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Health Care Delivery System. Evolution of HCDS Early 20 th Century – Prepaid medical plans –lumber and mining camps Nursing care still focused in homes.

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Presentation on theme: "Health Care Delivery System. Evolution of HCDS Early 20 th Century – Prepaid medical plans –lumber and mining camps Nursing care still focused in homes."— Presentation transcript:

1 Health Care Delivery System

2 Evolution of HCDS Early 20 th 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

3 1960s – 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 1970s – 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

4 1980s – Focus on Cost Control OBRA – Omnibus Budget Reconciliation Act (peer review, quality, restraints, payment to midwives) DRGs (Diagnosis Related Groups) HMOs increase Technology proliferates AIDS discovered 1980s – Focus on Cost Control – OBRA – Omnibus Budget Reconciliation Act (peer review, quality, restraints, payment to midwives) HMOs increase Technology proliferates AIDS discovered

5 1990s – Medicaid and welfare program reforms: welfare to work SCHIP – Childrens health insurance program UAPs (unlicensed assistive personnel) 2000s – More telemedicine utilization

6 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

7 Secondary – Early detection, Diagnosis and Treatment Screening, diagnosis Acute Care Surgery

8 Tertiary – Restorative and Rehabilitation actviities– return to optimal functioning Education and retraining Environmental modifications Provision of direct care

9 Health Care Settings Hospitals – General and specialized Proprietary Teaching and Research Public Voluntary

10 Health Care Settings Ambulatory Services Outpatient departments Physician group practices HMOs Nursing Care Centers Community Health Clinics Indian Health Service Ambulatory Care Facilities (urgent care centers)

11 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

12 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

13 EMT ??? Has a minimum 2 year preparation and performs diagnostic measures involving radiant energy

14 X-ray technician ??? A nurse who has studied an additional 2-3 years in an approved school or anesthesiology

15 CRNA (Certified Registered Nurse Anesthetist) ???Graduate of a month program and passed a certifying exam - provides treatments for breathing

16 Respiratory Therapist ???? Provides assistance for mobility and exercises – has completed a 2 year program

17 PTA – Physical Therapy Assistant ??? Has completed 4-5 years of education plus an internship regarding nutritional problems and therapeutic diets

18 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

19 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 masters degree.

20 Social Worker (MSW)

21 Financing Public Private Third Party

22 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

23 Fee for Service - Terminology Premium Deductible Co-Payment Co-Insurance Health Care Provider

24 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

25 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 Doctors 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

26 Public Financing - Medicare Part D – Prescription Drug Voluntary participation Doughnut Hole coverage Monthly premium based on plan chosen

27 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

28 Public Financing - Medicaid Medical assistance for low income and disabled State establishes services and requirements, including eligibility

29 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

30 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

31 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

32 Issues US rankings by WHO #1 – dignity, provider choice, confidentiality #37 – performance (outcomes vs expenditures) #54 – fairness in financing Hill, p. 317

33 Issues Uninsured Uncompensated care Aging population Cost of government health care programs Cost of prescription drugs Quality

34 Issues Limited resources – how are they allocated, and to whom? Private vs National Healthcare

35 Nurses Response to HCDS Issues Cost containment Quality Improvement Health, prevention focus NPs providing care Education

36 HCDS Issues in the Workplace Use of UAPs Nurse/Patient Ratios Acuity levels Mandatory Overtime Unionization

37 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?


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