Chapter 2 Health Care Systems

2:1 Private Health Care Facilities Growth—one of the largest and fastest growing industries in the United States Employment opportunities—employs over 13 million workers in over 200 careers Expenditures—it is a four-billion-dollar- per-day business and growing (continues)

Private Health Care Facilities Hospitals – General, Specialty, Govt. & University Clinics or satellite centers – Smaller or Specialty (Pediatrics, Cancer, Radiology, Pharmacy, Outpatient, Surgical) Medical Offices (Dental offices, Optical) Laboratories – Blood & Urine tests Emergency care services - Minor care Mental Health Facilities – psychiatric, abuse, alcohol, drug Genetic Counseling Centers – Pregnant or considering Rehabilitation Facilities (PT & OT or Speech Therapy)

Private Health Care Facilities (Elderly) Long-Term Care Facilities Nursing Home Independent living and/or assisted living Elderly Community Home Health Care Care in the Patients home, usually the elderly or disabled. Hospice agencies Terminally ill patients have life expectancy of 6 months or less

Private Health Care Facilities Health maintenance organizations (HMOs) Proposed by Kaiser Permanente Signed into Law by President Richard Nixon Both Health care delivery system & Health Insurance They provide Total Health Care Directed toward preventative health care For a fee that is usually fixed & prepaid

2:2 Government Agencies Government services are tax supported World Health Organization (WHO) Headquarters in Geneva, Switzerland International Agency Sponsored by the U.N. 1.Complies statistics on Disease 2.Publishes health Information 3.Investigates serious health problems throughout the world

U.S. Agencies U.S. Department of Health and Human Services (USDHHS) National Agency that deals with health problems of the U.S. National Institutes of Health (NIH) Division of USDHHS involved on research of disease Centers for Disease Control and Prevention (CDC) Division Division of USDHHS concerned with causes, spread, and control of disease. Statistic gathering Health Departments Division of USDHHS involved with the community. Statistics gathering. Immunization, and communicable disease control.

Government Agencies (continued) Food and Drug Administration (FDA) Drug manufacture Occupational Safety and Health Administration (OSHA) Standards that protect workers from job related injuries

Cost Increase to HealthCare Technological Advancements Aging Population Health-related Lawsuit

Reduction of HealthCare Costs Combination of Services Outpatient Services Intervention or Preventative Services Energy Conservation Diagnostic Related Groups DRG’s

Diagnostic Related Groups DRG’s Same diagnoses classified in one payment group Agency receives a set amount Agency makes every effort to provide care with this set amount Extra money the agency keeps If cost is more the agency must accept the loss

2:4 Health Insurance Plans Health care costs are rising faster than other costs of living Most people rely on health insurance plans to pay for health care costs Without insurance, the cost of an illness can become a financial disaster Preferred Provider Organization

Preferred Provider Organization Usually provided by large companies to a large group of employees The PPO forms a contract with the health care provider (doctor, hospital, clinic) to provide care at a lower rate. The PPO usually requires a deductible & a Co- payment The patient is encouraged to use affiliated providers, but may use nonaffiliated provider at a higher Copay

Insurance Terminology Premium: an amount to be paid for an insurance policy. Deductible: the amount of money to be paid out of pocket before the insurance will pay. Co-insurance: the percentage that money is paid by the patient and the insurance. Co-payment: a fixed rate paid by the patient.

Government Plans Medicare: Medicaid: Medigap 65 yr. older People with ESRD End Stage Renal (kidney) Disease Disability & receiving social security for 2 years. Medicaid: Low income individuals Children who qualify for public assistance People that are physically disabled or Blind Medigap Help pay expenses not covered by Medicare Offered by Private insurance companies

More Government Plans The State Children’s Health Insurance Program (SCHIP) State Children & Infants plan Uninsured children who earn too little for ins., but too much for Medicaid Worker’s Compensation Workers injured on the job U.S. government plans for all military personnel and their families formerly called CHAMPUS now known as TRICARE.

HIPAA Health Insurance Portability and Accountability Act Key components Health care access Preventing health care fraud Limits exclusion on pre-existing conditions Prohibits discrimination of individuals based on health status Maintain the confidentiality of health care information and medical records