Understanding Health Care Systems

Health Care Providers

It is the responsibility of every health care worker to help patients/clients solve their health problems. Since the health care industry has many delivery systems, it is important for future health care workers to be aware of health care agencies and facilities, their delivery systems, their organization, and some of their major services. When you understand how health care facilities and agencies serve the public, you will become a resource person for members of your community. Copyright (c) 2009 Pearson Education3

 Match key terms with their correct meanings.  Research a volunteer agency.  Define managed care.  Define ambulatory care.  Evaluate how managed care and ambulatory care meet the needs of the changing health care system.  Understand the role of government agencies in providing health care.  List six types of outpatient care and the type of treatment given. 4Copyright (c) 2009 Pearson Education

 Define wellness and preventive care.  Contrast the current trends with health care in the twentieth century.  Be able to use or read an organizational chart.  Give two reasons why the organization of health care facilities is important.  Explain a chain of command.  List and define the major services in health care.  Identify two departments in each major service. Copyright (c) 2009 Pearson Education5

 General hospitals  Patients stay for a short period of time  Specialty hospitals  Provide longer term care for those with complex or chronic conditions  Convalescent care  Geriatric care or long-term convalescence  Nursing homes  Residences for those who require constant care  Physician and dental facilities Copyright (c) 2009 Pearson Education6

 Rehabilitation centers  Outpatient care for physical or occupational therapies  Industrial health care centers  School health services  Health Maintenance Organizations (HMOs)  Home health care agencies  Senior day care  World Health Organization (WHO)  Hospices  End-of-life care for terminally ill patients (life expectancy is 6 months or less) Copyright (c) 2009 Pearson Education7

 Veteran’s Administration hospitals  U.S. Public Health Department  State psychiatric hospitals  State university medical centers  State public health services  U.S. Department of Health and Human Services (USDHHS)  National Institute of Health (NIC)  Centers for Disease Control (CDC) Copyright (c) 2009 Pearson Education8

 Food and Drug Administration (FDA)  Occupational and Safety Health Administration (OSHA)  Agency for Health Care Policy and Research (AHCPR)  County hospitals  Laboratories  May be government or private facilities  Local public health departments  Senior centers Copyright (c) 2009 Pearson Education9

 Receive money from donations, endowments, membership and fundraising efforts  Use funds for research and public education  Often support a specific disease or medical condition, such as:  American Cancer Society  National Foundation of the March of Dimes  American Red Cross  American Heart Association  …and many others Copyright (c) 2009 Pearson Education10

 Goal is to provide quality care at reasonable costs  Policies include:  Focus on preventive care, such as routine physicals and well-baby care  Use of primary care providers─the “family doctor”─as first contact in undiagnosed illness  Can refer patients to specialist, as needed  Use of emergency and urgent care facilities  Require preadmission authorization requirement for hospitalization Copyright (c) 2009 Pearson Education11

 Part of trend to provide managed care  Uses non-hospital facilities for care, whenever possible, including:  Rehabilitation centers  Outpatient surgery  Outpatient medical centers/clinics  Physicians’ offices  Day care Copyright (c) 2009 Pearson Education12

 Efficient health care centers are well organized  Organization chart:  shows how each department fits into the system  Identifies the line of authority  Chain of command is critical  Tells you to take questions and problems to your immediate supervisor  Provides efficient problem-solving structure Copyright (c) 2009 Pearson Education13

 Therapeutic services  Provide care over time  Diagnostic services  Such as x-rays or blood tests  Used to identify a particular condition or illness  Informational services  Document and process information  Environmental services  Help to create a relaxing and healing environment for patients Copyright (c) 2009 Pearson Education14

 ambulatory  audiology  chiropractic  chronic  communicable  convalescence  diagnostic  endowments  environmental sanitation  facilities  geriatric  hydroptherapy  hypertension  immunizations  licensing  managed care  maternal  obstetrics  occupational therapy orthopedics Copyright (c) 2009 Pearson Education15

 outpatients  podiatry  prosthetics  psychiatric  radiology  recreational therapy  refer  rehabilitation  specialties  surgical  therapeutic  trend  urology Copyright (c) 2009 Pearson Education16

Health Care Systems

The cost of health care has increased significantly over the years. It is important to understand the causes for the increase as well as methods providers use to help contain the costs. Every health care worker should also know the health care systems that help patients/clients afford the services they need. When patients/clients receive regular and complete care, they live healthier and happier lives. Copyright (c) 2009 Pearson Education18

 Match key terms with their correct meanings.  Explain how health care providers have modified their practices to provide patients quality health care at a lower cost.  Explain the purpose of the Health Plan Employer Data and Information Set.  Identify and differentiate the various health care systems.  Compare and contrast health maintenance organizations and preferred provider organizations.  Analyze and predict where and how certain factors such as cost, managed care, technology, an aging population, etc. may affect various health care delivery system models. Copyright (c) 2009 Pearson Education19

 Costs driven up by:  Technological advances  Health-related lawsuits  Aging population  New equipment  Cost containment:  Government legislation passed in 1983 to regulate health costs ▪Developed DRGs ― Diagnostic-related groupings ― with standard treatment and reasonable costs for each Copyright (c) 2009 Pearson Education20

 Health Plan Employer Data Information Set (HEDIS) provides guidelines and a report card that:  Measures health care performance  Identifies physicians who provide high quality medical care to their patients  Helps to identify physicians who do not meet health care guidelines Copyright (c) 2009 Pearson Education21

 Health insurance ― third party payers  Each insurer determines how much it will pay for specific services ▪Co-payments ▪Deductibles ▪Co-insurance  HMOs―must use a member physician or service provider and pay a co-pay  PPO―physicians and hospitals that band together to provide lower cost services to various large companies Copyright (c) 2009 Pearson Education22

 Medicaid  Provided by state and federal government to disabled and low income people  Medicare  Health insurance for those over 65  TRICARE  Health care for active duty service members, retirees, and their families  Workers’ Compensation  Employees who are injured, have workplace-related illness or die covered by state worker’s compensation Copyright (c) 2009 Pearson Education23

 Because of increasing number of uninsured people, a national health plan is under discussion  Goal is to provide good, comprehensive health care to everyone  Emphasis on preventive care, immunizations, education and behavior modification (such as stopping smoking) Copyright (c) 2009 Pearson Education24

 benefits  bulk  co-insurance  compensation  co-payment  deductible  eligibility  intervention  lawsuits  legislations  premium  preventative  systems Copyright (c) 2009 Pearson Education25