Chapter 7 The Health Care System

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

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

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

The Health Care System (cont.) Health Care Facilities (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

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

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

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

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

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

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

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

Health Care Financing Private Insurance Government Insurance Fee-for-service (indemnity) Prepaid (managed care plans) Government Insurance Social Security Act of 1965 Medicare Medicaid SCHIP (1997)

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)

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

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

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

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

Issues and Concerns Health Care System Health Care Providers 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

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

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

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.

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.

Question Cost-controlling measures include: Managed care plans Utilization review Fee-for-service Medicare

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.

Question State and local health departments are responsible for: Foods, medicines, and cosmetics Engaging in research Reporting communicable disease data to CDC Administering Medicare and Medicaid

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.