?Politics and the Law.

Chapter 11
The Health Care System
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U.S. Health Care System
Figure 11-1
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U.S. Health Care System (Cont.)
?
Private health care subsystem
?
?
?
?
Focus on the individual
Nonprofit and for-profit agencies
Models of services
• Solo practice
• Single specialty group practice
• Multispecialty group practice
• Integrated health maintenance model
• Community health center
Voluntary or nonofficial agencies
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U.S. Health Care System (Cont.)
?
Public health care system
?
Mandated by the U.S. Constitution
? Focus on the population
• “promote the general welfare of its citizens.”
? Federal policies and practices influence local and
state governments
? Coordination of services under Department of
Health and Human Services
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Public Health
Public health refers to the efforts organized by society
to protect, promote, and restore the people’s health.
? Concerned with a healthy population
? Concerned with a healthy environment
? Scope is broad
? Encompasses activities that promote good health
? Organized into multiple levels (federal, state, local)
? Provides services for those unable to obtain health
care without assistance
? Establishes laws, rules, and regulations to protect the
public
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Public Health System
?
Federal level subsystem
?
?
?
?
U.S. Department of Health and Human
Services
Surgeon General and numerous other
agencies
Targets general population, special
populations, and international health
IOM Report, HHS in the 21st Century:
Charting a New Course for a Healthier
America (2008), recommended
transformation of system
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Current HHS Strategic Plan
1. Transform health care
2. Advance scientific knowledge and innovation
3. Advance health, safety, and well-being of the
American people
4. Increase efficiency, transparency, and
accountability of HHS
5. Strengthen the nation’s health and human
services infrastructure and workforce
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Public Health System (Cont.)
?
State level subsystem
?
State health departments
? Responsible for the health of their citizens
? Central authorities in the public health care system
? Dependent on federal level for guidance and
resources
? Establish own state laws
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Public Health System (Cont.)
?
Local health department subsystem
?
Local health departments (LHD)
? Responsible for direct delivery of public health
services and protection of the health of citizens
? Not all communities have LHDs
? Responsible for:
• Community health services
• Environmental health services
• Personal health services
• Mental health services
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Health Care Providers
?
Provider organizations
?
?
Health care professionals
?
?
Any organization that provides health care to the
community
The interprofessional health care team
• Professionals and nonprofessionals
Nontraditional health care providers
?
Complementary and alternative therapies
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Quality Care
?
?
?
To Err Is Human: Building a Safer Health System
(IOM, 1999) focused on safety within the health care
delivery system
Crossing the Quality Chasm (IOM, 2001) focused on
developing a new health care system for the twentyfirst century, one that improves care
Leadership by Example (IOM, 2003) was a report
requested by Congress that examined the federal
government’s quality enhancement processes
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Quality Care (Cont.)
?
Who Will Keep the Public Healthy? (IOM,
2003) brought public health into the forefront
by focusing on issues including globalization,
rapid travel, scientific and technological
advances, and demographic changes
?
?
In-depth exploration of educational needs for
improved public health
Need for appropriately prepared public health
professionals
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Quality Care (Cont.)
?
Who Will Keep the Public Healthy? (Cont.)
?
New content areas for public health professionals:
• Informatics, genomics, communication, cultural
competence, community-based anticipatory research,
global health, policy and law, and public health ethics
?
Old content areas for public health professionals:
• Epidemiology, biostatistics, environmental health, health
services administration, and social and behavioral
science
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Quality Care (Cont.)
?
Health Professions Education (IOM, 2003),
the education of all health professionals is
viewed as a bridge to quality care.
?
Provide patient-centered care
? Work in interdisciplinary teams
? Employ evidence-based practice
? Apply quality improvement
? Utilize informatics
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Quality Care (Cont.)
?
Priority Areas for National Action (IOM, 2003)
identified priority areas that should be addressed to
improve quality
?
?
?
?
?
?
?
?
Patient and family engagement
Population health
Safety
Care coordination
Palliative care
Overuse
Access
Health systems infrastructure capabilities
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Quality Care (Cont.)
• Keeping Patients Safe: Transforming the
Work Environment (IOM, 2004) addressed
critical quality and safety issues with a focus
on nursing care and nurses
• Focused on nurses in acute care and the work
•
environment for safer patient care
Also looked at nursing shortage, health care
errors, patient safety risk factors, nurse’s role in
quality improvement, and work environment
threats to patient safety
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Quality Care (Cont.)
?
The Future of Nursing. Leading Change,
Advancing Health (IOM, 2011) focuses on the
nursing profession and how it might fit into
the change process
1. Nurses should practice to the full extent of their
education and training.
2. Nurses should achieve higher levels of education
and training through an improved education
system that promotes seamless academic
progression.
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Quality Care (Cont.)
?
The Future of Nursing. Leading Change,
Advancing Health (Cont.)
3. Nurses should be full partners with physicians
and other health professionals in redesigning
health care in the United States.
4. Effective workforce planning and policy making
require better data collection and an improved
information infrastructure.
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Accreditation
?
?
Joint Commission
National Committee for Quality Assurance
(NCQA)
?
?
?
?
Health Plan Effectiveness Data and Information
Set (HEDIS)
American Healthcare Commission
Consumer Assessment of Healthcare
Providers and Systems (CAHPS)
Agency for Healthcare Research and Quality
(AHRQ)
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… the ultimate test of the public health
subsystem is whether it effectively serves the
people by their measurements, not those of the
public health profession.
– Koop (1989)
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Critical Issues in Health Care
Delivery
?
?
Managed care
Information technology
?
?
?
?
Consumer advocacy and client rights
?
?
?
Telehealth
Electronic medical records (EMRs)
Social media
Client/consumer-centered health care
Coordination and access to care
Disparity in health care delivery
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Critical Issues in Health Care
Delivery (Cont.)
?
Globalization and international health
?
World has no real boundaries
? CDC active in responding to preparedness and
international travel
? WHO fosters collaborative global initiatives
? ICN gives nursing perspective
?
Health care reform
?
?
The Clinton Health Reform Initiative
Patient Protection and Affordable Care Act of 2010
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Future of Public Health
?
?
?
?
?
What services?
Who has access?
Who pays?
How is it delivered?
What is the role
of government?
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Impact on Community Health
Nursing
?
Principles of change that focus on quality,
access, and cost…
?
The need for patient-centered care
? The need for stronger primary care services
? The need to deliver more care in the community
? The need for seamless, coordinated care
? The need for reconceptualized roles for health
professionals
? The need for interprofessional collaboration
– The Future of Nursing. Leading Change,
Advancing Health (IOM, 2011)
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Chapter 12
Economics of Health Care
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Factors Influencing Health Care
Costs
?
?
?
?
?
?
?
?
?
Historical payment systems
Unnecessary use of services
Lack of preventive care
Lifestyle/health behaviors
Societal belief that disease would be eradicated
Technological advances
Aging of society
Utilization of drugs
Shift from nonprofit to for-profit health care
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Public Financing of Health Care:
Medicare
Entitlement program to provide health care to
the growing population of those 65 years of
age or older
?
Part A
?
?
?
Includes inpatient care in
hospitals/skilled nursing facilities,
hospice care, some home health care
Must pay a deductible for health
services
Does not pay for all health care costs of
enrollees; co-payments required after
60 days
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Public Financing of Health Care:
Medicare (Cont.)
Entitlement program to provide health care to the
growing population of those 65 years of age or older
?
Part B
?
Purchased by monthly fee
? Not compulsory
? Helps pay for out-of-pocket costs for physician
services, hospital outpatient care, durable medical
equipment, and other services, including some
home health care
? Enrollees must pay deductibles and coinsurance
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Public Financing of Health Care:
Medicare (Cont.)
Entitlement program to provide health care to the
growing population of those 65 years of age or older
?
Part C
?
Medicare Advantage Plans
? Optional “gap” coverage
? Provided by private insurance companies
approved by, and under contract with, Medicare
? May include HMOs and PPOs
? May include vision, hearing, dental care, and other
services not covered by Medicare Parts A, B, or D
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Public Financing of Health Care:
Medicare (Cont.)
Entitlement program to provide health care to the
growing population of those 65 years of age or older
?
Part D
?
Initiated in 2006 to help defray costs of
prescription drugs
? Optional; must enroll in an approved prescription
drug plan
? Monthly premium, deductibles, and co-payments
? Must pay 100% of costs when costs reach
“coverage gap” or “donut hole”
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Public Financing of Health Care:
Medicaid
Title XIX of the Social Security Act—a public welfare
assistance program
?
?
?
?
Provides universal health care coverage for the
indigent and children
A joint state and federal venture
Eligibility for this program depends on the size and
income of the family; federal government sets
baseline eligibility requirements, but states can lower
eligibility
Priority participation is given to children, pregnant
women, and the disabled
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Public Financing of Health Care:
Medicaid (Cont.)
?
Federal government sets baseline services,
but state governments may provide more
services
?
?
?
Must include inpatient and outpatient hospital
care, pregnancy-related care, vaccines for
children, family planning services, rural health
clinics, home health care, lab and x-ray services,
and EPSDT
Care by pediatric and family nurse
practitioners is covered
Children under 18 also eligible for Children’s
Health Insurance Program (CHIP)
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Public Financing of Health Care:
Governmental Grants
?
?
?
?
?
?
Directed toward funding large populations
and different aggregates
Historically for health promotion and
disease prevention measures
Administered by DHHS
“Block grants” provided to states to impact
the health of the public as a whole
Health care providers and programs
compete for funds through grant proposals
and applications
Closely related to Healthy People 2020
objectives
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Philanthropic Financing of
Health Care
?
?
Often research or disease oriented
Eligibility for services limited to the specific
disease or population of interest
?
?
?
May include services rendered plus ancillary needs
like transportation, parental housing, or wigs
Informational and research activities constitute the
majority of services provided by these organizations
Examples include American Heart Association and
the Shriners
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Health Insurance Plans
?
?
First established in 1930s
Types of plans
?
?
?
Reimbursement mechanisms
?
?
Indemnity, HMO, PPO, POS
Private insurance, cooperatives, cafeteria plans
Retrospective and prospective plans
Scope of services covered
?
Routine care, catastrophic, ambulatory
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Cost Containment
?
Capitated reimbursement
?
?
Access limitation
?
?
?
Prospective reimbursement for services
Primary care provider as gatekeeper
Managed care plans—preauthorization
requirements for additional services
Rationing
?
Determining the most appropriate use of health
care or directing the health care where it can do
the most good
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Trends in Health Financing
New and innovative health
care approaches
? Cost sharing
? Health alliances
? Self-insurance
? Flexible spending
accounts
? Health promotion and
disease prevention
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Health Care Financing Reform
Lack of insurance is the major factor associated
with lack of access to medical care.
The current dilemma is how to provide health
care to all Americans that is acceptable and
affordable.
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Caring for the Uninsured
?
?
Should health care be one of those
necessities available to all without
cost?
Should health care be a right for all
rather than a commodity to be
available only to those who can afford
it?
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Access to Health Care—Barriers
?
?
Insufficient financial support
Physical barriers
?
Structural inaccessibility, lack of appropriate
equipment, or inability to communicate
? Inequality in the distribution of services,
transportation difficulty, conflict with work hours,
and failure to provide services
?
Sociological barriers
?
Language difficulties and fear of reprisals
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Health Care Reform 2010
?
?
?
?
?
?
?
?
Individual mandate
Employer requirements
Expansion of Medicaid
Expansion of CHIP
Premium and cost-sharing subsidies to
individuals
Changes to private insurance
Cost-containment provisions
Prevention and wellness
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Nurse’s Role in Economics
?
Researcher
?
?
Investigate efficient, cost-effective care, culturally
sensitive treatment modalities, health education,
disease prevention, and factors to change
behaviors
Investigate, develop, and evaluate the
effectiveness of health promotion and disease
prevention
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Nurse’s Role in Economics
(Cont.)
?
Educator
?
?
?
?
Health education is the foundation of community
health nursing practice
Understand that knowledge empowers clients to
actively participate in their health care
Demonstrate the effectiveness and value of
education
Outcome measures for health education need to
be established
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Nurse’s Role in Economics
(Cont.)
?
Provider of care
?
Care must be appropriate, necessary, and cost
effective.
? Judicious application of the nursing process is
imperative.
? Serve as program service provider, health
education provider, and heath program participant
? Participate in grant proposal process, program
design, and evaluation of these programs
? Participate in statistical information–gathering
process as basis for determining needs
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Nurse’s Role in Economics
(Cont.)
?
Advocate
?
Become more involved in the economics of health
care
? Increase knowledge of health care funding and
policy making
? Use political power to influence health care
funding
? Advocate for increase in health promotion/disease
prevention funding
? Plan programs, seek funding, and evaluate
program effectiveness through outcome measures
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