Healthcare Delivery System Pt.1

• Definition of Health Care Delivery System

  • Organization of people, institutions, and resources used to deliver services for health needs.

Healthcare Delivery

• Complex System with many layers:

  • Roles:

    • Nurses provide nursing care (not medical care).

    • Physicians provide medical care and practice medicine.

    • Allied Health Professionals complement the roles.

  • Communication is key between providers and layers of care.

  • Focus on patient/client outcomes across all levels. (PCC)

Levels of Healthcare Services

1. Tertiary Care

   • Advanced diagnostics and treatments or rehabilitation.

   • Goal: Restore health or quality of life.

2. Secondary Care

   • Diagnosis and treatment of acute illness.

   • Goal: Cure or restore optimal health.

3. Primary Care

   • First contact; focus on health promotion and disease prevention.

   • Goal: Encourage optimal health.

Nursing Roles and Work Settings

• Work Environments:

  • Hospitals

  • Community clinics

  • Schools

  • Jails

  • Outpatient services, research facilities, home care, provider offices, etc.

  • Varied settings, including unique locations (e.g., cruise ships, military).

Members of the Healthcare Team

• Key Members:

  • Unlicensed Personnel

  • Nurses

  • Allied Health Professionals

  • Physicians

Practice Setting

• Non-Clinical Practice RN

  • Case management, Administrators, Educators, Researchers

• Advanced Practice Nurses

  • NP, Midwives, CRNA, CNS

Quality and Access in Healthcare

• Institute for Health Care Improvement - Triple Aim:

  • Population Health, Per Capita Cost, Experience of Care

• Quadruple Aim: Supporting clinician experience alongside patient experience and cost improvement.

• Access Factors:

  • Funding, geography, trust, health literacy.

Paying for Healthcare in the U.S.

• Influencing Factors:

  • Payors, rising costs, regulation (both government and private).

Health Insurance

• Shares the RISK of high medical costs by spreading the risk among MANY

• Premium

• Deductible

• Co-Pay

• Netwrok

• HMO, PPO, POS, FSA, HRA, etc.

How Providers are paid

1. Retrospective (Fee for Service):

   • Popularity in the 1960s; dictated by providers.

   • Lead to overuse and rapid cost inflation.

2. Prospective (Payment based on DRGs):

   • Initiated in the 1980s; dictated by insurance providers (e.g., Medicare).

   • Limits payments based on diagnosis-related groups.

   • Resulted in the development of Managed Care Organizations (MCOs).

3. Pay for Performance (PFP):

   • Financial incentives to providers for meeting performance measures.

Managed Care Organizations

Health Maintenance Organization (HMO)

• Care is directed by PCP

• A referral must be made in order to see specialists

• Very specific list of providers

• Lower premiums

Preferred Provider Organization (PPO)

• Gives more choice

• Allows for out of network providers to be used at a higher cost

• Higher premiums

Point of Service (POS)

• Hybrid of HMO & PPO

• PCP but members can go out of network if wanted with a higher cost

Patient Protection and Affordable Care Act

• Financial Assistance

• Required benefits package

• Regulated insurance company spending

• Reduces Medicare payments for certain conditions

• Insurance Marketplace

• Preexisiting condition clause

• Young Adult Coverage

• Funding expansion for Medicaid

• Bronze, Silver, Gold, and Platinum Plans