1. Chapter 7 The Health Care System

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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)

14. 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)

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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.

23. 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.

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

25. 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.

26. 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

27. 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.