Health Care Systems

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General Hospitals

Wide-range of conditions and age groups.

-Diagnostic, medical, surgical, emergency care.

Speciality Hospitals

Special conditions or age groups.

-burn hospitals, oncology, pediatric, psychiatric, orthopedic.

Government Hospitals

operated by federal state and local government agencies.

-Veterans Administration

University or College Medical Centers

provided hospital services w. research and education.

-funded by private and/or government sources.

Long-term Care Facilities

disabled and old people. (assistance and care)

Residents

reside —> Long-term care facilities. (They live there)

Rehab

clients, short-term.

What are three types of Long-Term Care

Residential care, Extended care facilities, and Independent living.

Residential Care

Nursing Homes, basic physical and emotional care.

• For individuals who cannot take care of themselves.

Extended Care Facilities

Skilled facilities.

• skilled nursing care and rehab care to patients or residents to return home.

Independent Living

Individuals who can care for themselves.

• rent and purchase apartment in facility. (Meals, Housekeeping, laundry, and transportation.)

Medical Offices

Offices —> Privately owned by a physician to larger complex that operates as corporations and employ many physicians/health care professionals.

• Examinations

• Minor Surgery

• Diagnosis

• Laboratory Testing

• Experiments.

Dental Offices

Privately owned by one or more dentists.

Clinics

Satellite clinics or Ambulatory Centers. Many types of HC.

• Surgical Clinic

• Urgent of emergency care

• specialty. (Kidney Disease, oncology, diabetic)

• substance abuse.

• outpatient clinics.

DHEC —> DPH

South Carolina Department of Health and Environment Control. Split into two agencies.

• DPH —> SC Department of Public Health

• SCDES —> SC Department of Environmental Services.

Effective —> July 1st, 2024.

Optical Services

Individually owned by Ophthalmologist or Optometrist.

• Vision exams, prescribe eye glasses/contact lens.

• Check for eye diseases

  • Ophthalmologist —> Check Retina/surgery.

    • Glaucoma

  • Optometrist —> Check Vision

    • Glasses

Laboratories

Perform special diagnosis tests —> blood and urine.

• Also repair or replace teeth.

Home Health

Provide care in patients home.

• Elderly and disabled, frequent use.

  • Nursing care, personal care, therapy, home making.

Hospice

Terminally ill

• Six months or less to live

• In a persons home or in a hospice facility.

Palliative care or support and comfort.

• Directed to allow patients to die with dignity.

Psychological, social, spiritual and financial counseling.

FOR BOTH PATIENT AND FAMILIES.

Behavioral and Mental Health

Treat patients w. mental disorders and diseases.

• Drug abuse, alcohol abuse, psychiatric clinics and hospitals, spousal abuse.

Genetic Counseling Centers

Work w. Couples or individuals who are pregnant or consider it.

• perform prenatal (before birth) screening tests.

• Check for genetic abnormalalities.

Rehabilitation

Provide care —> Help patients w. physical or metal disabilities obtain maximum self-care and function.

Industrial Care Centers

Found in large companies or industries.

• healthcare —> for employees of industry.

School Health Services

Found in schools and colleges

• emergency care —> victims of accidents and sudden illness.

  • check for speech, vision, and hearing.

Concierge Medicine

Retainer medicine —> type of personalized healthcare.

• in exchange for an annual or monthly fee paid by patient —> advanced lvl of care

  • Provided by primary care physicians.

Physician —> care for fewer patients while having more ability. Not a lot of Patients.

Emergency Care Services

Provides special care for victims of accidents or sudden illness.

• Ambulatory services, rescue squads, fire department, Emergency care clinics and centers, emergency department, helicopter.

Ambulance is written backwards —> so that drivers ahead can read it correctly in their rearview mirrors.

Cosmetic Services

Branch of plastic surgery.

• reshaping or improving appearance of body parts.

Not medically necessary reconstruction.

Orthodontics Services

Treatment of irregularities in the teeth and jaws. (Braces)

• alignment and occlusion.

Pulmonary Services

Medical specialty —> Diagnosis, Treatment, and Preventable Diseases.

• Respiratory System —> Lungs, airways, upper respiratory.

Surgical Services

Medical Procedures that involve the use of surgical techniques to diagnose, treat, or repair medical conditions.

Pharmaceutical Services

Pharmacies, chemists, or drugstores.

• Link health science w. chemical science.

  • Prepare and dispence medications

Government Agencies

• WHO - World Health Organization

• USDHHS - U.S Department of Health and Human Services.

• NIH - National Institutes of Health

• CDC - Centers for Disease Control and Prevention

• FDA - Food and Drug Administration

• OSHA - Occupational Safety and Health Administration

• VA - Department of Veteran Affairs

• USPHS - U.S Public Health Services

• CMS - Centers for Medicare and Medicaid Services

WHO

World Health Organization

• International agency, complies statistics and information on serious disease throughout the world.

  • Like Covid-19

USDHHS

U.S Department of Health and Human Services

• National agency that deals w. health problems in the US.

NIH

National Institutes of Health

• Research in disease and conducting scientific studies.

CDC

Centers for Disease Control and Prevention.

• Concerned w. causes, spread, and control of diseases in population.

FDA

Food and Drug Administration

• Responsible for regulation food and drug products sold to the public

OSHA

Occupational Safety and Health Administration

• Enforces standards that protect workers from job related injuries and illness.

VA

Department of Veteran Affairs

• Federal Agency —> health care for veterans and their families.

Americas Largest integrated healthcare system, care at hospitals, medical centers, and outpatient site.

• serving 9 million enrolled veterans each year.

USPHA

U.S Public Health Services or PHS.

• Collection of agencies of Department of Health and Human Services.

  • Manages public Health, containing 9 out of the department. Twelve operating Divisions.

CMS

Centers for Medicare and Medicaid Services.

• Medicare and Medicaid. The Children’s Health Insurance Program (CHIP) and The Health insurance Marketplace.

  • Millions of Americans, Agency overseeing health coverage programs.

    • CMS 1500.

Health Departments

Provide health services as directed by the U.S department of Health and Human Services. (USDHHS).

Voluntary Agencies

Funded by money from donations, membership fees, fundraisers, and Federal/State grants. They provide services at national, state, and local levels.

NON-PROFIT AGENCIES.

American Red Cross, St. Judes Children’s Research Hospital, American Cancer Society, American Heart Association,

Joint Commission

non-profit U.S based organization that is created to ensure patients receive the safest, highest quality care in any healthcare setting.

SYMBOL OF QUALITY.

Accredited is required to receive Medicade reimbursement.

Health Insurance

This is what most people rely on to pay for cost of Health Care.

Medicare, Medigap, Medicaid, Tricare, Workers comp, etc.

Medicare

For people over the age of 65, any person w. end of stage kidney disease, and disability who received social security benefits.

ONLY PAYS 80%, individual pays the rest.

Type A —> Hospitals Insurance

Type B —> Doctors Services

Type C —> Private insurance (cover cost that medicare does not)

Type D —> Medication Expenses

Medigap

Pay expenses not covered by Medicare.

You choose how much coverage you want which is offered by private insurance companies.

TYPE C MEDICARE.

Medicaid

Federal Government and State funded.

For individuals with low income, Children who qualify for public assistance, and Blind individuals.

COVERS hospital, physician care, long-term care services, and therapies. Also Dental, Eye, and other specialized services.

Worker’s Compensation

Treatment for workers injured on the job.

This reimburses worker wages lost because of on-the-job injury.

Tri-Care

Formally CHAMPUS

—> Civilian Health and Medical Programs for the Uniform Service.

For all military personnel (active, retired, survivors).

Provided by the VA.

Managed Care

Designed to help with high cost of Health Care.

This works by providing preventable care (avoiding high cost of treating diseases.)

Also creates network of doctors, specialists, therapists, and health care facilities at a reasonable cost.

CATCH EARLY

HMO

Directed towards preventable care for a fix or prepared fee.

PREVENATBLE CARE.

PPO

this is a contract with certain hospitals, doctors, or dentists to provide care at a lower rate that needs deductible and co-payment (40-60%)

CERTAIN DOCTORS.

IPA

A business entity with a network of independent physician practices who work together to negotiate contracts with payers and reduce administrative overhead.

Spreads money efficiently, nothing wasteful.

Managed care plan —> quailty care at most reasonable cost.

PRIVATE DOCTORS.

Fee-for-AService Compenstation

Payment Plan.

Doctors or providers paid for each service rendered.

Paid at a set amount for each visit, test, and procedure.

Value-Based Compensation

Bundled Payments

Plan in which doctors are paid for performance.

Certain amount paid.

Private Insurance

Purchased from private insurance company as opposed to a government run program.

Private Plans are commonly offered through employers, but can be purchased directly by individuals and families.

Aetna, Cigna, All-state, United Healthcare, Humana.

The Children’s Health Insurance Program (CHIP)

Provided Healthcare to uninsured children of WORKING FAMILIES.

established in 1997.

HIPAA

Health Insurance Portability and Accountability Act.

Keep information confidental.

The Affordable Care Act.

Formally PPACA —> Patient Protection and Affordable Care Act.

prohibits insurance companies from rescinding coverage to any individuals as long as premiums are paid. (or else fine.)

Named Changed on March 24, 2010.

Deductible

amount paid by a patient before policy begins to pay.

Co-insurance

specific percentage of expenses shared by the patient and the insurance company (80-20)

Co-payment

specific amount of money a patient pays for a service.

(ex: 25$ for every visit, regardless of total cost of visit.)

Claim

Formal request from another healthcare provider or patient to an insurance company for payment of medical services rendered.

EOB

Explanation of Benefits.

Document from healthcare insurance company that explains what medical treatments and/or services were paid on your behalf.

NOT A BILL. just a summary of how a claim was processed.

total cost of service, what your plan paid, what you may owe, and the remaining deductible/out of pocket.

Fraud

Criminal Act —> intentional deception to gain unfair financial advantage from an insurance company.

Staging accidents, fake information, billing for service not rendered, and over exaggerations.

Policy Holder Fraud

• Exaggerated a Legit Claim. (Stolen items and injuries)

• Faking loss or event (accident, theft, arson)

• Misrepresenting facts on application (false information)

• Faking Death or disability (collection on life or disability insurance.)

Provider Fraud

• Billing for services not provided (charging for unnecessary or nonexistent treatments or repairs.)

• Upcoding (billing for expensive service or part than what was actually provided.

• Premium Diversion (agent keeps policy holder premium payment instead of sending it to the insurance company.)

Medical Coding

process of translating patients diagnoses, procedures, and services from medical document into universal alphanumeric codes for billing, date tracking, and insurance reimbursement.

Premium

amount of money you pay to an insurance company to keep your policy ACTIVE and to be protected against financial risks.

Payment on regular Basis (Monthly, quarterly, yearly.)

The PRICE FOR THE COVERAGE ITSELF.

Compliance

Adherence of Laws, regulations, and ethical standards within legal frameworks.

Patient’s Bill of Rights

Protects individuals legal and ethical rights in healthcare.

• Respectful and non-discriminatory care.

• Understand and use these rights in a Hospital

• Right to Refuse Treatment

• Right to Privacy and Confidentiality

• Right to Access Medical Records

Self Advocacy

Refers to the active participation of patients in their own healthcare decisions.

Behavior and Mental Health

Severe straining healthcare delivery.

Burnout! growing mental health crisis

Bioethics

interdisciplinary fields that examine ethical issues that arise from advances in biology, healthcare, and medicine.

• Euthanasia, organ donations, end-of-life decisions.

Epidemiology

Study of diseases

Tract disease spread and predict trends.

Socioeconomics

Old people get older, we are living longer bc of new technology.

AGING POPULATION, WORKPLACE SHORTAGES, INCOME INEQUALITY, INCREASE DEMAND FOR SERVICES.

LIVING LONGER.