1. Chapter 2
HEALTH CARE SYSTEMS

2. 2:1 Private Health Care Facilities
Today’s healthcare system include the many agencies, facilities and personnel involved in the delivery of heath care.
Growth—one of the largest and fastest growing industries in the United States
Employment opportunities—employs over 13 million workers in over 200 careers
Wide range of ed. Backgrounds because of various career options
Expenditures—it is a four-billion-dollar- per-day business and growing
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3. Private Health Care Facilities (continued)
Most PHF require fee for services. In some cases, grants and donations provide financial support.
Hospitals
Long-term care facilities (LTC or LTCF)
Independent living and assisted living

4. Medical offices- diagnosis, treatment, examination, basic lab testing
Medical offices- diagnosis, treatment, examination, basic lab testing. Vary from offices that are privately owned or large complexes.
Dental offices
Clinics or satellite centers
Optical centers

5. Private Health Care Facilities (continued)
Emergency care services
Laboratories-Special diagnostic test
Home health care-provide care in patients home
Hospice agencies-care far terminally ill
Mental health facilities
Genetic counseling centers
Rehabilitation facilities
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6. Private Health Care Facilities (continued)
Health maintenance organizations (HMOs)
Provide preventative healthcare
Types of health insurance
Industrial health care centers or occupational health clinics
School health services

7. 2:2 Government Agencies
Government healthcare facilities are offered at international, national, state, local levels
Government services are tax supported
World Health Organization (WHO)
International level
Compiles info of stats and info on disease
Investigates and addresses serious health problems throughout the world
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8. 2:2 Government Agencies cont.
U.S. Department of Health and Human Services (USDHHS)
National
Agency that deals with the health problems in the U.S.
National Institutes of Health (NIH)
Division of the USDHHS involved in research on disease
Centers for Disease Control and Prevention (CDC)
Another division of the USDHHS
Concerned with causes, spread, and control of diseases in populations

9. Government Agencies (continued)
Food and Drug Administration (FDA)
Federal Agency responsible for regulating food and drug products sold to the public
Agency for Health Care Policy and Research (AHCPR)
Federal agency to research the quality of health care delivery
Identify and establishes the standards of treatment by a health care facility

10. Government Agencies (continued)
Occupational Safety and Health Administration (OSHA)- establishes and enforces standards that protect workers from job related injuries and illnesses
Health Departments
Provide health services directed by the USDHHS
Provide services needed by the state or local community
Ex. of services include
Immunization for disease control
Health inspections
Stats related to health
Clinics for health care and prevention

11. 2:3 Voluntary or Nonprofit Agencies
Supported by donations, membership fees, fundraisers and grants
Health services are provided at various levels
Organizations focus on specific diseases
Study the disease
Provide funding for research
Promotes public education
Provide special services
Purchase medical equipment- for victims of disease
Treatment centers
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12. Voluntary or Nonprofit Agencies (continued)
Staffed by many health care workers
and volunteers
Examples include the American Cancer Society, March of Dimes, American Red Cross and many more

13. 2:4 Health Insurance Plans
Nearly every industrialized country has a national health care system.
Some countries have public or national health care systems, and other countries have private health care
How Does the U.S. Compare with Other Countries?

14. We provide the same medical care
We use the same medical technology
But…
We have large numbers of uninsured
We spend much more
We remain the only major country that builds its health care system around private for-profit insurance companies.

15. Public / National Health Care System
Mainly funded by taxes and social security insurance.
• Advantage – Every citizen is guaranteed health care regardless of economic status.
Disadvantages – Health care is not always comprehensive, and taxes may be higher.
Norway, France, the United Kingdom, and Canada

16. Private Health Care Systems
Mainly funded by private insurance agencies and out-of-pocket payments.
Advantages – Coverage is often comprehensive (covers a wide range of services, taxes may be lower, and economic growth is stimulated.
Disadvantage – Not every citizen is guaranteed health care.
United States and Switzerland

17. 2:4 Health Insurance Plans
Health care costs are rising faster than other costs of living (more than 15% of gross national product/ goods and services)
To pay for the cost of healthcare people rely on health insurance plans
Offered by thousands of insurance agencies ex. Blue Cross Blue Shield
Employer sponsored health insurance
Without insurance, the cost of an illness can become a financial disaster

18. Insurance Terminology
Premium- a fee an individual pays for insurance coverage
Deductible- Amounts that must be paid by the patient for medical services before the policy begins to pay
Co-insurance-requires that specific percentages of expenses are shared by the patient and insurance company
Ex percent co-insurance
Co-payment- a specific amount of money a patient pays for a particular service
Out-of-Pocket- a medical bill that must be paid by the patient

19. THE COST OF CARE CREATES HEALTH PROBLEMS AS WELL AS FINANCIAL PROBLEMS
In nearly 3 in 10 (29%) households, someone skips a medical treatment, cuts pills, or does not fill a prescription because of cost
Nearly 1 out of 4 (23%) Americans have problems paying medical bills
More than 1 in 5 (21%) Americans had an overdue medical bill at the time of a 2004 survey
1 million people experience medical bankruptcy each year Health Care Costs Survey, USA Today/Kaiser Family Foundation/Harvard School of Public Health, August 2005; D. Himmelstein et al, Health Affairs, 2005
Many people still believe that people without health insurance get the care they need. Its just not true.

20. Managed Care
Managed care plans are a type of health insurance. They have contracts with health care providers and medical facilities to provide care for members at reduced costs.
Managed care plans usually offer a lower premium and require less paperwork.
There are three types of managed care programs
Health Maintenance Organizations (HMO’s)
Preferred Provider Organizations (PPO’s)
Point of Service

21. HIGH COST OF HEALTH INSURANCE PREMIUMS
National Average for Employer-provided Insurance
Single Coverage $4,024 per year
Family Coverage $10,880 per year
Note: Annual income at minimum wage = $10,300
Annual income of average Wal-Mart worker = $17,114
Source: Kaiser Family Foundation/HRET Survey, 2005

22. Types of Plans Health maintenance organization (HMO)
Access to doctors, hospitals in network. (providers that agreed to lower rates for plan members)
Cover routine examinations and preventative care (unlike other insurance companies)
Premiums are generally lower for HMO plans, and there is usually no deductible or a low one.
Disadvantage: required to only use HMO-affiliated healthcare providers
Must pay out of pocket if a non-affiliated provider is used
Need a referral from a doctor
More restrictions for coverage than other plans
# of visits, tests, or treatments
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23. Types of plans cont. Preferred Provider Organization (PPOs)
Usually provided by large industries or companies to their employees
PPO’s forms a contract with various healthcare agencies (hospitals/ doctors etc.) to provide healthcare at a reduced rate
PPO’s require a premium, deductible and a co-payment
Provides flexibility
Picking doctors or hospitals
Less restrictions on seeing non-network providers

24. Benefits of PPO’s cont.
You can see the doctor or specialist you’d like without having to see a PCP first.
You can see a doctor or go to a hospital outside the network and you may be covered.
However, your benefits will be better if you stay in the PPO network.
Premiums tend to be higher, and it’s common for there to be a deductible.

25. Point of Service (POS) Plan
Similar to HMO’s
Clients must pay a premium.
Clients must choose a primary care physician.
For in-network physicians, there is usually no deductible and co-payments are low.
Specialists may be non-network physicians, but coverage may be limited
These plans let you choose between an HMO or a PPO each time you need care.

26. Government Programs
In the 20th century, the United States government began to realize the need for public medical assistance.
In 1965, President Lyndon B. Johnson instituted two medical assistance programs to help those without health insurance.
o Medicaid
o Medicare

27. Medicaid Income or needs based program (blind/ disabled)
Designed by the federal government, but administered by state governments
Usually includes individuals with low incomes, pregnant women, children (of low income), and individuals who are blind or physically disabled.
Florida
Not eligible if:
Able bodied
No dependents
Regardless of income

28. How to qualify for Medicaid
Almost every state has multiple Medicaid programs. But, as a good rule of thumb, if you make less than 100% to 200% of the federal poverty level(FPL) and are pregnant, elderly, disabled, a parent/caretaker or a child, there’s likely a program for you.

29. FPL’s in 2018 Federal poverty levels in 2018 People in household
Poverty guideline 1
$12,140 2
$16,460 3
$20,780 4
$25,100 5
$29,420 6
$33,740 7
$38,060 8
$42,380
Over 8 people
Add $4,320 per extra person

30. How do I calculate my percentage of FPL?
Divide your income by the poverty guideline for your household size.
Carry the decimal two places in your result.
Add a percentage sign, and you have your answer.
Formula for % FPL
Income ÷ poverty guideline for household size = percentage of poverty guideline

31. Example 1
Example 1: You are a single individual with an income of $25,000. The 2018 poverty guideline for a one-person household is $12,140.
$25,000 ÷ $12,060 = 2.05
2.05 x 100 = 205
Rounding up, you’re at 205% of the federal poverty guidelines
Do you qualify for Medicaid?

32. Example 2
You are married with three kids, and your household’s annual income is $150,000. The 2018 poverty guideline for a five-person family or household is $29,420.17
$150,000 ÷ $29,420 = 5.09
5.09 x 100 = 509
Rounding up, you are at 509 percent of the federal poverty guidelines 

33. Government Insurance Plans
Medicare
Medicaid
Medigap

34. Types of Plans (continued)
The State Children’s Health Insurance Program (SCHIP)
Worker’s Compensation
U.S. government plans for all military personnel and their families
Managed care plans

35. HIPAA Five components Health care access Preventing health care fraud
Tax-related health provisions
Application and enforcement of group health plan requirements
Revenue offsets

36. 2:5 Organizational Structure
Line of authority or chain of command
Indicates areas of responsibility
Goal: most efficient operation of facility
Complex or simple structure determined by size and needs of organization
Sample organizational charts (See Figure 2-4 and 2-5 in text)
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37. Organizational Structure (continued)
The line of authority must be clearly indicated in any organizational structure
Workers must identify and understand their position in the structure
To follow proper channels of communication, workers must take problems, reports, and questions to their immediate supervisor