U.S. Health-Care Delivery & Policy – Comprehensive Study Notes

Regulatory Landscape

• Federal & State Regulation

  • U.S. health-care organizations must comply with an extensive web of mandatory rules.
  • States dedicate roughly \frac{1}{3} of their total budgets to health care.
  • State governments:
  • Define what qualifies as a chronic illness for coverage purposes.
  • Control, accept, and administer Medicaid dollars → directly impacts reimbursement formulas.
  • Regulate licensure boards for health-care practitioners (e.g., Boards of Nursing).
  • Curb pharmaceutical costs via price-cap legislation.
  • Programs: State Children’s Health Insurance Program (SCHIP) expands coverage for kids; state-imposed caps on drug prices.

• Key Point: Federal statutes create the baseline; states add layers that often determine day-to-day operational realities for facilities and providers.

Accreditation & Quality Infrastructure

• Accrediting Bodies
  • The Joint Commission (TJC): certifies hospitals, long-term care, home-health agencies, ambulatory centers, etc.
  • Signals public commitment to safety and quality through periodic site surveys.
  • Publishes annually updated National Patient Safety Goals (NPSGs) tailored to each care setting.
  • Survey outcomes: identifies improvement areas; requires corrective action plans.

Major Federal Acts Influencing Coverage & Cost

• Affordable Care Act (ACA, 2010)

  • Expanded Medicaid eligibility for low-income adults.
  • Eliminated denials for pre-existing conditions.
  • Emphasized preventive care and value-based payment models to curb overall costs.
  • Marketplace subsidies reduce premiums, yet deductibles/out-of-pocket expenses remain barriers for many enrollees.

• American Rescue Plan (ARP, 2021)

  • Temporary provisions lowered premiums further & closed several Medicaid coverage gaps.
  • Greater marketplace tax credits → increased enrollment & affordability for mid-income consumers.

Sentinel Events

• Definition: An unexpected event causing death, permanent harm, or severe temporary harm.
• Common examples
  • Wrong-blood-product transfusion.
  • Wrong-site surgery (e.g., amputation of incorrect limb).
  • Unanticipated infant death.
• Response workflow
  • Immediate Root Cause Analysis (RCA) → identify latent system failures.
  • Mandatory/voluntary reporting to TJC → fosters system-wide learning and safer practice redesign.

Patient-Satisfaction Measurement Tools

• HCAHPS (Hospital Consumer Assessment of Healthcare Providers & Systems)

  • 29-item standardized survey for inpatient acute-care hospitals.
  • Domains: communication with nurses/physicians, pain control, responsiveness, discharge information, care transition, etc.
  • Administered (phone, mail, IVR) within 4–6 weeks post-discharge.
  • Publicly reported; required for institutions paid under the Inpatient Prospective Payment System (IPPS).

• Press Ganey (PG) Surveys

  • Private, third-party, optional.
  • Concentrates on access, wait times, staff courtesy, overall engagement.
  • E-mailed shortly after outpatient or ambulatory visits.
  • Generates internal dashboards for rapid quality-improvement cycles.

Health-Insurance Programs & Coverage Structures

• Medicare (Federal, entitlement)

  • Eligibility: \ge 65\,\text{yr}, or <65 with a qualifying disability, ESRD, or ALS.
  • Four Parts:
  • Part A – Hospital Insurance: inpatient, SNF (time-limited), hospice, some home health. Funding: payroll taxes; no premium for most, but some pay a premium.
  • Part B – Medical Insurance: physician/NP services, outpatient PT/OT, Dx tests, some home-health. Funded by general tax revenue + monthly premium + cost sharing.
  • Part C – Medicare Advantage: private plan bundles A+B (often D); extra benefits, network limits.
  • Part D – Prescription Drug Coverage: tier-based formularies, separate premium.

• Medicaid (Joint Federal–State)

  • Means-tested: income relative to Federal Poverty Level (FPL); criteria vary state-to-state.
  • Mandatory benefit set: inpatient/outpatient, physician, lab/X-ray, family planning, transportation, home health.
  • Optional benefits: Rx drugs, PT/OT, dental, case management, etc.

• Children’s Health Insurance Program (CHIP/SCHIP)

  • Covers children above Medicaid cutoff but lacking private insurance.
  • Services: well-baby/child visits, immunizations, dental, behavioral health.
  • Financed by federal matching funds; administered by states.

• Private / Employer-Based Insurance

  • Major carriers: Blue Cross Blue Shield, Cigna, Aetna, HMOs, etc.
  • Features: provider networks, prior authorization, deductibles, co-payments, tiered Rx cost-sharing (percentage vs flat fee).
  • Complex navigation → financial counselors help patients optimize benefits & charity programs.

Reimbursement Models

• Fee-for-Service (FFS)

  • Volume-driven: \text{Payment} \propto \text{Number of Services}.

• Value-Based Purchasing / Quality-Tied Payments

  • Both public & private payers now withhold or enhance payment depending on outcomes, safety metrics, readmission rates, and patient-experience scores.
  • Goal: reward quality over quantity.

Healthy People Program, Health Disparities & Social Determinants of Health (SDOH)

• Healthy People (HHS, once per decade; current version: Healthy People 2030)

  • Framework: promote health, prevent disease, and reduce disparities.
  • Integrates SDOH into national objectives and tracking.

• Vulnerable Populations

  • Racial/ethnic minorities, LGBTQIA+, low-SES groups, people experiencing homelessness, etc.

• Five Key SDOH Domains

  1. Economic Stability – income, employment, food security, housing → affects ability to purchase meds & healthy foods.
  2. Education Access & Quality – literacy drives understanding of instructions & adherence.
  3. Social & Community Context – social cohesion; transportation accessibility governs attendance of appointments.
  4. Neighborhood & Built Environment – safe housing, green spaces, pollution levels; poorly maintained structures ↑ disease risk.
  5. Health Care Access & Quality – provider density and proximity; insurance coverage.

• Health Disparities

  • Stretch beyond race/ethnicity to encompass socioeconomic & environmental inequalities.
  • Influenced by: physical environment, SES, legislation, availability of services.

Continuum of Care: Settings & Services

• Acute Care (Hospitals, ED, OR, diagnostic centers)

  • Short-term stabilization → discharge to home, SNF, rehab, or LTCH.

• Long-Term Care (LTC) Facility

  • Residential; assistance with ADLs ± minimal skilled interventions; 24-h supervision.

• Skilled Nursing Facility (SNF)

  • Post-acute rehab, IV antibiotics, complex wound care, PT/OT, limited duration under Medicare Part A.

• Long-Term Care Hospital (LTCH)

  • High acuity >25-day stays (ventilator dependence, extensive burns).

• Assisted Living

  • Apartment-style; clients mostly independent; meals, meds, housekeeping, transportation; 24-h staff.

• Primary Care

  • Wellness, routine illness, chronic disease management, referrals, screening coordination.

• Community Health

  • Population-level prevention & education; settings include public-health departments, schools, voluntary agencies.

• Hospice (\le 6 months prognosis)

  • Comfort care; family support; bereavement follow-up.

• Palliative Care

  • Symptom relief during any stage of serious illness; concurrent with curative therapies.

• Respite Care

  • Short-term relief for caregivers (hours → weeks).

• In-Home Care

  • Skilled nursing, therapies, social-work in patient’s residence; wound care, tube feeds, IV therapy.

Interprofessional Team Roles & Collaboration

• Core Competencies: Cooperation, Communication, Coordination → ↓ errors, ↑ efficiency, patient-centeredness.

• Provider Roles

  • Advanced Practice Registered Nurse (APRN) – dx, treat, prescribe; scope varies by state.
  • Case Manager – integrates services across settings; curbs costs/readmissions.
  • Dentist – oral diagnostics, restorations, extractions.
  • Registered Dietitian (RD) – dietary assessment, therapeutic menus.
  • LPN/LVN – basic nursing care & meds under RN supervision.
  • Naturopathic Physician – holistic, non-pharmacologic regimens.
  • Occupational Therapist (OT) – ADL retraining, adaptive devices.
  • Emergency Medical Technician (EMT) – field stabilization, transport.
  • Pastoral/Chaplaincy – spiritual counseling.
  • Pharmacist – dispense, monitor interactions; patient education.
  • Physical Therapist (PT) – mobility, strength, pain control.
  • Physician (MD/DO) – diagnose, treat, coordinate.
  • Physician Assistant (PA) – works under MD supervision; exam, orders, prescribing.
  • Respiratory Therapist (RT) – airway management, ventilators, education.
  • Registered Nurse (RN) – comprehensive assessment, interventions, education, delegation.
  • Social Worker (SW) – resource linkage, psychosocial assessments, discharge.
  • Speech-Language Pathologist (SLP) – speech and swallow therapy.
  • Assistive Personnel (CNA, PCA) – ADLs, vitals, basic comfort care.

• Benefits of Collaboration

  • Eliminates duplication of services.
  • Aligns care plans with patient goals.
  • Encourages mutual respect for expertise of every discipline.