Health Care Delivery System Study Notes

Structure of the Health Care Delivery System

• The health care system of the United States is complex and continues to undergo significant changes.

  • Regulatory agencies shape health care delivery by providing standards and guidelines for quality care.

  • Compliance with regulatory standards ensures that providers and facilities meet recommendations for quality and safe services to clients.

Health Care Reform

• Many individuals in the U.S. are uninsured, face limited ability to pay for medications, or have limited access to health care, leading to unexpected health outcomes.

• Efforts aimed at making health care affordable and accessible include health care reforms.

  • In 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law by President Barack Obama.

  • Goals of the ACA include improving health care quality, lowering costs, and increasing access to care.

  • The ACA expanded eligibility for Medicaid to include all adults with incomes below 138% of the federal poverty level.

  • The act also banned lifetime caps on insurance benefits.

Focus of the Affordable Care Act (ACA)

• Disease prevention is a focal point of the ACA.

  • Clients are encouraged to sign up for insurance and seek preventive care to maintain health.

  • Those with insurance do not pay copayments or deductibles for preventive screenings, helping avoid costly chronic illnesses.

  • Despite advancements, many clients still choose between living expenses and medication costs.

  • Some individuals remain uninsured or cannot afford premiums in the ACA marketplace, where coverage options are available.

  • The New York Times reported in 2020 that premiums had more than doubled over recent years, complicating access to necessary care.

  • Lawmakers revise ACA details to further achieve the law’s original goals.

The American Rescue Plan (ARP)

• The ARP Act was implemented in 2021 by the Biden-Harris Administration.

  • It aimed to strengthen the ACA by lowering health care costs further and increasing the number of insured individuals.

Goals of the Patient Protection and Affordable Care Act

• Select all that apply:
  A. Making affordable health insurance available to more people.
  B. Reducing Social Security costs.
  C. Providing protection to those who are ACA-funded services.
  D. Eliminating the requirement to pay income tax.
  E. Expanding Medicaid to adults with incomes below 138% of the poverty level.
  F. Lowering the costs of health care.

State Regulation

• States maintain regulations that health care organizations must follow.

  • Managers and directors ensure compliance with state regulations.

  • Each state interprets federal definitions and regulates Medicaid funding disbursement.

  • States also legislate pharmaceutical coverage, with some imposing price caps on medications.

  • The Inflation Reduction Act aims to decrease prescription drug costs for Medicare recipients, including capping insulin costs and annual out-of-pocket spending.

Regulation of Practitioners

• Each state determines regulations for health practitioners.

  • Example: The State Board of Nursing (BON) manages eligibility, licensure, governance, and disciplinary actions for nursing.

  • The National Council of State Boards of Nursing (NCSBN) provides guidance to BONs and develops nursing licensure exams.

Accreditation of Health Care Facilities

• Client care facilities often achieve accreditation from external organizations that ensure quality and safety standards.

  • Accrediting organizations set operational standards, including policies on environmental practices, HR, patient safety, and documentation.

  • Accreditation signals a commitment to quality to the public.

The Joint Commission (TJC)

• TJC is a nonprofit organization that accredits health care organizations across various settings.

  • Formerly JCAHO until its name shortened in 2007.

  • TJC accreditation visits involve expert surveyors who review documentation, policy, and compliance through interviews and observations.

  • Full accreditation from TJC lasts three years and is recognized by many state regulatory bodies, thus eliminating the need for additional state accreditations.

  • TJC standards maintain a two-part monitoring system for compliance with state regulations.

National Patient Safety Goals (NPSGs) by TJC

• TJC publishes NPSGs annually based on current client safety issues, with category-specific goals for various settings (e.g., ambulatory, hospitals).

  • NPSGs focus on trends in patient safety, and TJC addresses any necessary modifications or new requirements.

Sentinel Events

• A sentinel event is defined as a client’s death or severe permanent harm.

  • Examples: Transfusion reactions due to misidentified blood types, mistaken amputations.

  • Reporting these events to TJC aids in improving systemic issues and enhancing client safety.

National Committee for Quality Assurance (NCQA)

• NCQA is an independent nonprofit that accredits health care plans, focusing on developing evidence-based standards to improve care.

Nursing Excellence Programs

• Programs such as the Magnet Recognition Program and Pathway to Excellence recognize high-quality nursing practices in facilities.

Magnet Recognition Program

• Promotes quality nursing care, supporting professional practice and recognizing excellence in service delivery.

  • Facilities apply for Magnet status based on evidence demonstrating superior client outcomes (e.g., lower fall rates).

  • The application process requires participation across all organizational levels.

  • Magnet recognition remains valid for four years, renewable upon continued excellence.

Pathway to Excellence Program

• Focuses on creating a healthy workplace for nursing staff, with standards affecting turnover, engagement, and job satisfaction.

  • Awarded after facilities prove standards integration within their practice.

Patient Accountability and Satisfaction Measurements

• Facilities use tools such as HCAHPS and Press Ganey surveys to gauge client satisfaction and performance.

Health Care Coverage

• Medicare eligibility requires clients to be 65+, disabled, or with specific diseases.

  • Medicare Parts overview:

  • Part A: Hospital insurance covering inpatient care.

  • Part B: Medical insurance covering outpatient services.

  • Part C: Medicare Advantage plans.

  • Part D: Prescription drug coverage.

Medicaid and CHIP

• Medicaid offers coverage to individuals below poverty level, varied by state.

• CHIP provides services for children not qualifying for Medicaid, focusing on preventive care.

Private Insurance

• Private insurance is provided by employers or purchased directly, with various plans and complex reimbursement rules.

Managed Care

• Managed care systems, including case management and pre-authorization, help control costs and improve service delivery effectiveness.

Social Determinants of Health (SDOH)

• SDOH significantly impact health outcomes, particularly for vulnerable populations. Key areas include economic stability, education, social context, neighborhoods, and access to health care.

Public Health Nurse Role

• The role focuses on community health advancements, health education, and preventative health strategies to alleviate health disparities.