health care delivery system. evolution of hcds early 20 th century – prepaid medical plans...

Health Care Delivery System

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

• 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

• 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

• 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

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

Secondary – Early detection, Diagnosis and Treatment

• Screening, diagnosis• Acute Care• Surgery

Tertiary – Restorative and Rehabilitation actviities– return to optimal functioning

• Education and retraining• Environmental modifications• Provision of direct care

Health Care Settings

• Hospitals – General and specialized Proprietary Teaching and Research Public Voluntary

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)

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

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

• EMT

• ??? Has a minimum 2 year preparation and performs diagnostic measures involving radiant energy

• X-ray technician

• ??? A nurse who has studied an additional 2-3 years in an approved school or anesthesiology

• CRNA (Certified Registered Nurse Anesthetist)

• ???Graduate of a 12-18 month program and passed a certifying exam - provides treatments for breathing

• Respiratory Therapist

• ???? Provides assistance for mobility and exercises – has completed a 2 year program

• PTA – Physical Therapy Assistant

• ??? Has completed 4-5 years of education plus an internship regarding nutritional problems and therapeutic diets

• 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

• 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.

• Social Worker (MSW)

Financing

• Public• Private• Third Party

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

Fee for Service - Terminology

• Premium• Deductible• Co-Payment• Co-Insurance• Health Care Provider

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

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 agencyNOT COVERED: prescription drugs, routine

physicals, dental, cosmetic, foot care, hearing aids, vision

Public Financing - Medicare

• Part D – Prescription Drug• Voluntary participation• “Doughnut Hole” coverage• Monthly premium based on plan

chosen

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

Public Financing - Medicaid

• Medical assistance for low income and disabled

• State establishes services and requirements, including eligibility

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

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

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

Issues

• US rankings by WHO• #1 – dignity, provider choice,

confidentiality• #37 – performance (outcomes vs

expenditures)• #54 – fairness in financing

Hill, p. 317

Issues

• Uninsured• Uncompensated care• Aging population• Cost of government health care

programs• Cost of prescription drugs• Quality

Issues

• Limited resources – how are they allocated, and to whom?

• Private vs National Healthcare

Nurses’ Response to HCDS Issues

• Cost containment• Quality Improvement

• Health, prevention focus• NP’s providing care• Education

HCDS Issues in the Workplace

• Use of UAPs• Nurse/Patient Ratios

• Acuity levels• Mandatory Overtime• Unionization

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?