NSG 4000- US Healthcare System and the Economics of Healthcare

US healthcare system

"it is regularly praised for its technological breakthroughs, frequently criticized for its high costs, continues to experience major problems with its quality, and often is difficult to access for those most in need"

Healthcare system

key components:

- private and public subsystems

- major focus of public health subsystem-prevention of disease and illness

- cost effectiveness and cost containment have become critical driving forces

- public health nurses are in a unique position to provide leadership and facilitate change in the health care system

Private

______________ healthcare subsystem:

- most personal health services are provided in the private sector

- Managed Care Organizations (MCOs)

- personal care delivered by MDs and other professions following 5 basic models

- managed care has become dominant form of health care delivery

Private

5 basic models of the _____________ healthcare subsystem:

- solo practice

- single specialty group model

- multispecialty group practice

- integrated health maintenance model

- community health center

Managed care

physicians, providers, and specialist are increasingly grouped into a system such as an HMO

- part of the private health care subsystem

PCMH (Pt Centered Medical Home)

offers a team approach to assist in the coordination of care for positive health outcomes

- connected to health care reform/newer

- long term success is unknown

- part of the private health care subsystem

Voluntary agencies

nongovernmental, nonprofit, entities support health care provision and sometimes direct health services

- part of the private health care subsystem

categories:

- specific diseases

- organ or body structure

- health and welfare of special groups

- particular phases of health

Public

____________ healthcare subsystem:

- US constitution mandates "the general welfare of its citizens"

- required by law

- 1953 Department of Health, Education and Welfare (Eisenhower)

- 1979 was separated into Department of Education and Department of Health and Human Services

- Public health-refers to the efforts organized by society to protect, promote and restore people's health

Public

____________ healthcare subsystem:

- organized into multiple levels (federal, state, local)

- states: administer Medicaid=jointly funded by federal and state government

- the scope of health services decided by states can vary widely

Local health departments (LHDs)

organizations that vary from state to state and not every community/county has one

- responsible for the protection of health and its citizens

Categories of services

- community health

- environmental health

- personal health

- mental health

Healthcare providers

- health care professionals are multidisciplinary

- nontraditional healthcare providers who participate in CAM

Issues in healthcare delivery

- quality care

- accreditation

- managed care

- information technology

- consumerism and pt rights

- coordination and access to care

- disparity in healthcare delivery

Quality care

the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

- Agency for Healthcare Research and Quality (AHRQ) is the main federal organization devoted to this

- support effort for clinicians/providers in STEPPS program

Accreditation

outcomes goal based continues to be the standards/measurable

- healthcare providers: Joint Commission founded in 1951 to promote health care quality through setting and maintaining standards

- National Committee for Quality Assurance (NCQA) oversees accreditation for individual MDs, health plans, and medical groups

- one means to assess the quality of services

Managed care

- any method of healthcare delivery designed to reduce unnecessary use of services, improve cost containment or cost-effectiveness, and ensure high quality care

Information technology

- implementation of EMR/HER

- Telehealth

- social media-health promotion and prevention strategies

Consumerism and pt rights

- pt centered health care

- pt rights addressed through legislation

- health care facilities- pt bill of rights

Coordination and access to health care

- fragmented across various providers

- uncoordinated

- availability of services geographically can vary

- competition among providers for pts

Disparity

_____________ in healthcare delivery:

- observable or quantifiable differences in the presence of disease, health outcomes or access to care among different groups or populations

- Black Americans, American Indians, and Alaska Native adults higher prevalence of asthma, DM and cardiovascular disease

- Black Americans and Latinos twice as likely to develop DM

- cross cultural education for healthcare professionals to impact healthcare

Costs

factors influencing health care _________:

- historical perspective

- use of health care

- lack of preventive care

- lifestyle and health behaviors

- societal beliefs

- technological advances

- aging of society

- pharmaceuticals

- shift to for profit health care

- health care fraud and abuse

Public financing

_____________ ____________ of healthcare:

- Medicare

- Medicaid

- governmental grants

Philanthropic financing

_____________ _____________ of health care:

- faith based programs like Medishare

limited finances to support specific issues:

- Susan G Komen foundation

- March of Dimes

- American Health Association

Private health care insurance

- private insurance

types of health care plans:

- indemnity

- HMO (health maintenance org)

- PPO (preferred provider org) (don't have to stay in network but you may have to pay a greater % of the cost depending on the plan; more flexibility for MDs than HMO)

- POS plan (point of service)

- EPO (exclusive provider org)

- HDHP (high deductible health plans)

- HAS (health savings account)

HMO

- private health care insurance

- must stay in network

- must select a PCP

- referral to specialists must come from PCP

PPO

- private health care insurance

- don't have to stay in network

- doesn't have to have a PCP

- referral to specialist must come from a PCP

POS

- private health care insurance

- can but do not have to say in network

- usually must select a PCP

- referral to specialist must come from a PCP

EPO

- private health care insurance

- must stay in network

- do not have to select a PCP

- referral not needed to see a specialist

Reimbursement

______________ mechanisms of insurance plans:

- retrospective reimbursement

- prospective reimbursement

Prospective

________________ reimbursement:

- rates are based on the diagnosis and pt characteristics and are designated by diagnosis related group (DRG)

- represented by codes following the International Classification of Disease (ICD-10)

- Hospital Cost shifting to private insured to cover for losses related to Medicare funding

- private insurances moved to actuarial classification to determine premiums

- physician services current procedural terminology

Covered services

until implementation of the ACA, insurance plans designated the types of services they would cover

- consumer advantages and disadvantages of insurance reimbursement plans

Cost containment

numerous attempts over decades to decrease cost-marginal success

- attempts to do this from multiple methods eventually gave raise to managed care

three categories:

- capitated reimbursement

- access limiting

- rationing

Cost containment

3 cateogies:

- capitated reimbursement- max reimbursement provider will get for pt with specific diagnosis for a population

- access limitation- primary care-gatekeeper to specialist/testing

- rationing- determining the most appropriate use of health care or directing it where it can do the most good

Financing

trends in health ____________:

- cost sharing

- health care alliances

- self insurance

- HSAs and FSAs

- reimbursement for health promotion/disease prevention

Financing reform

healthcare ___________ __________:

- access to health care

- historical perspective (key provision of the ACA)

- societal perceptions

Public health nurse

roles of _________ __________ _________ in the economics of healthcare:

- researcher

- educator

- provider of care

- advocate