Health policy and delivery

1. HEALTH POLICY
AND THE DELIVERY SYSTEM
JACEY MITCHELL, RDH, MS
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2. The Patient Protection and Affordable Care Act (PPACA)
• New health care federal reform law signed in 2010 requiring the largest
change in the financing of the American health care system since the
enactment of Medicare and Medicaid
• Designed to address the issues of affordability, accessibility, and financing
of health care
• Focus efforts on meeting the needs of vulnerable populations
• US Supreme Court upheld the ACA in June 2012
• Will be fully enacted by 2018
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3. The Health of the Nation
• Measuring the nation’s health
• Health, United States report
• Informs policymakers of trends in nation’s health
• Healthy People 2020
• Goal is to increase quality and years of healthy life, and eliminate
health disparities
• World Health Organization (WHO) statistics
• Morbidity data
• Compares United States with other countries
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4. US Health Trends
• Successes in infection, other diseases
• Concerns: Sedentary lifestyle, obesity, chronic illness
• Health disparities persistent
• Contribute to unfavorable US health indicators
• Compromise progress in world health
• Vulnerable populations due to age, education, language, location
• Work environment changes identified for a safer US health care system
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5. A Safer System
• The health care delivery system in the United States is experiencing changes sparked by
health care reform, recommendations from large organizations involved in forming
health policy.
• The Institute of Medicine (IOM) conducts research from a systems approach to advise
the nation in improving health.
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6. Global Health
• The World Health Organization’s (WHO) overriding objective is to influence health
opportunities and outcomes for all people so that they can attain the highest possible
level of health.
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7. Split Between Preventative
and Curative Measures
• Early prevention
• Within medical practice
• Focus on poor
• Development of preventative services
• Within public health
• Incorporated clinical medicine (immunizations, screenings)
• Evolution: Emphasis on societal values
• Government involvement in financing
• Health care reform efforts to address health care barriers
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8. Organization of the Delivery System
• Source of power—shared federal/state
• Federal: Tax/spend general welfare
• State: Health authority based on 10th Amendment
• Influence of political philosophy
• Future health policy
• Lack of political consensus
• Major factors: Cost, access, quality
• Selected initiatives: Health savings accounts (HSA) and electronic records
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9. Official Health Care Agencies
Type of
Agency
Key Characteristics
Local  Local health department
 Direct services to public
State  State health department
 Policy, planning, program coordination
Federal  Run by executive and legislative branches—
determine health policy
 USHHS—administers policy
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10. Official Health Care Agencies (Cont.)
Type of Agency/
Personnel
Key Characteristics
Chief Nursing
Officer
 Serves in US Public Health Service
 Works with US Surgeon General on nursing and
public health policy
Military Health
Systems
 Department of Defense health system
 Active duty personnel, dependents, retirees
Wounded Warrior
Care
 Extensive rehabilitation to return soldiers to active
duty or transition to VA health system
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11. Health Care Legislation and Agencies
Legislation/ Agencies Key Information
Americans with
Disabilities
 Prohibit job discrimination and require services to
people with disabilities
Patient Self-
Determination Act
 Advanced directives for health care
Federal Health
Information Privacy
 Safeguards security/confidentiality of health
information
International-
WHO
 Worldwide guidance in promoting world health
through standards, programming, and
collaboration
Voluntary (not-for-profit)  Influence policy/legislation
 Philanthropic (nongovernmental)
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12. Financing Health Care
• Costs
• Increasing due to multiple factors
• Less time in system for health promotion
• Sources
• Government (Medicare, Medicaid)
• Third-party payment (insurance)
• Independent sources
• Out-of-pocket: deductibles, co-pays, health savings accounts
• Mechanisms
• Independent nursing practice (APNs)
• Payment
• Salary—set amount for services in time frame
• Capitation—flat fee regardless of services used
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13. Financing Health Care (Cont.)
• Cost-containment initiatives
• Prospective payment system, limits on provider payments, Medicare
Advantage (MA) plans
• Care management
• Determines and coordinates care
• Across continuum of health care services
• Reduce waste, improve quality, control costs
• Managed care issues
• Quality of care vs. cost control
• PCP as gatekeeper
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14. Financing Health Care (Cont.)
• Health insurance
• Private insurance
• Traditional insurance companies (BC/BS)
• PPOs—“brokers” between insurers/providers
• HMOs—prepayment plans
• POS—combination of HMOs and PPOs
• Self-insurance/self-funded
• Public insurance/assistance
• Medicare
• Medicaid
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15. Medicare
Title XVIII, Social Security Act
• Federal program
• Paid through taxes
• Finances medical care for:
• People over 65
• Disabled
• People with end-stage renal disease
• Hospice
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16. Medicare
Title XVIII, Social Security Act (Cont.)
• Part A
• Inpatient care in hospitals, skilled nursing facilities, home health care, hospice
• Part B
• Supplementary voluntary coverage
• Pays doctor’s visits
• Part D
• Pharmaceutical costs—multiple plans available
• Challenges
• Growth in elderly population
• Depletion of Medicare resources (trust fund)
• Uncovered services (glasses, hearing aids)
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17. Medicaid
Title XIX, Social Security Act
• Assistance program managed jointly by federal and state funds
• State-determined eligibility
• Costs up to 50% of state budgets—open-ended program
• Benefits vary by state
• Available to:
• Certain low-income individuals
• No age requirements
• Families with children: 5-year lifetime limit
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18. The Uninsured
• Of all developed countries, the United States has the highest proportion of
population with no health insurance
• 2008: 46 million uninsured younger than age 65
• Most uninsured individuals live in families in which there is at least one
full-time worker
• Groups at most risk
• Persons of Mexican origin
• Young adults
• Working uninsured
• Illegal aliens
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19. The Uninsured (Cont.)
• The Affordable Care Act is expected to reduce the
number of uninsured people by 60% through the
use of the following measures
• Expansion of Medicaid
• Subsidies to pay premiums in health insurance
exchanges
• A federal mandate requiring most legal citizens to
enroll in an insurance plan or face tax penalties for
noncompliance
• A provision allowing children to remain on employer
family insurance until the age of 26
• Health Insurance Portability and Accountability
Act (HIPAA)
• Provisions for maintaining coverage if lose/leave job
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20. Health Care Systems in Other Countries
• Canadian health care system
• Universal coverage; social insurance plan
• Private plans available for unpaid services
• Issues: 2-tiered system, shortage of providers, delays in service
• German health care system
• Nearly universal access (87%), but private insurance (10%) pays providers better
• Issues: 2-tiered system, weakening public system, increased cost
• United Kingdom health care system
• National health insurance—spends least on health care per capita
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