Health Care Systems

1. Health Care Systems Where Do You See Yourself?

2. Private Health Care Facilities • According to US government statistics, health care is one of the largest and fastest-growing industries in the US. • This industry employs over 13 million workers in more than 200 different health careers. • Many different health care facilities provide services that are a part of the industry called health care. • Most private health care facilities require a fee for services.

3. Hospitals • One of the major types of health care facilities • Vary in size and types of service provided • Classified as private or propriety (operated for profit), religious, nonprofit or voluntary, and government, depending on the sourced of income received by the hospital.

4. Hospitals • General Hospitals: treat a wide range of conditions and age groups; usually provide diagnostic, medical, surgical, and emergency care services • Specialty Hospitals: provide care for special conditions or age groups • Ex: Burn, Oncology (cancer), Pediatric (children’s), psychiatric (mental diseases and disorders, orthopedic, rehabilitation

5. Hospitals • Government Hospitals: operated by federal, state, and local government agencies • University or College Medical Centers: provide hospital services along with research and education

6. Long-Term Care Facilities • Mainly provide assistance and care for elderly patients, usually called residents. • Also, provide care for individuals with disabilities or handicaps and individuals with chronic or long-term illness • Residential Care Facilities: (nursing homes, geriatric homes) designed to provide basic physical and emotional care for themselves

7. Long-Term Care Facilities • Extended Care Facilities or Skilled Care Facilities: provide skilled nursing care and rehabilitative care to prepare patients or residents for return to home environments or other long-term care facilities • Independent Living/Assisted Living: allows individuals who can care for themselves to rent or purchase an apartment in the facility

8. Medical Offices • Vary from offices that are privately owned by one doctor to large complexes that operate as corporations and employ many doctors and other health care professionals • Services can include: diagnosis, treatment, examination, basic laboratory testing, minor surgery, and other similar care

9. Dental Offices • Vary in size from offices that are privately owned by one or more dentists to dental clinics that employ a group of dentists • Services can include: general care, specialized care, care for certain dental conditions

10. Clinics or Satellite Centers • Health care facilities found in many types of health care • Surgical Clinics/ Surgicenters: perform minor surgical procedures; aka: one-day surgical centers • Urgent/Emergency Care Clinics: provide first aid or emergency care to ill or injured pt • Rehabilitation Clinics: offer physical, occupational, spech, and other similar therapies

11. Clinics or Satellite Centers • Specialty Clinics: provide care for specific diseases; ex: DM, kidney dialysis, oncology • Outpatient Clinics: usually operated by hospitals or large medical groups • Health Dept Clinics: may offer clinics for pediatric health care, tx of STD and respiratory disease, immunizations, and other special services

12. Clinic or Satellite Centers • Medical Center Clinics: usually located in colleges or universities; offer clinics for various health conditions; offer care and treatment and provide learning experiences for medical students

13. Optical Centers • Can be individually owned by an ophthalmologist or optometrist or they can be part of a large chain of stores • Provide vision exams, rx eyeglasses or contact lenses, and check for the presence of eye diseases

14. Emergency Care Services • Provide special care for victims of accidents or sudden illness • Ex: ambulance (private and government), rescue squads, emergency care clinics and centers

15. Laboratories • Often a part of other facilities but can operate as separate health care services • Can perform special diagnostic tests • Dental laboratories can prepare dentures and many other devices used to repair or replace teeth

16. Home Health Care • Designed to provide care in a patient’s home • Ex include: nursing care, personal care, therapy, and homemaking • Health dept, govt agencies, and nonprofit or volunteer groups can offer home care services.

17. Hospice • Provide care for terminally ill persons who usually have life expectancies of 6 months or less • Care can be provided at home or in a hospice facility • Gives the pt the chance to die with dignity • Psychological, social, spiritual, and financial counseling are provided for both the patient and the family • Also provides support to the family following a patients death

18. Mental Health Facilities • Txpts with mental disorders and diseases • Ex: Guidance and Counseling Centers • Psychiatric Clinics and Hospitals • Chemical Abuse Tx Centers • Physical Abuse Tx Centers

19. Genetic Counseling Centers • Can be independent facility or located in another facility • Hospitals • Clinics • Physician’s Office • Work with couples or individuals who are pregnant or considering a pregnancy

20. Genetic Counseling Centers • Perform prenatal screening tests • Check for genetic abnormalities and birth defects • Explain the results of the tests • Identify medical options when a birth defect is present • Help the individuals cope with the psychological issues caused by a genetic disorder

21. Rehabilitation Facilities • Located in hospitals clinics, and/or private centers • Provide care to help pts with physical or mental disabilities obtain max self-care and function • Services: physical, occupational, recreational, speech, and hearing therapy

22. Health Maintenance Organizations • Provide total health care directed toward preventive health care for a fee that is usually fixed and prepaid • Services: Exams, Basic Medical Services, Health Education, and Hospitalization or Rehab • Some are operated by large industries or corporations • Others are operated by private agencies • Often use the services of other HC facilities including medical and dental offices, hospitals, rehabilitative centers, home health agencies, clinics, and labs

23. Industrial Health Care Centers • Occupational Health Clinics: found in large companies or industries • Provide HC for employees of the industry or business by performing: • basic exams • teaching accident prevention • providing emergency care

24. School Health Services • Found in schools and colleges • Provide emergency care for victims of accidents and sudden illnesses • Perform tests to check for health conditions • Speech, vision, and hearing • Promote health education • Maintain a safe and sanitary school environment

25. Government Agencies • World Health Organizations (WHO) • U.S. Department of Health and Human Services (USDHHS) • National Institutes of Health (NIH) • Centers for Disease Control and Prevention (CDC) • Food and Drug Administration (FDA) • Agency for HC Policy and Research (AHCPR) • Occupational Safety and Health Administration (OSHA) • Health Dept

26. Government Agencies • WHO: an international agency sponsored by the United Nations; compiles stats and info on disease, publishes health info, and investigates and addresses serious health problems throughout the world • USDHHS: a national agency that deals with the health problems in the US • NIH: a division of the USDHHS; involved in research on disease

27. Government Agencies • CDC: another division of the USDHHS; concerned with causes, spread, and control of diseases in populations • FDA: a federal agency responsible for regulating food and drug products sold to the public • AHCPR: a federal agency est in 1990 to research the quality of HC and identify the standards of tx that should be provided by HC facilities

28. Government Agencies • OSHA: establishes and enforces standards that protect workers from job-related injuries and illnesses • Health Dept: provide health services as directed by the USDHHS; also provide specific services needed by the state or local community;

29. Voluntary or Nonprofit Agencies • Supported by donations, membership fees, fund-raisers, and federal/state grants • Provide health services at national, state, and local levels • Ex: American Cancer Society • American Heart Associations • American Respiratory Disease Association • National Kidney Foundation • Leukemia Lymphoma Society • Etc

30. Voluntary or Nonprofit Agencies • Many org focus on one specific disease or group of diseases • Studies the disease • Provides funding to encourage research directed at curing or tx the disease • Promotes public education regarding info obtained via research • Provide special services to victims of disease • Purchasing medical equipment and supplies • Providing tx centers • Supplying info regarding other community agencies that offer assistance

31. Health Insurance Plans • Cost of HC is a major concern • HC costs are increasing much faster than other costs of living • To pay for the costs of HC, most people rely on health insurance plans. • Offered by several thousand insurance agencies • Ex: Blue Cross/Blue Shield

32. Health Insurance Plans • Premium: a fee the individual pays for insurance coverage (made to the insurance company) • Deductibles: amounts that must be paid by the pt for medical services before the policy begins to pay • Co-insurance: requires that specific percentages of expenses are shared by the pt and insurance company; ex: 80-20, the company pays 80 and the pt pays 20

33. Health Insurance Plans • Co-payment: a specific amount of money a pt pays for a particular service • Many individuals have insurance coverage via their places of employment (employer-sponsored health insurance or group insurance) • The individual also pays a percentage of the premium

34. Health Insurance Plans • HMO: provides a managed care plan for the delivery of HC services • Monthly fee or premium is paid for membership • Fee stays the same regardless of the amount of HC used • Premium can be paid by an employer and/or an individual • Total care provided is directed toward preventive type HC • Individual insured under this type of plan has ready access to health exams and early tx and detection of disease

35. Health Insurance Plans • Disadvantages: the insured is required to use only HMO-affiliated HC providers for HC • Preferred Provider Organization (PPO): another type of managed care health insurance plan usually provided by large industries or companies to their employees • Forms a contract with certain HC agencies to provide certain types of HC at reduced rates • Employees are restricted to using the specific hospital and/or doctors, but the industry or company using the PPO can provide HC at lower rates

36. Health Insurance Plans • PPO usually requires a deductible and co-payment • If an enrollee uses a nonaffiliated provider, the PPO may require co-payments of 40-60 percent • Medicare: a federal gov’t program that provides HC for almost all individuals over the age of 65, for any person with a disability who has received Social Security Benefits for at least 2 years, and for any person with end-stage renal disease

37. Health Insurance Plans • Consists of 3 kinds of coverage: • A: covers hospital services, care provided by an extended care facility or home-health care agency after hospitalization, and hospice care for people with a terminal illness • B: offers additional coverage for doctors’ services, outpatient tx, therapy, clinical lab services, and other HC; individual does pay a premium for type B coverage and also must pay an initial deductible for services; pays for only 80% of the services; must pay the balance or have another insurance policy to cover the expenses • D: pharmaceutical expenses

38. Health Insurance Plans • Medigap: health insurance plans that help pay expenses not covered by Medicare • Offered by private insurance companies and require the payment of a premium by the enrollee • Policies must meet specific federal guidelines • Provide options that allow enrollees to choose how much coverage they want to purchase

39. Health Insurance Plans • Medicaid: a medical assistance program that is jointly funded by the federal gov’t and state gov’t but operated by individual states • Benefits and individuals covered under this program vary slightly from state to state • Each state has the right to establish its own eligibility standards, determine the type and scope of services, set the rate of payment for services, and administer its own program

40. Health Insurance Plans • Medicaid pays for the HC of individuals with low incomes, children who qualify for public assistance, and individuals who are physically disabled or blind • Provide hospital services, physician’s care, long-term care services, and some therapies • In some states, offers dental care, eye care, and other specialized services

41. Health Insurance Plans • State Children’s Health Insurance Program (SCHIP): est in 1997 • Provide HC to uninsured children of working families who earn too little to afford private insurance but too much to be eligible for Medicaid • Provides inpatient and outpatient hospital services, physician’s surgical and medical care, lab and X-ray tests, and well-baby and well-child care, including immunications

42. Health Insurance Plans • Workers’ Compensation: health insurance plan providing tx for workers injured on the job • Administered by the state, and payments are made by employers and the state • Also reimburses the worker for wages lost because of on-the-job injury

43. Health Insurance Plans • TRICARE: formerly called CHAMPUS (Civilian Health and Medical Programs for the Uniform Services • A US gov’t health insurance plan for all military personnel • Provides care for all active duty members and their families, survivors of military personnel, and retired members of the Armed Forces • Veterans Administration provides for military veterans

44. Health Insurance Plans • Managed Care: an approach that has developed in response to rising HC costs • Want to ensure that such money is spend efficiently rather than wastefully • Principle behind managed care: all HC provided to a pt must have a purpose • Second opinion/Verification of need is frequently required before care can be provided

45. Health Insurance Plans • Every effort is made to provide preventive care and early diagnosis of disease to avoid the high cost of tx disease • Employers and insurance companies create a network of doctors, specialists, therapists, and HC facilities that provide care at the most reasonable cost • Individual receives quality care at the most reasonable cost but is restricted in choice of HC providers

46. Health Insurance Plans • Health Insurance Portability and Accountability Act (HIPAA) • HC Access, Portability, and Renewability • Preventing HC Fraud and Abuse; Administrative Simplification, and Medical Liability Reform • Tax-Related Health Provisions • Application and Enforcements of Group Health Plan Requirements • Revenue Offsets

47. Health Insurance Plans • Health Care Access, Portability, and Renewability • Limits exclusions on preexisting conditions to allow for the continuance of insurance even with job changes • Prohibits discrimination against an enrollee or beneficiary based on health status • Guarantees renewability in multiemployer plans • Provides special enrollment rights for individuals who lost insurance coverage in certain situations such as divorce or termination of employment

48. Health Insurance Plans • Preventing Health Care Fraud and Abuse; Administrative Simplification, and Medical Liability Reform • Establishes methods for preventing fraud and abuse • Imposes sanctions or penalties if fraud or abuse does occur • Reduces the costs and administration of HC by adopting a single set of electronic standards to replace the wide variety of formats used in HC • Provides strict guidelines for maintaining the confidentiality of HC information and the security of HC records • Recommends limits for medical liability

49. Health Insurance Plans • Tax-Related Health Provisions: • Promotes the use of medical savings accounts (MSAs) by allowing tax deductions for monies placed in the accounts • Establishes standards for long-term care insurance • Allows for the creation of state insurance pools • Provides tax benefits for some health care expenses

50. Health Insurance Plans • Application and Enforcement of Group Health Plan Requirements: • Establishes standards that require group health care plans to offer portability, access, and renewability to all members of the group