration (OSHA) imposes safety and health legislation to prevent injury, illness, and death in the workplace. The Agency for Healthcare Research and Quality (AHRQ) works to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Section 2.1: Health Care Providers

Government Agencies, continued County hospitals provide care for the ill and injured, especially those patients/clients who require financial help in order to receive care. A laboratory is a facility (which may be a government or private facility) that provides controlled conditions in which scientific research, experiments, and measurements can be performed. Local public health departments provide services to local communities—focusing on the reporting of communicable diseases, public health nursing, health education, environmental sanitation, maternal and child health services, and public health clinics. Section 2.1: Health Care Providers

Government Agencies, continued Senior centers have clinics that provide special services for geriatric patients (e.g., podiatry clinic, hypertension clinic, general medical care). Hhs.gov Nih.gov Cdc.gov Fda.gov Section 2.1: Health Care Providers

Not-for-Profit Agencies Not-for-profit, organizations receive support from donations, gifts, membership fees, fundraisers, and endowments. They are not supported by the government, and many of the people who work for them are not paid. They raise funds for medical research and for public education about various health problems. Many of them focus on a particular disease or medical condition. Section 2.1: Health Care Providers

List of some Non Profits American Cancer Society March of Dimes American Red Cross American Heart Association American Diabetes Association National Alliance on Mental Health National Association of People with AIDS National Coalition Against Domestic Violence American Lung Association

Managed Care: Quality Care and Managed Costs Managed care is a system of health care in which patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by a managing company, such as an HMO, another type of doctor/hospital network, or an insurance company. Preventive care, such as routine physicals, well-baby care, immunizations, screenings for patients with specific risk factors, and wellness education, helps keep patients healthy. Section 2.1: Health Care Providers

Managed Care: Quality Care and Managed Costs, continued Primary care providers may include family and general practice physicians, internists, nurse practitioners, and physician’s assistants. Specialty care is care given by a provider who is trained in one special area. Emergency care is for life-threatening conditions that require hospitalization. Urgent care is for non-emergencies that require prompt treatment. Ambulatory care provides a variety of medical services on an outpatient basis. Section 2.1: Health Care Providers

Section 2.1: Health Care Providers Organization An efficient health care facility must be well organized. The most common organizational structure for health care organizations is a pyramid-shaped hierarchy, which defines the functions it carries out. Most health care organizations utilize an organizational chart that identifies the key management and supervisory positions assigned to its various functions. An organizational chart establishes a chain of command that helps to ensure communication among relevant parties and facilitates problem-solving. Section 2.1: Health Care Providers

Health Care Regulatory Agencies State and federal regulatory agencies for the health care industry set standards for health care, keep health care workers informed, and monitor facilities’ and workers’ compliance with laws that pertain to health care. As a health care worker, one of your first encounters with a health care regulatory agency will be for licensure. Based on your chosen profession, you will need to meet specific requirements set forth by the federal or state board that regulates that profession. Section 2.1: Health Care Providers

2.2 Health Care Systems Section 2.2: Health Care Systems

Section 2.2: Health Care Systems Health Care Reform Health care reform has been—and continues to be—a hot topic on our nation’s political, economic, and social agendas. The Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA), was signed into law in March 2010. The ACA requires most U.S. citizens and legal residents to have health insurance coverage or else pay a per month fee. The ACA created a “marketplace” for subsidized plans that provide individuals, families, and small businesses with free or low-cost health insurance coverage. Section 2.2: Health Care Systems

Quality Health Care Costs: Cost Containment The high cost of health care has drawn much attention in recent years. Technological advances in the medical field, an aging population, and health-related lawsuits have all been factors in driving up the price of medical care and services offered by health care systems. The federal government passed legislation in 1983 to regulate the price of medical care. This legislation approved the grouping of medical conditions, the reasonable cost for each condition, and its standard treatment; these groupings are known as diagnostic-related groupings (DRGs). Section 2.2: Health Care Systems

Section 2.2: Health Care Systems Quality Health Care Costs: Measuring the Performance of Care and Service The Healthcare Effectiveness Data and Information Set (HEDIS) was developed to establish guidelines on the quality of health care given in this country. HEDIS is a tool used by more than 90 percent of the country’s health plans to measure performance on important aspects of care and service: Measure health plan performance Identify physicians and other providers who give high-quality medical care to their patients/clients Identify physicians and other providers who do not meet the quality care guidelines Section 2.2: Health Care Systems

Quality Health Care Costs: Health Care Payments Insurance plans are called third-party payers. Insurance companies require the subscriber to pay a fee for insurance coverage and in return agree to pay for specific medical care. Each insurance company determines what it will and will not pay for and how much it will pay. Many third-party payers require a co-payment. Most insurance companies also have a deductible, an amount the subscriber must pay before the insurance begins to pay. Section 2.2: Health Care Systems

Section 2.2: Health Care Systems Quality Health Care Costs: Health Maintenance Organizations/Preferred Provider Organizations Health maintenance organizations (HMOs) require members to pay a co-payment, or co-pay, for medical services. Physician groups and hospitals work together to give comprehensive health care at a reduced cost to various large companies and corporations. Employees of these companies contract with a preferred provider organization (PPO) and agree to see providers on the PPO list. Section 2.2: Health Care Systems

Quality Health Care Costs: Medicaid/Medicare Medicaid is a health insurance program provided by the state and federal government for low-income Americans. Medicare is a health insurance program provided by the federal government to people over the age of 65. Subscribers pay a monthly payment to the Social Security Administration. Medicare consists of two parts. Part A covers in-patient care at hospitals, hospice care, and home health care. Part B helps cover medical services like doctors’ services, outpatient care, and other medical services that Part A does not cover. Section 2.2: Health Care Systems

Quality Health Care Costs: TRICARE/Workers’ Compensation TRICARE is a health care program for active duty service members, retirees, and their families. One part of TRICARE is called TFL (TRICARE for Life). This medical care is for Medicare-eligible uniformed services retirees age 65 or older. Workers’ compensation is a state-mandated insurance program that provides compensation to employees who suffer job-related injuries and illnesses. Benefits include payment for lost wages and payment of medical bills. Section 2.2: Health Care Systems