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Ch13 outline
- 1. Health Care Delivery inthe United States Chapter 13
- 2. Introduction • Health caredelivery in U.S. is unlike other developed countries • Is delivered by an array of providers in a variety of settings • Is paid for in a variety of ways • Is U.S. health care a “system?”
- 3. History of HealthCare Delivery in the U.S. • Self-care has been a category of health care throughout history and today • Assumed self-care occurs before seeking professional help • From colonial times through late 1800’s, anyone trained or untrained could practice medicine • Past medical education not as rigorous as today
- 4. History of HealthCare Delivery in the U.S. • Early medical education not grounded in science; experience-based only, prior to 1870 • Most care was provided in patients’ homes • Hospitals only in large cities and seaports • Functioned more in a social welfare manner • Not clean; unhygienic practice • Almshouses • Pesthouses
- 5. Health Care Deliveryin the Late 1800’s – Early 1900’s • Care moved from patient’s home to physician’s office and hospital • Building and staffing better; designed for patient care; trained people; medical supplies • Reduced travel time • Science had bigger role in medical education • Mortality decline due to improved public health measures
- 6. Health Care Deliveryin the Late 1800’s – Early 1900’s • Early 1920s chronic diseases passed communicable as leading causes of death • New procedures: X-ray, specialized surgery, chemotherapy, ECG • Training: doctors and nurses more specialized • 1929 – 3.9% GDP on health care • Two party system – patients and physicians • Physicians collected own bills, set and adjusted prices based on ability to pay
- 7. Health Care Delivery– 1940s and 1950s • WWII impact • Due to wage restrictions employers used health insurance to lure workers • Huge technical strides in 1940s and 1950s • Hill-Burton Act • Improved procedures, equipment, facilities meant rise in cost of health care • Concept of health care as basic right vs. privilege
- 8. Health Care Delivery– 1960s • Late 1950s had overall shortage of quality care and maldistribution of health care services • Increased interest in health insurance • Third-party payment system became standard method of payment • Cost of health care rose • Increased access, little expense for those with insurance; those without unable to afford care • 1965 Medicare and Medicaid
- 9. Health Care Delivery– 1970s • Health Maintenance Organization Act of 1973 • National Health Planning and Resources Development Act of 1974 • Health Systems Agencies in place to cut costs and prevent building unnecessary facilities and purchasing unnecessary equipment
- 10. Health Care Delivery– 1980s • Reagan and Congress eliminated Health System Agencies • Deregulation of health care delivery • Proliferation of new medical technology • Questions in medical ethics • Elaborate health insurance programs
- 11. Health Care Delivery– 1990s • American Health Security Act of 1993 • Managed care • Achieve efficiency • Control utilization • Determine prices and payment • 1996 – U.S. health care bill $1 trillion; 13.6% GDP • CHIP
- 12. Health Care Deliveryin the 21st Century • 2010 – U.S. health care costs $2.6 trillion; 17.3% GDP • Health care costs outpacing inflation for past few decades • America spends more per capita annually on health care than any other nation • Still no national Patient Bill of Rights • Health Savings Accounts • 2010 – Affordable Care Act
- 13. Health Care Structure •Spectrum of health care delivery • Various types of care • Types of health care providers • Health care facilities and their accreditation
- 14. Spectrum of HealthCare Delivery • Population-based public health practice • Medical practice • Long-term practice • End-of-life practice
- 15. Population-Based Practice • Interventionsaimed at disease prevention and health promotion • Health education • Empowerment and motivation • Much takes place in governmental health agencies • Also occurs in a variety of other settings
- 16. Medical Practice • Primarymedical care • Clinical preventive services; first-contact treatment; ongoing care for common conditions • Secondary medical care • Specialize attention and ongoing management • Tertiary medical care • Highly specialized and technologically sophisticated medical and surgical care • For unusual and complex conditions
- 17. Long-Term Practice • Restorativecare • Provided after surgery or other treatment • Rehab care, therapy, home care • Inpatient and outpatient units, nursing homes, other settings • Long-term care • Help with chronic illnesses and disabilities • Time-intensive skilled care to basic daily tasks • Nursing homes and various settings
- 18. End-of-Life Practice • Servicesprovided shortly before death • Hospice care • Terminal diagnosis • Variety of settings
- 19. Spectrum of HealthCare Delivery
- 20. Types of HealthCare Providers • 14.5 million workers in U.S. (10.4% of pop.) • 41.3% in hospitals; 25.6% in ambulatory care settings; 16.3% in nursing/residential facilities • Over 200 types of careers in industry • Independent providers • Limited care providers • Nurses • Nonphysician practitioners • Allied health care professionals • Public health professionals
- 21. Independent Providers • Specializededucation and legal authority to treat any health problem or disease • Allopathic and osteopathic providers • Nonallopathic providers
- 22. Allopathic and OsteopathicProviders • Allopathic providers • Produce effects different from those of diseases • Doctors of Medicine (MDs) • Osteopathic providers • Relationship between body structure & function • Doctors of Osteopathic Medicine (DOs) • Similar education and training • Most DOs work in primary care
- 23. Nonallopathic Providers • Nontraditionalmeans of health care • Complementary and Alternative medicine (CAM) • Used together with conventional medicine, therapy is considered “complementary”; in place of considered “alternative” • Chiropractors, acupuncturists, naturopaths, etc. • Natural products, mind-body medicine, manipulation, etc.
- 24. Limited (or Restricted)Care Providers • Advanced training in a health care specialty • Provide care for a specific part of the body • Dentists, optometrists, podiatrists, audiologists, psychologists, etc.
- 25. Nurses • Over 4million working in nursing profession • Licensed Practical Nurses (LPNs) • 1-2 years of education in vocational program • Pass licensure exam • Registered Nurses (RNs) • Completed accredited academic program • State licensure exam • Advanced Practice Nurses (APNs) • Master or Doctoral degrees
- 26. Nonphysician Practitioners • Practicein many areas similar to physicians, but do not have MD or DO degrees • Training beyond RN, less than physician • Nurse practitioners, certified midwives, physician assistants
- 27. Allied Health CareProfessionals • 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
- 28. Public Health Professionals •Work in public health organizations • Usually financed by tax dollars • Available to everyone; primarily serve economically disadvantaged • Public health physicians, environmental health workers, epidemiologists, health educators, public health nurses, research scientists, clinic workers, biostatisticians, etc.
- 29. Health Care Facilities& Their Accreditation • Physical settings where health care is provided • Inpatient care facilities • Patient stays overnight • Outpatient care facilities • Patient receives care and does not stay overnight
- 30. Inpatient Care Facilities •Hospitals, nursing homes, assisted-living • Hospitals often categorized by ownership • Private – profit making; specialty hospitals • Public – supported and managed by government jurisdictions • Voluntary – not-for-profits; ½ of U.S. hospitals • Teaching and nonteaching hospitals • Full-service or limited-service hospitals
- 31. Clinics • Two or more physicians practicing as a group • Do not have inpatient beds • For-profit and not-for-profit • Tax funded • Public health clinics, community health centers • Over 1,100 community health centers in U.S. • Support primary health care needs of underserved populations in the U.S.
- 32. Outpatient Care Facilities •Care in a variety of settings, but no overnight stay regardless of why patient is in the facility • Health care practitioners’ offices, clinics, primary care centers, ambulatory surgery centers, urgent care centers, services offered in retail stores, dialysis centers, imaging centers
- 33. Rehabilitation Centers • Workto restore function • May be part of a clinic or hospital, or freestanding facilities • May be inpatient or outpatient
- 34. Long-Term Care Options •Nursing homes, group homes, transitional care, day care, home health care • Home health care • Growing due to restructuring of health care system, technological advances, and cost containment
- 35. Accreditation of HealthCare Facilities • Assists in determining quality of health care facilities • Process by which an agency or organization evaluates and recognizes an institution as meeting certain predetermined standards • Joint Commission • Predominant accrediting organization
- 36. Health Care SystemFunction • U.S. “system” unique compared to other countries • Recent decades’ challenges led to new legislation • Affordable Care Act • Goal: to put American consumers back in charge of their health coverage and care • Signed into law March, 2010; changes to be implemented 2010-2020; some effective mid- 2010; bulk go into effect 2014
- 37. Structure of theHealth Care System • U.S. structure – complex, expensive, many stakeholders, intertwined policies, politics • Major issues: • Cost containment, access, quality • All equally important; expansion of one compromises other two
- 39. Access to HealthCare
- 40. Access to HealthCare • Variety of means to gain access • Insurance coverage and generosity of coverage are major determinants of access to health care • 2009 – 46.3 million uninsured (15.4%); 58.5 million uninsured for part of the year (19.4%) • Likelihood of being uninsured greater for those: young, less education, low income, nonwhite • Greatest reason for lack of insurance: cost
- 41. Access to HealthCare • 8 out of 10 uninsured are from working families • Medically indigent • Working poor • Major component of Affordable Care Act is increasing the number of Americans with health insurance
- 42. Quality of HealthCare • Doing the right thing, at the right time, in the right way, for the right people, and having the best results • Quality health care should be: • Effective • Safe • Timely • Patient centered • Equitable • Efficient
- 43. The Cost ofand Paying for Health Care
- 44. The Cost ofand Paying for Health Care • Reimbursement • Fee-for-service • Packaged pricing • Resource-based relative value scale • Prepaid health care • Prospective reimbursement
- 45. Health Insurance • Arisk and cost-spreading process, like other insurance • Cost is shared by all in the group • Generally “equitable,” but increased risk may lead to increased costs
- 46. Health Insurance Policy • Policy • Premiums • Deductible • Co-insurance • Copayment • Fixed indemnity • Pre-existing condition • HIPPA
- 47. Types of HealthInsurance Coverage
- 48. The Cost ofHealth 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
- 49. Self-Funded Insurance Programs •Programs created for/by employers rather than using commercial insurance carriers • Many benefits to the employer • Generally for larger companies, unless low- risk employees
- 50. Health Insurance Providedby the Government • Government health insurance plans only available to select groups • Medicare • Medicaid • Children’s Health Insurance Program • Veterans Administration benefits • Indian Health Services • Federal employees • Health care for the uniformed services • Prisoners
- 51. Medicare • Covers morethan 46.5 million people • Federal health insurance program for those: • 65+, permanent kidney failure, certain disabilities • SSA handles enrollment • Contributory program through FICA tax • Four parts • Hospital insurance (Part A), medical insurance (Part B), managed care plans (Part C), prescription drug plans (Part D)
- 52. Medicare • Part A– mandatory; has deductible & co- insurance • Part B – those in part A automatically enrolled unless decline; has deductible & co-insurance • Part C – offered by private insurance companies; not available in all parts of U.S. • Part D – optional; run by insurance companies; monthly premiums; large number of plan available; complex to navigate • Uses DRGs
- 53. Medicaid • Health insuranceprogram for low-income; no age requirement • 46+ million covered by Medicaid • Eligibility determined by each state; very costly budget item for states • Noncontributory program
- 54. CHIP • Created in1997 for 10 years • Reauthorized in 2009 through 2013 • Funding assisted by increase in federal excise tax rate on tobacco • 2009 – 7.8 million children enrolled • Targets low-income children ineligible for Medicaid • State/federal program
- 55. Problems with Medicareand Medicaid • Programs created to help provide health care to those who might have impossibilities of obtaining health insurance • Recurrent problems: • Some providers do not accept Medicare or Medicaid as forms of payment • Medicare/Medicaid fraud
- 56. Supplemental Health Insurance •Help cover out-of-pocket costs not covered through primary insurance • Medigap • Specific-disease insurance • Fixed-indemnity • Long-term care insurance • Preserve financial assets, prevent need for family or friends to provide care, enable people to stay independent longer, easier to go into facility of choice
- 57. Who pays forlong-term care?
- 58. Managed Care • Goalto control costs by controlling health care utilization • 2010 – 135 million enrolled in managed care plan • Managed by MCOs • Have agreements with providers to offer services at reduced cost • Common features – provider panels, limited choice, gatekeeping, risk sharing, quality management and utilization review
- 59. Types of ManagedCare • Preferred provider organization (PPO) • Exclusive provider organization (EPO) • Health maintenance organization (HMO) • Staff model HMO • Independent practice association (IPA) • Other HMO models
- 60. Other Arrangements for Delivering Health Care • National health insurance • A system in which the federal government assumes responsibility for health care costs of entire population; primarily paid for with tax dollars • U.S. only developed country without national health care plan • Seven failed attempts at national health care in U.S. over past 70 years • State health plans
- 61. Health Care Reformin the United States • Consumer-directed health plans (CDHPs) • Consumer responsibility for health care decisions with tax-sheltered accounts • Health savings accounts • High reimbursement arrangements • Affordable Care Act
- 62. Discussion Questions • Howdoes payment for health care services affect the various types of health care providers now and in the future? • What changes will need to occur for all U.S. citizens to have affordable health insurance? • Is the Affordable Care Act going to effectively combat the numerous problems within the U.S. health care system?