1 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 6 Health Care

2 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. The Progression of Payment for Health Care  Up until the late 19 th Century – Care was provided in the home  Early 20 th century - People paid for services in hospitals  Mid 20 th century – Medicare and private insurance companies entered the health care arena  By the late 20 th century – costs had risen exponentially and insurance companies began to look for more cost effective ways to pay for health care

3 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Factors That Influence the Financial Burden of Health Care in the United States  Demographic influences  Uninsured individuals  Medical technology

4 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Health Insurance Plans Private health care payment sources  Private insurance  Point of service plans

5 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

6 Health Insurance Plans U.S. Government Insurance Plans  Medicaid  State Children’s Health Insurance Program (SCHIP)  Medicare

7 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Medicare  The U.S. government’s largest health care financing program  Administered by the Social Security Administration  Covers elderly and disabled people

8 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Medicare (Cont’d)  Part A – Hospital Insurance  Pays for hospital stays  Pays for skilled nursing facility for up to 100 days (not for custodial or long-term care)

9 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Medicare (Cont’d)  Part B – Medical Insurance  Physician  Nursing services (home care for specific skilled need)  X-rays, lab work, diagnostic tests  Ambulance transport (limited)  Flu and pneumonia vaccines  Dialysis  Medications for organ transplant recipients  Chemotherapy  Durable medical equipment (DME)  Prosthesis  Oxygen

10 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Medicare (Cont’d) Part C – Medicare Advantage Plans  In order to reduce costs, Medicare participants were given the opportunity to select a Medicare plan through a private insurance company. These are also known as Medicare+Choice plans.  These plans are similar to private insurance plans where referrals are required to see specialists and pre-authorizations are required for procedures.

11 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Medicare (Cont’d) Part D – Prescription Drug Plans  Began January 1, 2006  Anyone using Part A and Part B coverage is eligible for Part D, but they must enroll in a stand-alone prescription drug plan.  Anyone enrolled in a Medicare Advantage Plan will enroll in a Medicare Advantage+Prescription Drug Plan.  Each Prescription Drug Plan chooses which drugs they choose to cover and at what payment tier they wish to cover.  It is up to the insured to look over all of the plans to see which plan covers the biggest portion of the drugs they use.

12 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Medicare (Cont’d) Hospice  Additional coverage for Medicare recipients during the last 6 months of life  Provides home care (on a 24-hour basis if needed)  Palliative management of pain  24-hour interdisciplinary team  Volunteers  Bereavement care to survivors after the death

13 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

14 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

15 Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Health Care Is Rapidly Changing  Many changes in past 10 years  Nurse works with the case manager to advocate for the care the patient needs  Sadly, the reimbursement method often dictates much of the care available to the patient