Health Care Systems

1. Health Care Systems Unit 2.2

2. Objectives • Match key terms with their correct meanings • Explain how health care providers have modified their practices to provide patients quality health care at a lower cost • Explain the purpose of the health plan employer data and information set. • Identify and differentiate the various health care systems • Compare and contrast health maintenance organizations and preferred provider organizations • Analyze and predict where and how certain factors such as cost, managed care, technology and aging population, etc. may affect various health care delivery systems models

3. Background • The cost of health care has increased significantly over the years. It is important to understand the causes for the increase as well as methods providers use to help contain the costs. Every health care worker should also know the health care systems that help patients/ clients afford the services they need. When patients/ clients receive regular and complete care, they live healthier and happier lives.

4. Quality Health Care Costs • Cost Containment- health care cost’s lots of money • Technological advances in the medical field, , an aging population, and health related lawsuits have driven up the price of medical care and affected health care systems. • Advanced equipment helps make more thorough diagnosis is expensive to purchase and maintain. • As the population continues to grow and age, the demand for this type of care increases.

5. Standards of care • Promote quality of care • When proven standards for effective care and quality outcomes are developed and encouraged for use by individual caregivers the patient will be more inclined to “get what has been proven to work”

6. Health care costs • Health care providers and the government are working to lower health care cost. • The federal government passed legislation in 1983, (Medicare) and then modified it for the general population to regulate the price of medical care. • Ensures that the specific health care agency will have to pick up any extra costs after the government and patient have paid their part.

7. Diagnostic-related groupings (DRG’s) • Helps to reduce unnecessary procedures and encourage self-care and home care. • Example: pt wakes up with fever, sore throat and ringing in her ears. She goes to an urgent care facility where she can be seen that morning and is diagnosed with strep throat. • Throat culture for testing strep and 10 days of antibiotics. • Based on the DRG the facility will only be reimbursed by insurance or Medicare for a fee that falls with in a specific range. • Not x-rays or CAT scan

8. Cost containment • Health care providers also promote lower health care costs by combining services, offering outpatient services, purchasing supplies in bulk, and emphasizing early intervention and preventative care.

9. Health Plan Employer Data Information Set • National Committee for Quality Assurance (NCQA) directed the Health Plan Employer Data and Information Set (HEDIS) established guidelines and gives a report care that: • Measures health plan performance • Helps identify physicians who give high quality medical care to their patients/ clients. • Help identify physicians who do not meet the quality care guidelines. • Used to measure health plans performance.

10. Health Care Payments • Health Insurance: (Third-Party Payers) • Health and dental cost are expensive. • Insurance companies require the subscriber pay a fee for insurance coverage and agree to pay to medical and dental care • Co-payment- a set amount the subscriber pays for each medical service • Deductible- an amount the subscriber must pay before the insurance begins to pay • Co-insurance- a percentage the subscriber is required to pay of every medical bill

11. Health Maintenance Organizations (HMO) • Require members to pay a co-payment, or co-pay for medical services. • Members must get medical care from the physicians, labs, hospitals etc. That agree to the fee the HMO is willing to pay. • If the member gets medical care outside the HMO he or she will have to pay for the care.

12. Proffered Provider Organization (PPO) • Physician groups and hospitals work together to give comprehensive health care at a reduced cost to various large companies and corporations. • Employees of these companies contract with a preferred provider organization (PPO) and agree to see providers on the PPO list. • If they see other providers, they pay a larger fee

13. Medicaid • Provided by the state and federal government • Benefits and eligibility are different in each state. • People who are blind, disabled, or of low income are generally able to get Medicaid insurance.

14. Medicare • Provided to people over the age of 65 • Subscribers pay a monthly payment to the social security administration • Consists of two parts • Part A- covers in-patient care at hospitals, hospice care, and home health care • Part B- help cover medical services like doctors’ services, outpatient care and other medical services that Part A does not cover • Covers some preventative services • Most get Part A without paying a monthly payment, Part B requires a premium each month

15. Tricare • Is a health care program for active duty service members, retirees, and their families. • One part is called TLF (TRICARE for life) • Medical care is for Medicare-eligible uniformed retirees age 65 and older. The plan also covers family members and survivors. • Works with Medicare to provide service members additional health benefits

16. Workers Compensation • Health care program for employees who are injured or die at work are covered by state workers compensation laws. • Includes any illness that may result from the workplace • Employers are required to have workers compensation insurance • Benefits include payment for lost wages and payment of medical bills

17. National Health Plan With a 75% increase in the cost of health insurance from 2001 to 2007 the number of uninsured Americans is no surprise • Supports the issue of providing good comprehensive health care to everyone • Having a government paid insurance planwith an emphasis on preventive health care, immunization, education, and behavior modification (smoking cessation) • The American Medical Association (AMA) was against regulating the health care system. • Some believe by eliminating private insurance bureaucracy and paperwork will save enough to give care to all Americans