Health Insurance

1:5 Health Insurance Plans A- Health Insurance - without insurance, the cost of an illness can mean financial disaster for an individual of family Example: Blue Cross-Blue Shield – premium is paid to the insurance company and insured individual is covered for certain health care expenses

B- Health Care Insurance Terms 1- Deductible 2- Co-insurance 3- Co-payment amounts paid by the patient for medical services before the policy begins to pay specific percentages of expenses shared by the patient and insurance company (80% - 20%) specific amount of money a patient pays for a particular service ($20 office visit)

C- Types of Health Insurance Plans 1- Health Maintenance Organization (HMO) a) monthly fee or premium is paid b) fee stays the same regardless of the amount of health care used c) Disadvantage: insured person required to use ONLY HMO affiliated health care providers – if not the patient pays the cost

2- Preferred Provider Organization (PPO) a) usually provided by large companies or industries to their employees c) person restricted to specific hospitals and doctors b) Industry or company forms a contract with certain health care agencies to provide health care at reduced rates

3- Medicare – pays 80% of services, patient pays balance or has additional insurance a) Federal government program b) Provides health care for almost all persons over the age of 65 and any person with a disability who has received Social Security Benefits c) Type A – hospital insurance – covers hospital services, care provided by an extended care facility, home-health care after hospitalization d) Type B – medical insurance – pay premium for doctor’s services, outpatient treatment, therapy, etc.

4- Medicaid – medical assistance program a) Operated by individual states- government program b) Usually pays for health care of individuals with low incomes, children who qualify for public assistance, and individuals who are disabled or blind

5- State Children’s Health Insurance Program (SCHIP) a) Established in 1997 b) Provides health care to uninsured children of working families who earn to little to afford private insurance but too much to be eligible for Medicaid

6- Worker’s Compensation – health insurance plan providing treatment for workers injured on the job a) In addition to providing payment for needed health care, also reimburses the worker for wages lost because of on the job injury

7- TRICARE (formerly called CHAMPUS (the Civilian Health and Medical Programs for the Uniform Services)) a) Provides health care for all active duty members, their families, survivors of personnel and retired members of the Armed Forces.

8- Managed Care – developed in response to rising cost of health care a) All health care provided to a patient must have a purpose b) Second opinion or verification is often required c) HMOs and PPOs are the main providers of managed care

1:6 Organizational Structure A- Complex in larger facilities and simple in smaller facilities B- Always encompasses a line of authority or chain of command

1:7 Trends in Health Care A- Cost Containment – trying to control the rising cost of health care and achieving the maximum benefit for every dollar spent

B- Reasons for High Health Care Costs 1- Technological Advances a) Heart, kidney and lung transplants can cost hundreds of thousands of dollars b) Computers that can examine internal body parts can cost millions of dollars

2- Aging Population a) Increases the use of pharmaceutical products (medications) b) Have more chronic diseases and need frequent health care services

3- Increase in Health Related Lawsuits a) Health care providers forced to obtain expensive malpractice insurance b) Health care providers forced to order diagnostic tests even though they may not be needed c) Health care providers practice defensive health care to avoid lawsuits

C- Methods of Cost Containment 1- Diagnostic Related Groups (DRGs) a) One way congress is trying to control costs for Medicare and Medicaid b) Patients with certain diagnoses who are admitted to the hospital are classified in one payment group c) Limit is placed on the cost of care and the agency is paid a set amount.

2- Combination of Services a) Done to eliminate duplication of services b) Health care agencies join together or share specific services so as to provide care to a larger number of people at a decreased cost per person

3- Outpatient Services a) Patients receive care without being admitted to the hospital 4- Mass or Bulk Purchasing a) Buying equipment and supplies in larger quantities at reduced prices by combining purchases of different departments

5- Early Intervention and Preventative Services a) Provide care before acute or chronic disease occurs b) Education, immunizations, regular physical exams, easy access for all individuals to preventative health care

6- Energy Conservation a) Monitoring the use of energy to control costs and conserve resources b) Major expenses for every health care facility are electricity, water and/or gas.

D- Home Health Care 1- shorter hospital stays and Diagnostic Related Groups (DRGs) have created need for providing care in the home 2- nursing care, physical therapy, occupational therapy, respiratory therapy, social services, nutrition and food service, etc.

E- Geriatric Care 1- care for the elderly rapidly growing 2- large number of individuals living longer 3- adult day care centers, retirement communities, long term care facilities, etc.

F- Omnibus Budget Reconciliation Act (OBRA) – led to development of many regulations regarding long term care and home health care 2. Requires: c) compliance with patients rights guidelines to ensure rights are observed and enforced a) training and competency evaluation programs for nursing and geriatric assistants b) continuing education, periodic evaluation of performance and retesting if out more than 2 years

G- Telemedicine 1. Uses video, audio and computer systems to provide medical and/or health care services H- Wellness 1- State of being in optimum health 2- Recognize the importance of exercise, good nutrition, weight control and health living habits

3- Factors and Ways to Promote Wellness a) Physical wellness b) Emotional wellness c) Social wellnessd) Mental and intellectual wellness e) Spiritual wellness 4- Holistic Health Care a) Promotes physical, emotional, social, intellectual, and spiritual well being by treating the whole body, mind and spirit

I- Alternative and Complementary Methods of Health Care 1- Alternative Therapies – methods of treatment that are used in place of biomedical therapies 2- Complementary Therapies – treatment that are used in conjunction with conventional medical therapies

3- Examples of alternative/complementary therapies a) Chinese medicine practioners – ancient holistic- based healing practice based on belief that life energy (chi) flows through every person B) Chiropractors – believe that the brain sends vital energy to all body parts through nerves in the spinal cord – misalignment causes pressure to be placed on nerves and disease results

4- Office of Alternative Medicine (OAM) a) Established at the National Institute of Health in 1992 because of the increase use of alternative and complementary therapies b) Researches various therapies and determines standards of quality care

J- National Health Care Plan 1- demand due to high cost of health care and the large number of uninsured individuals 2- one plan involves nationalized medicine – government would pay for all health services and levy taxes to pay for those services 3- goal is to ensure that all Americans can get health coverage

Assignment: Complete the packet “Unit 1 – Health Care Systems”