Copyright © 2008 Delmar. All rights reserved. Chapter 7 Health Care Organization and Financing.

Copyright © 2008 Delmar. All rights reserved.

Chapter 7

Health Care Organization and Financing


2

Historical Developments

• National Health Insurance (social insurance)– Germany, 1833– 1921 Shepherd-Towner Act

• Gave matching funds to states that would provide prenatal and child health care


3

Historical Developments

• 1965 President Roosevelt’s Great Society– Medicare and Medicaid

• States and federal government accountable for long term care

• 1980s DRG’s – Determined length of inpatient care– Growth in home care


4

Insurance-Based Care

• Public insurance– Medicare– Medicaid– TRICARE

• Insurance-based care– Purchased by employer/employee


5

Private Insurance

• Massachusetts Health Insurance Company – First private plan in the United States– Montgomery Ward first company to provide

benefits to workers unable to work due to illness or injury

– 1920s Blue Cross plan started


6

Private Insurance

• Third Party Payer– Company that pays for health care for a

business or individual – Insured individual first party– Second party is the business/company

individual works for


7

Private Insurance

• Retrospective payment system

• Prospective payment system

• Fee for service

• Premiums

• Deductibles

• Copayment


8

Private Insurance

• Medical Savings Accounts– Tax exempt– Individual sets aside money to be used to

cover cost not covered by insurance


9

Private Insurance

• Managed Care Plans– Form of private insurance– Gate keepers

• Consumers have less choice


10

Managed Care Health Plans

• Preferred Provider Organizations (PPO)– Fee for service– Consumer chooses provider from a select

group– Negotiated discounted rate – Consumers retain their ability to choose

provider


11

Managed Care Health Plans

• Health Maintenance Organization (HMO)– HMO contracts with a group of physicians and

specialist– Consumer does not have an option to choose

provider– Fixed fee – Less flexible


12

Public Insurance

• Funded by state and federal governments– Medicaid

• Title XIX• Determined by income and resources • No age limit• TANIF• State Child Health Plan

– Spend down


13

Public Insurance

• Medicare– Title XVIII federal program for elderly age 65

and older– Three parts:

• Hospital Insurance Part A• Medical Insurance Part B• Prescriptions Part D

– Medigap


14

Public Insurance

• TRICARE– Active duty, retired service personnel, eligible

family members, survivors– Funded through Department of Defense– Consumers have two options:

• TRICARE Prime (managed care)• TRICARE Standard (fee for service)


15

Noninsurance-Based Models

• Managed competition– Supply and demand

• Accountable Health Plans (AHP)• Health Insurance Purchasing Cooperatives

(HIPCs)


16

Noninsurance-Based Models

• Universal coverage– Single payer system – Provides access to health care to all– One agency paying expenses rather than

multiple payer system


17

Challenges for Public Health Nurses

• Shrinking funds

• Minimal funding

• Increase in health care cost

• Organizational changes in the health care system

Copyright © 2008 Delmar. All rights reserved. Chapter 7 Health Care Organization and Financing.

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Transcript of Copyright © 2008 Delmar. All rights reserved. Chapter 7 Health Care Organization and Financing.