Healthcare Flashcards

The Spectrum of Healthcare Delivery

• Consists of:
  • Population-based public health practice
  • Medical practice
  • Long-term practice
  • End-of-life practice

Public Health Practice

• Interventions aimed at:
  • Disease prevention
  • Health promotion
  • Specific protection
  • Case findings
• Includes:
  • Health education
  • Empowerment and motivation
• Primarily takes place in governmental health agencies but also occurs in a variety of other settings.

Medical Practice

• Primary medical care:
  • Clinical preventive services
  • First-contact treatment
  • Ongoing care for common conditions
• Secondary medical care:
  • Specialized attention and ongoing management.
  • Examples: Cardiologist, dermatologist, urologist, etc.
• Tertiary medical care:
  • Highly specialized and technologically sophisticated medical and surgical care.
  • For unusual and complex conditions in advanced diagnostic centers/facilities.

Long-Term Practice

• Provided after surgery or other treatment
• Includes:
  • Rehab care
  • Therapy
  • Home care
• Settings: Inpatient and outpatient units, nursing homes, other settings
• Restorative care includes help with chronic illnesses and disabilities.
• Time-intensive skilled care to basic daily tasks provided in nursing homes and various settings.

End-of-Life Practice

• Services provided shortly before death
• Hospice care for terminal diagnosis in a variety of services and settings.

Types of Health Care Providers

• 22 million workers in U.S. (14% of all US workers)
• Distribution:
  • 31.7% in hospitals
  • 8.8% in outpatient settings
  • 8.8% in physician offices
• Over 200 types of careers in the industry
• Categories:
  • Independent providers
  • Limited care providers
  • Nurses
  • Non-physician practitioners/Allied health care professionals
  • Public health professionals

Independent Providers

• Focus on diagnosis and treatment of disease
  • Doctors of Medicine (MD) - Allopathic providers
  • Doctors of Osteopathic Medicine (DO)
    • Focus on relationship between body structure & function
    • ~20% of all Med Students in US - Osteopathic providers
• Nontraditional means of health care - Non-allopathic providers (CAM)
  • Acupuncture, homeopathy, chiropractic care

Limited (or Restricted) Care Providers

• Advanced training in a health care specialty
• Provide care for a specific part of the body
• Examples: Dentists, optometrists, podiatrists, audiologists, psychologists, pharmacists

Nurses

• Over 4 million nurses in the US in 2020, 3rd most in-demand job in US
• Training and Education:
  • RN – Associate’s Degree
  • BSN – Bachelor’s of Science in Nursing
  • Advanced Practice Nurses

Non-Physician Practitioners (NPPs)

• Practice in many areas like physicians, but do not have MD or DO degrees
• Training beyond RN but less than a physician
• Examples: Advanced Practice Nurses, Physician Assistant (PA)

Allied Healthcare Professionals

• Assist, facilitate, and complement work of physicians and other health care specialists
• Categories:
  • Laboratory technologist/technicians
  • Therapeutic science practitioners
  • Behavioral scientists
  • Support services
• Education and training varies by position

Public Health Professionals

• Work in public health organizations
• Usually financed by tax dollars
• Available to everyone; primarily serve economically disadvantaged
• Examples: Public health physicians, environmental health workers, epidemiologists, health educators, public health nurses, research scientists, biostatisticians

Types of Healthcare Facilities

• Inpatient care facilities: hospitals, nursing homes, and assisted living facilities
  • Types of hospitals:
    • Private – Profit making; specialty hospitals
    • Public – Supported and managed by government jurisdictions
    • Voluntary – Not-for-profit and receive tax benefits; About half of all U.S. hospitals
• Outpatient Care facilities: patient receives ambulatory care without being admitted
  • Health care practitioners’ offices, clinics, primary care centers, ambulatory surgery centers, urgent care centers, dialysis centers, imaging centers
• Rehabilitation Centers: restorative care is provided following injury, disease, or surgery
• Long-term Care Options:
  • Traditional institutional residential care, special care units, group homes, assisted-living facilities, transitional care, day care, home health care

Cost, Quality, Access - The Triangle of Healthcare

• Cost containment, quality, and access are the key components of the US health care system. Balancing these aspects is a challenge.
• Access to Health Care
  • Insurance coverage and generosity of coverage are major determinants of access to health care
  • 2018 – 89% of US residents under 65 were insured, compared to 82% in 2011
  • Likelihood of being uninsured greater for those: young, less education, low income, non-white, male
  • Lack of access to primary care important influence on health status
• Quality of Health Care
  • Quality health care should be:
    • Effective
    • Safe
    • Timely
    • Patient centered
    • Equitable
    • Efficient
  • Groups that measure quality: AHRQ, NCQA

Cost - Health Care Spending in the US

*   In 2020, the sources of funds were:
    *   Private health insurance: $1,151.4$ (27.9%)
    *   Medicare: $829.5$ (20.1%)
    *   Medicaid: $671.2$ (16.3%)
    *   Out-of-pocket: $388.6$ (9.4%)
    *   Other third party payers and programs: $315.8$ (7.7%)
    *   Other federal programs: $193.9$ (4.7%)
    *   Government public: $192.7$ (4.7%)
    *   Other health insurance programs: $157.2$ (3.8%)
    *   Investment health activity: $223.7$ (5.4%)

Health Insurance Terminology

• Premiums: Regular periodic payments
• Deductible: Amount of money that the beneficiary must pay before the insurance company begins to pay for covered services
• Co-insurance: Portion of an insurance company’s approved amounts for covered services that the beneficiary is responsible for paying
• Co-payment: Type of co-insurance, a negotiated set fee
• Fixed indemnity: Maximum amount an insurer will pay for a certain service
• Exclusion: Specific health condition that is excluded from coverage
• Pre-existing condition: Condition diagnosed or treated 6 months before health policy began

How You and Your Insurer Share Costs - Example (Jane's Plan)

• Deductible: $1,500$
• Coinsurance: 20%
• Out-of-Pocket Limit: $5,000$
  • Before Deductible is Met: Jane pays 100% of costs.
  • After Deductible is Met: Jane pays 20% coinsurance, the plan pays 80%.
  • After Out-of-Pocket Limit is Met: The plan pays 100% of covered services for the rest of the year.

The Cost of Health Insurance

• Cost of insurance mirrors cost of care
• In U.S., burden falls primarily on the employer, then the employee:
  • Increased worker share of premium
  • Raising deductibles
  • Increasing prescription co-payments
  • Increasing number of exclusions
• Cost of policy determined by risk of group and amount of coverage provided

Health Insurance Provided by the Government

• Medicare: > 65 years of age, with kidney failure, certain disabilities. Financed by FICA tax.
• Medicaid: Payment for those in poverty; income below 133% of federal poverty level; 65.3 million people covered in 2019
• CHIP: Targets low-income children ineligible for Medicaid; State/federal program; 9.6 million children enrolled in 2018

Managed Care

• Goals:
  • Control costs through efficiency & coordination
  • Reduce unnecessary or inappropriate utilization
  • Increase access to preventive care
  • Maintain or improve quality of care
• Common Features:
  • Provider panels
  • Limited choice
  • Gatekeeping
  • Risk sharing
  • Quality management
  • Utilization review

Types of Managed Care

• Preferred Provider Organizations (PPO):
  • An organization that buys fixed-rate health services from providers and sells them to consumers
  • Can go in or out-of-network
  • No referral for specialists
• Exclusive Provider Organizations (EPO):
  • Like PPO but with fewer providers and stronger financial incentives
  • Must use in-network providers
  • No referral for specialists
• Health Maintenance Organizations (HMO):
  • Groups that supply prepaid comprehensive health care with an emphasis on prevention and primary care
  • Must stay in-network
  • Primary care provider required
• Point-of-Service plan (POS):
  • Allows you to go out-of-network for covered services, but for a higher cost; Hybrid of HMO and PPO
  • Primary care provider required
  • No referral for specialists

National Health Insurance

• A system in which the federal government assumes responsibility for health care costs of the entire population
• Primarily paid for with tax dollars
• The U.S. is the only developed country without national health care plan

Health Care Reform in the U.S.

• Health Savings Account (HSA):
  • Function like 401(k) plans
  • High deductibles/Lower premiums
  • Pay for any medical need tax-free
  • Saves money used at the end of the cycle
• Health Reimbursement Arrangements (HRA):
  • Established by employers to pay employees’ medical expenses
• Flexible Spending Account (FSA):
  • Function on an annual basis
  • Estimate annual health care costs
  • Pay for health care tax free
  • Lose any money not used at end of the cycle

Health Care Reform in the U.S. - Affordable Care Act (ACA)

• Primary goal: Increase the number of U.S. citizens who have health insurance
• Undocumented immigrants are not covered by this act
• Introduction of a Patient’s Bill of Rights:
  • No pre-existing exclusions for children under 19 years of age
  • No unjustified rescissions of insurance coverage
  • No lifetime limits on coverage
  • Restricted annual limits on coverage
  • Protects choice of doctors
  • More accessible emergency service
• Key Features of ACA:
  • New federal insurance market rules
  • Premium assistance for low- and middle-income families (Medicare covers up to 133% of the poverty level)
  • Improved Medicare drug prescription benefits
  • Investment in primary care – 100% of primary care services are covered by insurance
  • Creation of a long-term care financing program to support community living for those living with disabilities