Chapter 2HEALTH 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:

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