1. Chapter 2
Health Care Systems

2. Health Care Facilities
Growth—one of the largest and fastest growing industries in the United States
Employment opportunities—employs over 17 million workers in over 200 careers
Expenditures—it is a four-billion-dollar- per-day business and growing
By 2020 employment will exceed 5.6 jobs with 22.7 million workers
Healthcare expenditure trillion dollars
trillion dollars
(continues)

3. Private Health Care Facilities (continued)
Hospitals
General hospitals
Vary in size
Treat wide variety of
Provide diagnostics, treatments, surgery, ER care
Specialty hospital
Provide care for specific conditions
Government
Operated by local, state or federal governments
Include VA and state psychiatric hospitals
University/ College Medical Centers
Provide service, research and education
Can be publicly or privately funded

4. Private Health Care Facilities
Long-term care facilities (LTC or LTCF)
Provide care and assistance for the elderly, handicap and disabled
Common types of LTC include: residential, extended care skilled nursing care facility
Independent living and assisted living
Rent or purchase apartments with assistance available if needed
Medical offices
Single or multi physician owned and operated
Provide: diagnosis, treatment, examination, labs, minor surgery
Dental offices
single or multiple dentist, to clinic setting
Provide dental exams, and treatment many dental conditions
Clinics or satellite centers
Surgicenters, urgent care, rehab clinics, substance abuse clinics, specialty clinics, outpatient clinics, health department clinics and medical center clinics.

5. Private Health Care Facilities (continued)
Emergency care services
Optical centers
Laboratories
Home health care
Hospice agencies
Mental health facilities
Genetic counseling centers
Rehabilitation facilities
(continues)

6. Private Health Care Facilities (continued)
Health maintenance organizations (HMOs)
Services directed at preventative care
Fees are fixed and prepaid
Industrial health care centers or occupational health clinics
Found in large companies- geared at employee health
School health services
Found in school districts and colleges-provide care for sudden illness, screenings, ER care for accidents and for students with chronic conditions

7. 2:2 Government Agencies Government services are tax supported
World Health Organization (WHO)
International health agency sponsored by UN for global health issues
U.S. Department of Health and Human Services (USDHHS)
Deals with health issued in the USA
National Institutes of Health (NIH)
A division of USDHHS- involved in disease research
Centers for Disease Control and Prevention (CDC)
Division of USDHHS- deals with spread, cause and control of disease in the USA
(continues)

8. Government Agencies (continued)
Food and Drug Administration (FDA)
Responsible for regulating food & drug products
Agency for Health Care Policy and Research (AHCPR)
Federal agency which deals with improving quality, safety, efficiency and effectiveness of HC in the USA
Occupational Safety and Health Administration (OSHA)
Establish and enforce standard that protect workers from job related injury and illness
Health Departments
Provide health services as directed by the USDHHS

9. 2:3 Voluntary or Nonprofit Agencies
Supported by donations, membership fees, fundraisers and grants
Health services are provided at national, state, and local levels
Examples include the American Cancer Society, March of Dimes, American Red Cross and many more
(continues)

10. Voluntary or Nonprofit Agencies (continued)
Organizations focus on specific diseases
Educate the public
Provide special services
Purchase medical equipment
Staffed by many health care workers
and volunteers

11. 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

12. Insurance Terminology
Deductible
Amount that must be paid by the patient for medical services before insurance begins to pay
Co-insurance
A specific amount of expenses that must be shared by the patient and insurance company
Ex; 80:20
Co-payment
A specific amount a patient pays for service
Ex: $10.00 co-pay for office visit

13. Types of Health Insurance Plans
Health maintenance organization (HMO)
Managed care with predetermined monthly rates
Focus is on prevention- if care is rendered outside HMO- the patient will incur all costs
Preferred provider organization (PPO)
Managed care plan which contracts with a health care agency to provide care at reduced rates
Require copays and deductibles
Must use in network provides or will have to pay greater fees
(continues)

14. Types of Health Insurance Plans
Medicare
Federal government insurance for 65 and over
Has 3 parts– A,B,D
A is hospital insurance coverage
B offers additional coverage for outpatient, therapy, clinical labs, and other health care
D offers medication coverage
Medigap
A Medicare supplement (Medigap) insurance, sold by private companies, can help pay some of the health care costs that Original Medicare doesn't cover, like copayments, coinsurance, and deductibles

15. Types of Plans (continued)
Medicaid
Medicaid is a joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, like nursing home care and personal care services.
The State Children’s Health Insurance Program (SCHIP)
The Children's Health Insurance Program (CHIP) provides free or low-cost health coverage for more than 7 million children up to age 19.  CHIP covers U.S. citizens and eligible immigrants

16. Types of Plans Worker’s Compensation
Health insurance plan providing treatment for workers injured on the job
U.S. government plans for all military personnel and their families
TRICARE-Health Insurance plan for military personnel

17. Types of Plans (continued)
Managed care plans are a type of health insurance. They have contracts with health care providers and medical facilities to provide care for members at reduced costs. These providers make up the plan's network

18. WHAT IS HIPAA?
HIPAA is the federal Health Insurance Portability and Accountability Act of 1996
The primary goal of the law is to make it easier for people to keep health insurance
protect the confidentiality and security of healthcare information
help the healthcare industry control administrative costs.

19. Portability
This section allows individuals to carry their health insurance from one job to another so that they do not have a lapse in coverage.
It also restricts health plans from requiring pre-existing conditions on individuals who switch from one health plan to another

20. Administrative Simplification
This section is the establishment of a set of standards for receiving, transmitting and maintaining healthcare information and ensuring the privacy and security of individual identifiable information.

21. Privacy
HIPAA provides for the protection of individually identifiable health information that is transmitted or maintained in any form or medium. The privacy rules affect the day-to-day business operations of all organizations that provide medical care and maintain personal health information

22. What Health Information is Protected?
Names
Dates relating to a patient , i.e. birthdates, dates of medical treatment, admission and discharge dates, and dates of death
Telephone numbers, addresses (including city, county, or zip code) fax numbers and other contact information
Social Security numbers
Medical records numbers
Photographs
Finger and voice prints
Any other unique identifying number

23. Who Must Comply?
Health Care Providers:  Any provider of medical or other health Services that bills or is paid for healthcare in the normal course of business.
Health Care Clearinghouse: It includes groups such as physician and hospital billing services. Health Plans: Individuals or group plans that provide or pay the cost of medical care and includes both Medicare and Medicaid programs

24. WHAT ARE A PATIENT’S RIGHTS UNDER HIPAA’S PRIVACY STANDARDS?
Patients have a right to:
receive a notice of the privacy practices of any health care provider.
see their PHI and get a copy.
that changes be made to correct errors in their records or to add information that ha been omitted.
to see a list of some of the disclosures that have been made of their PHI.
request that you give special treatment to their PHI.
request confidential communications.
to complain

25. Compliance of HIPAA regulations was required by April 2004

26. Affordable Care Act signed March 2010 / 2014
AKA---OBAMACARE
Provisions in place
Requires all insurers to charge the same premium to all applicants of gender, age, geographic location- regardless of pre-existing conditions
Can not deny converge if premiums are paid
Expand Medicaid coverage to include families with incomes of 133% the poverty rate
Creates affordable insurance exchanges in all states

27. Affordable Care Act signed March 2010 / 2014
Mandates all must purchase insurance
Provides subsides for low income families, small business
Young adults can be covered up to 26 years old by parent
Improve enrollment for Medicaid and CHIP
Enforces shared responsibly payment for employers
Improves Medicare & prescription drug coverage
Allow restructuring of Medicare reimbursement from fee for service to bundled payments

28. VIDEO
Obamacare Video

29. What do you think?
Divide into 4 groups of 4-5 and answer the following questions?
Does the Patient Protection and Affordable Care Act provide health care insurance to every individual in the USA? Why or Why not?
Will Affordable Care Act impact quality of care and how doctors practice medicine? Will care improve or deteriorate? Explain with specific examples.
Will Obamacare worsen the physician shortage? Explain / What are some solutions?
Opponents of the individual mandate insist that they are only defending individual freedom. What do you think?

30. Organizational Structure of Hospitals

31. 2:5 Organizational Structure
Line of authority or chain of command
Indicates areas of responsibility
Goal: most efficient operation of facility
Complex or simple structure determined by size and needs of organization
Sample organizational charts (See Figure 2-4 and 2-5 in text)
(continues)

32. Organizational Structure (continued)
The line of authority must be clearly indicated in any organizational structure
Workers must identify and understand their position in the structure
To follow proper channels of communication, workers must take problems, reports, and questions to their immediate supervisor

33. Acute Care Hospitals Acute Care Hospitals Organizational Structure and
Regulatory Agencies

34. Organizational Chart • Board of Trustees • Administrator
• Nursing Management
• Medical Director
• Ancillary Services
• Management
• Business Management
• Patient Care
• Unit Leadership
– Respiratory Therapy
– Physical Therapy, etc

35. Lines of Authority- Chain of Command
PCT
• Licensed Nurse (LVN/RN)
who takes direction from:
• The Charge Nurse-
who takes direction from
• The Nurse Manager
• Nursing Supervisor-
• Chief Nursing Officer
• The Administrator (CEO)
• The Board of Trustees

36. Hospital Organization
Governing Board- Board of Trustees or Board of Directors
Persons from business/professional
communities and all socioeconomic groups.
Duty is to establish policies, provide financing, oversee personnel standards.
• CEO – Chief Executive Officer
directly in charge of hospital and answers to board.
• COO – Chief Operating Officer
answers to CEO and is responsible for day to day operations.
• Vice President or Director of each service:
reports to COO

37. Lines of Authority on Nursing Units
• Chief Nursing Officer
Assistant Director of Nursing
House Supervisor
Unit Managers
ER, OB, OR, RT, PT, Peds, ect
• Staff Nurses
Nursing Assistants
Patient Care Technicians
Unit Secretaries

38. Accreditation of Acute Care Hospitals
• Joint Commission on Accreditation of Health Care Organizations (JCAHO)
JCAHO accredited means hospital has been surveyed, graded, and approved by the Joint Commission
Participation in JCAHO is voluntary.
Department of Health Services
License to operate is granted by the Department of Health Services of each individual state.

39. Regulatory Agencies
Occupational Safety and Health Administration ( OSHA)
• Board of Registered Nurses (BRN)
• Licensed Vocational Nurses/Psychiatric Technicians
• Medical Board
• Department of Consumer Affairs

40. Hospital Departments/Services
Business Services
The Admitting Department
Purchasing
Diagnostic & Therapeutic Services
Support Services
Operational Services

41. Hospital Mission Statements

42. What is a Mission/Vision Statement
Definition:
A sentence describing a company's function, markets and competitive advantages; a short written statement of your business goals and philosophies

43. Assignment First “Test Grade”- Due Wednesday 9/3
Create a concept map of:
B) Typical hospital organizational structure
Name your hospital & create a meaningful Mission Statement
At a minimum it must include the following departments with examples of healthcare professionals specific to the grouping:
Board
Administration
Nursing Services
Information Services
Therapeutic Services
Diagnostic Services
Support Services