Health Care Delivery Systems

1. Health Care Delivery Systems

2. Health Care Delivery Systems • The health care industry is made up of many delivery systems. • A delivery system is a facility or organization that provides health care services. • Examples of delivery systems include hospitals, long-term care facilities, medical offices, laboratories, and nonprofit organizations.

3. Components of Delivery Systems • Services • Consumers • Health Care Personnel • Payment for Services

4. Hospitals • Size • Small • Large • Ownership • Proprietary • Nonprofit • Government • Religious • Services • General • Specialty

5. Long-Term Care Facilities • Provide long-term care for elderly patients and for patients in rehabilitation. • Levels of long-term care: • A nursing home provides care for patients who can no longer care for themselves. • An independent living facility allows patients to use only the services they need, such as transportation or housekeeping.

6. Medical Offices • Some medical offices are operated by just one or two doctors. Other are made of large groups of health care professionals. • Some medical offices treat a wide range of conditions. Others are specialized for specific ages or medical conditions.

7. Mental Health Services • A healthy mind is just as important as a healthy body. • Mental health professionals treat and counsel patients with a variety of conditions: • Mental disorders • Substance abuse and addiction • Domestic violence and abuse

8. Other Systems • Emergency care services • Laboratories • Hospice • Home Health Agencies

9. Government Facilities • Government health care facilities exist at several levels: • International • National • State • Local • Government facilities are supported by taxes.

10. World Health Organization • International agency sponsored by the United Nations • 192 member countries • The goal of W.H.O. is that all people obtain the highest possible level of health, including physical, mental, and social well-being.

11. Department of Health and Human Services • Its goal is to protect the health of American citizens and to provide essential human services, especially for those who cannot help themselves. • It is broken into many divisions, including: • National Institute of Health • Center for Disease Control and Prevention • Food and Drug Administration

12. Nonprofit Agencies • Focus on one disease or group of diseases. • Research, search for a sure, promote public awareness, and provide services to victims. • Supported by donations, membership fees, fundraisers, and government grants. • Examples include: • American Cancer Society • American Heart Association • American Red Cross

13. Organizational Structure • An organizational structure helps a facility run smoothly by outlining the responsibilities of employees. • Four divisions: • Informational • Support • Diagnostic • Therapeutic

14. Line of Authority • The line of authority determines a worker’s position in a facility’s organizational structure. • The line of authority also establishes levels of supervision.

15. Medical Office Structure • The organizational structure and line of authority at a community medical office is different from a large medical facility. • The doctor is the primary supervisor at a medical office.

16. Lesson 3– Interdependence • All members of the health care team are dependent on each other. • If one worker does not fulfill the required duties, the entire team is hindered.

17. Lesson 4– Trends • Technology • Epidemiology • Geriatric Care • Wellness • Cost Containment

18. Lesson 4– Technology • Computers and audiovisual devices • Telemedicine • “Long distance” surgery

19. Lesson 4– Epidemiology • Epidemiology is the study of diseases. • Many researchers are focusing of diseases that are influenced by lifestyle factors. • Taking responsibility for one’s own health is a growing trend in today’s world.

20. Lesson 4– Geriatric Care • Because people are living longer, geriatric care is in high demand. • Geriatric facilities have developed quickly in recent years: • Adult day care centers • Independent living facilities • Retirement communities • Nursing homes

21. Lesson 4– Wellness • Change in focus from “sick care” to “health care.” • Wellness centers include: • Weight control facilities • Health food stores • Nutritional services • Stress reduction counseling • Habit cessation management

22. Cost Containment • Outpatient Services – Reduce the length of hospital stays to reduce costs. • Preventive Care – Get regular check-ups and vaccinations to prevent illness. • Energy Conservation – Use energy-efficient lighting, solar power, and automatic faucets.

23. Health Insurance

24. Health Insurance • The rising cost of health care is good for the economy, but the expenses are a burden for most individuals and families. • In the 1920’s, the United States developed a system of health insurance to help cover the cost of medical expenses.

25. Health Insurance Terms • Premium – the amount paid to an insurance agency for a health insurance policy • Deductible - the amount that must be paid by the patient before the insurance agency will begin to make payments • Co-payment - an amount paid by the patient for a certain service • Out-of-pocket - a medical bill that must be paid by the patient

26. Individual and Group Insurance • Individual insurance is when a person purchases a policy and agrees to pay the entire premium for health coverage. • Group insurance is generally purchased through an employer. The premium is split between the employer and the person being insured.

27. Indemnity Insurance • In indemnity insurance, patients must pay for all health care expenses out of their own pockets. Afterward, the insurance agency will reimburse the patient for a percentage of the expenses. • Indemnity insurance does not work for everyone. Many people cannot afford to pay for their medical expenses out-of-pocket.

28. Managed Care • Two primary concepts of managed care: • To promote good health • To practice preventive medicine • Managed care plans offer medical services through a system of health care providers. The system of providers offers services at reduced rates.

29. Managed Care versus Indemnity • Payment for medical services • Choosing a health care provider

30. Reimbursement • Health insurance agencies do not always reimburse the full amount charged for services. • Physicians will either “absorb” the loss, or they will charge the patient for the amount that was not paid by the insurance agency.

31. Managed Care • Health Maintenance Organizations • Preferred Provider Organizations • Point of Service

32. Health Maintenance Organizations • Clients must pay a premium, deductible, and co-payments. • Clients must visit in-network doctors and select a primary care physician. • HMOs urge clients to practice healthy living and to receive preventive treatments.

33. Preferred Provider Organization • Clients must pay a premium, deductible, and co-payments. • Clients do not have to choose a primary care physician. • Clients may visit non-network physicians, but coverage is greater with in-network physicians. • PPOs often have other fees and co-payments.

34. Point of Service • Clients must pay a premium. • Clients must chose a primary care physician. • For in-network physicians, there is usually no deductible and co-payments are low. • Specialists may be non-network physicians, but coverage may be limited.

35. Socio-Economics • Socio-economics is the study of how economics is affected by society, culture, and politics. • Socio-economics has revealed the need for medical assistance for the elderly, disabled, and poor.

36. Government Programs • In the 20th century, the United States government began to realize the need for public medical assistance. • In 1965, President Lyndon B. Johnson instituted two medical assistance programs to help those without health insurance. • Medicaid • Medicare

37. Medicaid • Need-based program • Designed by the federal government, but administered by state governments • Provides medical assistance to individuals and families who are determined by the state to be “needy.” Each state must determine its own definition of “needy.”

38. Medicaid Service • Services typically include: • Hospital services • Prenatal care • Child vaccines • Pediatric services • Physician services • Diagnostic testing and X-rays • Rehabilitation and physical therapy • Prescription drugs • Home health care

39. Medicaid Limits • Medicaid is not guaranteed to every low-income individual. • If a low-income individual does not have children or is not disabled, this person may be unable to receive any medical insurance.

40. Medicare • Entitlement program for any citizen age 65 or older • Administered by the federal government • After an individual pays a deductible, Medicare will cover 80% of all medical expenses.

41. Medicare Services • Part A: Hospital Care • Hospitalization • Skilled nursing facilities • Home health care • Hospice care • Long-term care facilities • Part B: Outpatient Services • Medical expenses, including therapy, medical equipment, and testing • Preventive Care