Unit 1

Health Care Systems

Pages 2 – 18

Introduction

Health care is one of the largest and fastest-growing industry in the US

Expenditures – it is a two billion dollar per day business and growing

Over 12 million health care workers in US 80% of health care work force are women

*Data from obtained from CDC

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1.1 Health Care Facilities

Many different types of facilities Employ many types of health care workers Individual facilities can vary in:

– Size (individual doctor or complex of doctors facility for a community or for a county, etc)

– Service provided (general or specific to disease, age, gender)

– Sources of income (public, private, religious, nonprofit, government)

Important to be aware of facilities and type of services

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Types of Health Care Facilities Hospitals Long-term care facilities Medical offices Dental offices Clinics Optical centers Emergency care services Laboratories Home health care Hospice agencies Mental health facilities

Rehabilitation facilities Genetic counseling centers Health Maintenance Organizations Industrial health care centers School health services Government agencies World Health Organization U.S. Department of Health and

Human Services Occupational Safety and Health

Administration Voluntary and nonprofit agencies

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Health Care Facilities

HOSPITALS– One of the major types of facilites– Most hospitals are general hospitals that treat

a wide range of conditions– Specialty hospitals include:

• Burn, oncology, pediatric, psychiatric, orthopedic, rehabilitative, government

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Health Care Facilities LONG-TERM CARE FACILITIES (LTCs)

– Patients live at facility and are known as residents• May care for elderly, disabled patients, individuals with

chronic or long-term illnesses– Extended Care Facilities – rehabilitative care to prepare

patients to return home– Subacute Units – rehabilitative care for patients recovering

from major illness, intensive medical treatments or surgery– Independent Living – residents can care for themselves,

but live in the facility. The facility provides residents with food, housekeeping, transportation and basic medical care

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Health Care Facilities MEDICAL OFFICE

– Can offer a variety of services:• Diagnosis, treatment, exams, lab tests, minor surgery

CLINICS– Usually a group of doctors that share a facility and personnel– Many hospitals have outpatient clinics

EMERGENCY CARE SERVICES– Special care for victims of accidents, sudden illness or

patients without a general physician LABORATORIES

– Often part of other facilities, but occasionally a separate facility

– Run blood tests, urine tests, can prepare dentures, etc

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Health Care Facilities HOME HEALTH CARE

– Provide care in patient’s home– Usually used by elderly or disabled patients

HOSPICE– Provides care for terminally ill patients with a life expectancy

of less than 6 months MENTAL HEALTH FACILITIES

– Treat patients with mental disorders and diseases• Counseling center, psychiatric hospitals, abuse treatment

centers REHABILITATION

– Can be found in hospitals, clinics or a private center– Can be inpatient or outpatient

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Health Care Facilities GENETIC COUNSELING

– Provides individuals or perspective parents information on their genetic background and disposition to passing on genetic disorders

• If an individual or couple has a certain likelihood of being a carrier for a disorder, a blood test will be recommended to screen for a particular gene

HEALTH MAINTENANCE ORGANIZATIONS (HMOs)– Provide total health care directed towards preventative health

care INDUSTRIAL HEALTH CARE CENTER

– Occupational health clinics, found in large companies to provide health care for the employees

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Health Care Facilities SCHOOL HEALTH SERVICES

– Provides students with emergency treatment as well as health education and counseling

GOVERNMENT AGENCIES– Provides facilities for government personnel and their

dependents• Hospitals, psychiatric treatment, rehabilitation, etc

– WORLD HEALTH ORGANIZATION (WHO)• Sponsored by the United Nations• Addresses and studies health problems throughout the

world

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Health Care Facilities U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

(DHHS)– National agency that deals with US health problems– NATIONAL INSTITUTE OF HEALTH (NIH) - Researches

diseases

– CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) – studies causes, spread and control of diseases in the population

– FOOD AND DRUG ADMINISTRATION (FDA) – regulates food and drugs sold to the public

– OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (OSHA) – establishes and enforces job safety standards

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Health Care Facilities NONPROFIT

– Also known as voluntary agencies– Supported by donations, grants, fundraising, etc– Usually focuses on one type of disease

• American Cancer Society• American Red Cross• March of Dimes

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1:4 Health Insurance Plans

Health care costs are rising faster than other costs of living

Most people rely on health insurance plans to pay for health care costs

Without insurance, the cost of an illness can become a financial disaster

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Insurance Terminology You Should Know:

Deductible Co-insurance Co-payment Preferred provider Monthly fee or premium Managed care

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Types of Services

Inpatient services (e.g., hospitals, long-term care)

Outpatient services (e.g., clinics, provider offices)

Specialty services (e.g., laboratories, mental health)

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Types of Plans

Health insurance plans Health maintenance organizations (HMO) Preferred provider organizations (PPO) Medicare Medicaid Worker’s Compensation Managed Care

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Types of Plans HEALTH INSURANCE PLAN

– Insurance company pays for some or all of services (depends on plan, deductible, out-of-pocket expense, etc.)

HEALTH MAINTENANCE ORGANIZATIONS (HMO)– Person pays a monthly fee for the membership– Plan covers regular exams and check-ups

PREFERRED PROVIDER ORGANIZATIONS (PPO)– Provided to employees by their company– The company works with certain health care agencies to

provide the employees with health care at a reduced rate– Employees can only go to the selected agencies

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Types of Plans MEDICARE

– Insurance provided by the government to people over 65 or disabled persons on Social Security

– Type A coverage – hospital insurance, extended care or home care

– Type B coverage – medical insurance, doctor services, therapy

– Covers 80% of medical bills MEDICAID

– Government provided medical assistance program– Operated on a state level, benefits vary from state to state

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Types of Plans

WORKER’S COMPENSATION– Health insurance for people injured on the job

MANAGED CARE– One approach to health care in response to

the rising costs– Insurance covers wellness exams and check-

ups, but need to prove the necessity– Need referrals to see specialty doctors

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Summary

Health insurance plans do not solve all the problems of health care costs

Do help many people pay for all or part of cost

Important for individuals to understand what plan covers

Also need understanding of co-insurance and other restrictions plan may have

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1:5 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 To follow proper channels of communication,

workers must take problems, reports, and questions to their immediate supervisor

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1:6 History of Health Care

Beliefs and Developments– Beliefs about health care and cause of disease

has changed greatly from ancient times– This has also caused drastic changes in the

treatment of patients

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Future of Health Care

Questions you should be able to answer: When did most of the significant changes

in health care occur? Why were the greatest advances made in

this time period? What are some possibilities for the future

of health care?

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1:7 Trends in Health Care

Changes in Health Care– Many events lead to changes in health care– Changes in health care are inevitable and

occur rapidly– Health care workers must be flexible

to face and keep pace with

the rapid changes

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Some Current Issues

Cost containment Home health care Geriatric care Wellness Alternative and complementary

health care National health care plans

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Cost Containment

Purpose: control the rising cost of health care and achieve maximum benefit for every dollar spent

Necessity: costs increasing with technological advances, improved survival rates, aging population, and lawsuits

Issues: need to keep high quality of care, workers can decrease costs, consumers can decrease their own health care costs

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Cost Containment Methods

Diagnostic related groups (DRGs)– Patients with certain diagnoses put into a payment group– Agency sets limit of amount to be spent on care

• If care is below the limit, agency keeps the money• If care costs are above the limit, agency is responsible

Combination of services Outpatient services Mass or bulk purchasing Early intervention and preventive services Energy conservation

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Home Health Care

Industry grew rapidly when DRGs initiated Services provided in patient’s home Visits must be pre-authorized by insurance agency

(unless private pay) Often necessary to teach family members to

perform care since visits are limited Emphasis on cost containment also applies to Home

Health

– Allows for shorter hospital stays

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Geriatric Care

Care for the elderly Percentage of elderly population growing Need for more facilities Omnibus Budget Reconciliation Act (OBRA)

– Requires states to establish geriatric care, continuing education for staff, evaluation and retraining of staff

– Wellness of patient is monitored• Physical, emotional, social, mental, spiritual wellness

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Wellness

State of optimal health Increase awareness of maintaining health

and preventing disease Emphasis on preventative measures Different facilities will develop to meet

needs of wellness emphasis

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Holistic Health

Treat the whole body, mind, and spirit Each person is unique with different needs Use many methods of diagnosis

and treatment Emphasis on protection and restoration Promote body’s natural healing processes Patient responsible for choosing care and

worker respects the choice

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Alternative and Complementary Methods of Treatment

Increasingly used to replace or supplement traditional medical treatment

Holistic approach: belief that the effect on one part effects the whole person

Based on belief that the person has a life force or energy that can be used in the healing process

Alternative and Complementary Methods of Treatment

May vary by cultural values or beliefs Often less expensive than

traditional treatments Nonjudgmental attitude is essential –

patients have right to choose treatment Increased use requires increased

awareness by health care workers

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Types of Practitioners

Ayurvedic Chinese medicine Chiropractors Homeopaths Hypnotists Naturopaths

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Office of Alternative Medicine (OAM)

Established in 1992 at the National Institutes of Health (federal government)

Purpose: research therapies and establish standards of quality care

Many states have passed laws Know your state’s law regarding the legal

requirements of alternative therapies

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National Health Care Plan

Goal: All Americans have health coverage Various plan proposals

– Federal government pays for health care, money would come from taxes

– Health care cooperatives – consumer purchases health care at a lower cost

– Managed care – employers provide coverage, government provides coverage for poor

What are some potential problems?

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Summary

Health care has changed and will continue to change

Workers must be constantly aware of changes that occur

Workers must make every attempt to learn about trends