Transcript Health Care Delivery System - Des Moines Area Community

Health Care Delivery
System
Evolution of HCDS
• Early 20th Century – Prepaid medical
plans –lumber and mining camps
Nursing care still focused in homes
• 1920 – American hospitals offered
“Baylor Plan” (later Blue Cross) –
• 1935 – Social Security - benefits for
elderly, child welfare, training of
healthcare personnel
• WWII – veteran healthcare benefits
• 1960’s – Medicare and Medicaid health
care services for elderly and indigent
• Nursing Training Act (physician and nurse
shortage)
• Nurse Practitioners began
• Focus moves to health maintenance
• 1970’s – HMO Act – primary health care
service for a predetermined fee
• Amendments to SS allow nurse
practitioners to be paid directly for
service
• Rural Health Clinic Service Act
• 1980’s – Focus on Cost
Control
• “OBRA” – Omnibus Budget
Reconciliation Act (peer review,
quality, restraints, payment to
midwives)
• DRG’s (Diagnosis Related Groups)
• HMO’s increase
• Technology proliferates
• AIDS discovered
• 1990’s – Medicaid and welfare
program reforms: welfare to
work
• SCHIP – Children’s health
insurance program
• UAP’s (unlicensed assistive
personnel)
• 2000’s – More telemedicine
utilization
Levels of Health Care
Primary – Health Promotion
and Illness Prevention
• Ideal level to enter the health care
system
• Teaching, lifestyle modification,
referrals, immunization, promote
safe environment
Secondary – Early
detection, Diagnosis and
Treatment
• Screening, diagnosis
• Acute Care
• Surgery
Tertiary – Restorative and
Rehabilitation actviities–
return to optimal
functioning
• Education and retraining
• Environmental modifications
• Provision of direct care
Health Care Settings
• Hospitals – General and
specialized
Proprietary
Teaching and Research
Public
Voluntary
Health Care Settings
• Ambulatory Services
Outpatient departments
Physician group practices
HMO’s
Nursing Care Centers
Community Health Clinics
Indian Health Service
Ambulatory Care Facilities
(urgent care centers)
Health Care Settings
• Long Term Care Facilities
Residential care
Assisted Living
Skilled Care
• Public Health Agencies
• Home Care Agencies
• Adult Day Care
• Wellness Centers
• Hospice Care – hospital, nursing
home, free-standing hospice, home
Health Care Team
Guess the professional:
Has completed a 120 hour course
in basic life support skills and
passed a national test.
Provides care in an emergency
• EMT
• ??? Has a minimum 2 year
preparation and performs
diagnostic measures involving
radiant energy
• X-ray technician
• ??? A nurse who has studied an
additional 2-3 years in an
approved school or
anesthesiology
• CRNA (Certified Registered
Nurse Anesthetist)
• ???Graduate of a 12-18 month
program and passed a certifying
exam - provides treatments for
breathing
• Respiratory Therapist
• ???? Provides assistance for
mobility and exercises – has
completed a 2 year program
• PTA – Physical Therapy
Assistant
• ??? Has completed 4-5 years of
education plus an internship
regarding nutritional problems
and therapeutic diets
• Dietician
• ??? A graduate of a 4 year or
more program who helps
patients restore body function
through specific tasks and skills
related to activities they need
to function in their daily lives
• Occupational Therapist
• ??? A professional who helps the
patient solve problems with financial
concerns, assist with obtaining
services in the community after
discharge and has completed a
master’s degree.
• Social Worker (MSW)
Financing
• Public
• Private
• Third Party
Financing Health Care
• Fee for service – physician paid
by patient for each service
provided
• Capitation – set monthly fee
charged by provider for each
member of group for a specific
set of services
Fee for Service - Terminology
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Premium
Deductible
Co-Payment
Co-Insurance
Health Care Provider
Public Financing - Medicare
• Part A – Hospital Insurance
Provided free for those who have 40 or
more quarters of Medicare-covered
employment
• Deductible ($1024 in 2008)
• Coverage: Hospitalization
Skilled Care rehabilitation
service– 21 days plus 80 days
with $124/day deductible
May cover Home Health
Services (co-insurance applies)
Hospice Care
Public Financing - Medicare
• Part B – Medical Insurance (like major
medical insurance plan)
• Funded by monthly fixed-rate premiums
($96.40/mo 2008)
• Pays 80% of approved charges
Doctor’s services
Outpatient hospital services
Ambulance transportation
Diagnostic tests, lab, mammography
Physical , Occupational, Speech Therapy
outpatient or in rehab agency
NOT COVERED: prescription drugs, routine
physicals, dental, cosmetic, foot care,
hearing aids, vision
Public Financing - Medicare
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Part D – Prescription Drug
Voluntary participation
“Doughnut Hole” coverage
Monthly premium based on plan
chosen
Diagnosis Related Groups (DRG)
• A set fee is used , based on
illness category, to determine
hospital reimbursement
• Medicare and insurance
• Hospitals receive flat fee,
regardless of length of stay
• Hospital makes money if they
provide service for less than
DRG amount
• Goal – care provided in most
economical fashion possible
• Prospective-Payment system
Public Financing - Medicaid
• Medical assistance for low
income and disabled
• State establishes services and
requirements, including
eligibility
Health Care Financing –
Managed Care
HMO – Health Maintenance
Organization
• Prepaid fee paid to provider for
comprehensive care of the enrollees
• Encourage preventative medicine
• Discourage excessive tests and treatments
• Patient may not have option of choosing
physician each time treatment is needed
• Single point of entry
Health Care Financing –
Managed Care
Preferred Provider
Organization (PPO)
• Insurance companies contract
with groups (physicians and
hospitals) for discounted fees
• Patient may see anyone in the
network
Health Care Financing –
Managed Care
• Open Access – individuals may
see specialists within network
without a referral
• Gatekeeper – usually primary
physician – must give referral
before patient can see
specialist – goal is to keep
costs down
Issues
• US rankings by WHO
• #1 – dignity, provider choice,
confidentiality
• #37 – performance (outcomes vs
expenditures)
• #54 – fairness in financing
Hill, p. 317
Issues
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Uninsured
Uncompensated care
Aging population
Cost of government health care
programs
• Cost of prescription drugs
• Quality
Issues
• Limited resources – how are
they allocated, and to whom?
• Private vs National Healthcare
Nurses’ Response to
HCDS Issues
• Cost containment
• Quality Improvement
• Health, prevention focus
• NP’s providing care
• Education
HCDS Issues in the
Workplace
• Use of UAPs
• Nurse/Patient Ratios
• Acuity levels
• Mandatory Overtime
• Unionization
Assignment
• You are the self-employed head of
household for a family of four. Your gross
annual family income is $33, 280
(equivalent of $8/hr full time for 2 people).
• Research the cost of a family health
insurance policy with a $500 deductible.
• What is the monthly and annual cost of this
policy. What % of your annual income will
be spent on health insurance?