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Health Care Delivery System
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Evolution of HCDS Early 20th Century – Prepaid medical plans –lumber and mining camps Nursing care still focused in homes 1920 – American hospitals offered “Baylor Plan” (later Blue Cross) – 1935 – Social Security - benefits for elderly, child welfare, training of healthcare personnel WWII – veteran healthcare benefits
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Focus moves to health maintenance
1960’s – Medicare and Medicaid health care services for elderly and indigent Nursing Training Act (physician and nurse shortage) Nurse Practitioners began Focus moves to health maintenance 1970’s – HMO Act – primary health care service for a predetermined fee Amendments to SS allow nurse practitioners to be paid directly for service Rural Health Clinic Service Act
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1980’s – Focus on Cost Control
“OBRA” – Omnibus Budget Reconciliation Act (peer review, quality, restraints, payment to midwives) DRG’s (Diagnosis Related Groups) HMO’s increase Technology proliferates AIDS discovered 1980’s – Focus on Cost Control – OBRA – Omnibus Budget Reconciliation Act (peer review, quality, restraints, payment to midwives) HMO’s increase Technology proliferates AIDS discovered
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1990’s – Medicaid and welfare program reforms: welfare to work
SCHIP – Children’s health insurance program UAP’s (unlicensed assistive personnel) 2000’s – More telemedicine utilization
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Primary – Health Promotion and Illness Prevention
Levels of Health Care Primary – Health Promotion and Illness Prevention Ideal level to enter the health care system Teaching, lifestyle modification, referrals, immunization, promote safe environment
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Secondary – Early detection, Diagnosis and Treatment
Screening, diagnosis Acute Care Surgery
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Tertiary – Restorative and Rehabilitation actviities– return to optimal functioning
Education and retraining Environmental modifications Provision of direct care
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Health Care Settings Hospitals – General and specialized Proprietary
Teaching and Research Public Voluntary
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Health Care Settings Ambulatory Services Outpatient departments
Physician group practices HMO’s Nursing Care Centers Community Health Clinics Indian Health Service Ambulatory Care Facilities (urgent care centers)
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Health Care Settings Long Term Care Facilities Residential care
Assisted Living Skilled Care Public Health Agencies Home Care Agencies Adult Day Care Wellness Centers Hospice Care – hospital, nursing home, free-standing hospice, home
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Health Care Team Guess the professional:
Has completed a 120 hour course in basic life support skills and passed a national test. Provides care in an emergency
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EMT ??? Has a minimum 2 year preparation and performs diagnostic measures involving radiant energy
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X-ray technician ??? A nurse who has studied an additional 2-3 years in an approved school or anesthesiology
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CRNA (Certified Registered Nurse Anesthetist)
???Graduate of a month program and passed a certifying exam - provides treatments for breathing
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Respiratory Therapist
???? Provides assistance for mobility and exercises – has completed a 2 year program
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PTA – Physical Therapy Assistant
??? Has completed 4-5 years of education plus an internship regarding nutritional problems and therapeutic diets
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Dietician ??? A graduate of a 4 year or more program who helps patients restore body function through specific tasks and skills related to activities they need to function in their daily lives
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Occupational Therapist
??? A professional who helps the patient solve problems with financial concerns, assist with obtaining services in the community after discharge and has completed a master’s degree.
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Social Worker (MSW)
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Financing Public Private Third Party
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Financing Health Care Fee for service – physician paid by patient for each service provided Capitation – set monthly fee charged by provider for each member of group for a specific set of services
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Fee for Service - Terminology
Premium Deductible Co-Payment Co-Insurance Health Care Provider
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Public Financing - Medicare
Part A – Hospital Insurance Provided free for those who have 40 or more quarters of Medicare-covered employment Deductible ($1024 in 2008) Coverage: Hospitalization Skilled Care rehabilitation service– 21 days plus 80 days with $124/day deductible May cover Home Health Services (co-insurance applies) Hospice Care
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Public Financing - Medicare
Part B – Medical Insurance (like major medical insurance plan) Funded by monthly fixed-rate premiums ($96.40/mo 2008) Pays 80% of approved charges Doctor’s services Outpatient hospital services Ambulance transportation Diagnostic tests, lab, mammography Physical , Occupational, Speech Therapy outpatient or in rehab agency NOT COVERED: prescription drugs, routine physicals, dental, cosmetic, foot care, hearing aids, vision
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Public Financing - Medicare
Part D – Prescription Drug Voluntary participation “Doughnut Hole” coverage Monthly premium based on plan chosen
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Diagnosis Related Groups (DRG)
A set fee is used , based on illness category, to determine hospital reimbursement Medicare and insurance Hospitals receive flat fee, regardless of length of stay Hospital makes money if they provide service for less than DRG amount Goal – care provided in most economical fashion possible Prospective-Payment system
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Public Financing - Medicaid
Medical assistance for low income and disabled State establishes services and requirements, including eligibility
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Health Care Financing – Managed Care
HMO – Health Maintenance Organization Prepaid fee paid to provider for comprehensive care of the enrollees Encourage preventative medicine Discourage excessive tests and treatments Patient may not have option of choosing physician each time treatment is needed Single point of entry
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Health Care Financing – Managed Care
Preferred Provider Organization (PPO) Insurance companies contract with groups (physicians and hospitals) for discounted fees Patient may see anyone in the network
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Health Care Financing – Managed Care
Open Access – individuals may see specialists within network without a referral Gatekeeper – usually primary physician – must give referral before patient can see specialist – goal is to keep costs down
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Issues US rankings by WHO
#1 – dignity, provider choice, confidentiality #37 – performance (outcomes vs expenditures) #54 – fairness in financing Hill, p. 317
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Issues Uninsured Uncompensated care Aging population
Cost of government health care programs Cost of prescription drugs Quality
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Issues Limited resources – how are they allocated, and to whom?
Private vs National Healthcare
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Nurses’ Response to HCDS Issues
Cost containment Quality Improvement Health, prevention focus NP’s providing care Education
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HCDS Issues in the Workplace
Use of UAPs Nurse/Patient Ratios Acuity levels Mandatory Overtime Unionization
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Assignment You are the self-employed head of household for a family of four. Your gross annual family income is $33, 280 (equivalent of $8/hr full time for 2 people). Research the cost of a family health insurance policy with a $500 deductible. What is the monthly and annual cost of this policy. What % of your annual income will be spent on health insurance?
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