Chapter 2 Health Care Systems

1. Chapter 2Health Care Systems

2. Chapter Objectives: Define, pronounce, and spell all key terms Describe at least eight types of private health care facilities Analyze at least three government health service agencies & the services offered by each Describe at least three services offered by voluntary or nonprofit agencies Compare the basic principles of at least four different health insurance plans Explain the purpose of organizational structures in health care facilities

3. 2:1 Private Health Care Facilities • Today, health care systems include the many agencies, facilities, & personnel involved in the delivery of health care • Health care is one of the largest and fastest-growing industries in the U.S. - employs over 17 million workers in more than 200 different health related careers - by 2020, employment is expected to increase by 5.6 million jobs to over 22.1 million workers - the demand for healthcare workers is greater than the supply - health care spending in the U.S. is projected to increase from over 2.7 trillion dollars in 2012 to 4.6 trillion dollars in 2020

4. 2:1 Private Health Care Facilities Many different health care facilities provide services that are part of the industry called health care Most private health care facilities require a fee for services Sometimes grants & contributions help provide financial support for these facilities There are many types of facilities included as private health care facilities

5. Hospitals • Major type of health care facility • Vary in size & type of service provided - small & serve basic needs of community - large, complex centers offering a wide range of services • Classified depending on the sources of income received by the hospital: • Private or Proprietary (for profit) • Religious • Nonprofit or Voluntary • Government

6. Types of Hospitals General hospitals: treat a wide range of conditions and age groups; usually provide diagnostic, medical surgical, & emergency care services Specialty hospitals: provide care for special conditions or age groups. Examples: burn, oncology, pediatric, psychiatric, orthopedic, & rehab hospitals Government hospitals: operated by federal, state, & local government agencies; Include the many facilities that provide care for government personnel Examples: Veterans Administration hospitals, state psychiatric hospitals, and state rehabilitation centers University or college medical centers: provide hospital services along with research and education; can be funded by private and/or government sources *Classifications & types of hospitals can overlap

7. Long-Term Care Facilities (LTCs or LTCFs) Provide assistance & care for elderly patients, usually called residents Also provide care for individuals with disabilities or chronic or long-term illness Many different types, including: Residential care facilities – (nursing homes / geriatric homes) - designed to provide basic physical & emotional care to individuals who can no longer care for themselves; help with ADLs, provide safety/security, & promote opportunities for social interactions Extended care facilities or skilled care facilities– provide skilled nursing care & rehab care to prepare patients for return home; some have subacute units Independent living & assisted living facilities – allow individuals who can care for themselves to rent or purchase an apartment in the facility; provide services such as meals, housekeeping, laundry, transportation, social events, & basic medical care (such as assisting with meds); Allow an individual to move readily from one level of care to the next when health needs change.

8. Medical Offices Vary from offices that are privately owned by one physician to large complexes that operate as corporations & employ many physicians and other health care professionals Services include: diagnosis (determining nature of illness), treatment, examination, lab testing, minor surgery, & other similar care May treat a wide variety of illnesses or specialize

9. Dental Offices Private or group-owned clinic where dental care is provided May be privately owned by one or more dentists or a dental clinic with a group of dentists Dental services can include general care provided to all age groups or specialized care offered to certain age groups or for certain dental conditions

10. Clinics or Satellite Centers Health care facilities found in many types of health care May be groups of medical/dental physicians & support staff or clinics offering specialized care such as: Surgical centers (surgicenters) – perform minor surgical procedures Urgent, walk-in, or emergency care clinics-provide first aid or emergency care to ill or injured patients Rehabilitation clinics- offer physical, occupational, speech & similar therapies Substance abuse clinics-provide rehabilitation for drug & alcohol abuse Specialty clinics – provide care for specific diseases; examples include diabetic clinics, kidney dialysis centers, oncology clinics

11. Outpatient Clinics – usually operated by hospitals or large medical groups; provide care for outpatients Health department clinics- may offer clinics for pediatric health care, treatment of sexually transmitted diseases and respiratory disease, immunizations, and other special services Medical center clinics- usually located in colleges or universities; offer clinics for various health conditions; offer care & treatment and provide learning experiences for medical students

12. Optical Centers Provide vision health services Provide vision exams, prescribe eyeglasses or contact lenses, and check for the presence of eye disease Can be individually owned by an ophthalmologist or optometrist or may be part of a large chain of stores

13. Emergency Care Services Provide special care for victims of accidents or sudden illness Examples include: - Ambulance services/rescue squads, frequently offered by fire depts - Emergency care clinics - Emergency dept in hospitals - Helicopter/airplane emergency services that rapidly transport patients to medical facilities for special care

14. Laboratories A room or building where scientific tests, research, experiments, or learning takes place Often a part of other facilities but can operate as separate health care services Medical labs can perform special diagnostic tests such as blood and urine tests Dental labs can prepare dentures any other devices to repair or replace teeth

15. Home Health Care Designed to provide care in a patient’s home Health departments, hospitals, private agencies, government agencies, and nonprofit or voluntary groups can offer home care services Examples of services include: - nursing care, rehab therapy, personal care, assistance with ADLs

16. Hospice Agencies that provide care for the terminally ill Care can be provided in the person’s home or in a hospice care facility Offers palliative care, or care that provides support and comfort, that is directed toward allowing the person to die with dignity Psychological, social, spiritual, & financial counseling are provided for both the patient and the family Also provides support to the family following a patient’s death

17. Mental Health Facilities Facilities that treat patients with mental disorders and diseases Examples include: - guidance & counseling centers - psychiatric clinics & hospitals - chemical abuse treatment centers - physical abuse treatment centers

18. Genetic Counseling Centers Clinics where counselors provide information to patients and/or families on genetic diseases or inherited conditions. Often the patients are pregnant or trying to conceive. - may perform prenatal screening tests - check for genetic abnormalities & birth defects - explain results of the tests - identify medical options when a birth defect is present - help individuals cope with the psychological issues caused by a genetic disorder

19. Rehabilitation Facilities Provide care to help patients with physical or mental disabilities obtain maximum self-care and function Located in hospitals, clinics, and/or private centers Services may include physical, occupational, recreational, speech, & hearing therapy

20. Health Maintenance Organization (HMO) Type of health care delivery system AND type of health insurance Provide total health care services primarily directed toward preventative health care for a fee that is usually fixed & prepaid Services include: - exams & basic medical services - health education - hospitalization - rehab services Some operated by large industries or corporations, others by private agencies Often use services of other health care facilities

21. Industrial Health Care Centers Occupational health clinics Found in large companies or industries Provide health care for employees of the industry or business by: - performing basic exams - teaching accident prevention & safety - providing emergency care Major resort industries, such as Disney, may also provide emergency health care to visitors

22. School Health Services Provides services to students in schools and colleges such as: - emergency care for victims of accidents & sudden illness - health screenings such as vision, hearing, & speech - health education - counseling services The goal is to maintain a safe and sanitary school environment.

23. 2:2 Government Agencies

24. Government Agencies Health care services are offered at international, national, state, & local levels Government services are tax supported Examples include: World Health Organization (WHO)- an international agency sponsored by the United Nations; compiles statistics and information on disease, publishes health information, and investigates & addresses serious health problems throughout the world; www.who.int U.S. Department of Health and Human Services (USDHHS)- a national agency that deals with the health problems in the United States; www.hhs.gov

25. Government Agencies National Institute of Health (NIH) – A division of the USDHHS; involved in research on disease; www.nih.gov Centers for Disease Control and Prevention (CDC)- another division of the USDHHS; concerned with the causes, spread, and control of diseases in populations; www.cdc.gov Food and Drug Administration (FDA)- a federal agency responsible for regulating food and drug products sold to the public; www.fda.gov

26. Government Agencies Agency for Healthcare Research and Quality (AHRQ)- a federal agency established to improve the quality, safety, efficiency, and effectiveness of healthcare for Americans; www.ahrq.gov Occupational Safety and Health Administration (OSHA)-establishes and enforces standards that protect workers from job related injuries and illnesses; www.osha.gov Health Departments- provide health services as directed by the USDHHS; also provide specific services needed by the state or local community; examples of services include immunization for disease control, inspections for environmental health and sanitation, communicable disease control, collection of statistics and records related to health, health education, clinics for health care and prevention, and other services needed in a community; www.floridahealth.gov/chdstjohns/

27. 2.3 Voluntary or Nonprofit Agencies

28. Voluntary / Nonprofit Agencies Provide health services at national, state , & local levels Supported by donations, membership fees, fund-raisers, and federal or state grants Examples: American Cancer Society March of Dimes American Heart Association American Diabetes Association American Red Cross Autism Speaks Usually focus on one specific disease Typically study the disease, fund research, and promote public education Employ many health care workers in addition to using volunteer workers

29. 2:4 Health Insurance Plans

30. Health Insurance Plans Health care costs are increasing faster than other costs of living To pay for the cost of health care, most people rely on health insurance plans - without insurance, the cost of an illness can mean financial disaster for an individual or family Health Insurance- payment for health care expenses, which may or may not occur, in return for a specified payment in advance Health insurance plans are offered by several thousand insurance agencies Common example: Blue Cross / Blue Shield

31. Health Insurance Plans Premium: fee the individual pays for insurance coverage When the insured individual has health expenses covered by the plan, the insurance company pays for the services - Amount of payment & type of services covered vary from plan to plan Deductibles: amounts that must be paid by the patient for medical services before the policy begins to pay Co-insurance: requires that specific percentage of expenses are shared by the patient and insurance company Example: In an 80/20 percent co-insurance, the company pays 80% & the patient pays the remaining 20% Co-payment: specific amount paid by patient for a particular service Example: $10 for each office visit or $50 for ER visits

32. Health Insurance Plans Many have insurance through their employer, where premiums are paid by the employer \ the employee (the insured) also pays a percentage in most cases Private policies are also available for purchase by individuals HMO’s - The insured is required to use ONLYthe HMO-affiliated health care providers (doctor / lab / hospital) for care. If the insured individual chooses to use a nonaffiliated provider, they must usually pay for the care Preferred Provider Organization (PPO) – insurance plan usually provided by large companies which form a contract with providers so the insured individuals get a lower rate – if another nonaffiliated provider is used the PPO may require co-payments of 40-60%

33. Health Insurance Plans Two main government insurance plans are Medicare & Medicaid Medicare- Federal insurance providing coverage to eligible patients: - 65 and older - Disabled - End Stage Renal Disease (ESRD) *Medicare only pays for 80% of coverage *Medigap policies help pay expenses not covered by Medicare Medicaid – Jointly funded by federal & state government but operated by individual state; usually covers those with low income, disabled, or blind – offers medical, dental & eye care

34. Health Insurance Plans Workers’ Compensation – health insurance plan providing treatment for workers injured on the job - administered by the state, and payments are made by employers & state - also reimburses worker for wages lost because of on-the-job injury TRICARE – U.S government health insurance plan for all military personnel - provides care for all active duty members & their families, survivors of military personnel, and retired members of the Armed Forces - The VA provides for military veterans

35. Managed Care An effort to ensure health care money is spent efficiently, rather than wastefully Principle: All health care provided to a patient must have a purpose Verification of services is required before care can be provided HMOs and PPOs are the main providers of managed care, but many private insurance companies are establishing health care networks to provide care to their subscribers The patient who is enrolled in a managed care plan receives quality care at the most reasonable cost but is restricted in choice of health care providers

36. Health Insurance Portability and Accountability Act

37. Health Insurance Portability and Accountability Act (HIPAA) Passed by the federal government 5 main components: - Health Care Access, Portability, and Renewability - Preventing Health Care Fraud & Abuse; Administrative Simplification, and Medical Liability Reform - Tax-Related Health Provisions - Application and Enforcement of Group Health Plan Requirements - Revenue Offsets

38. Health Care Access, Portability, & Renewability: limits exclusions on preexisting conditions to allow for the continuance of insurance even with job changes Prohibits discrimination against an enrollee or beneficiary based on health status Guarantees renewability Provides special enrollment rights for those who lose coverage due to divorce or termination of employment

39. Preventing Health Care Fraud & Abuse; Administrative Simplification, & Medical Liability Reform: Methods & penalties for fraud and abuse Electronic standards Strict confidentiality guidelines Recommends limits for liability

40. Tax-Related Health Provisions: Promotes use of Medical Savings Accounts (MSAs) by allowing for tax deductions for monies placed in the accounts Establishes standards for long-term care insurance Allows for the creation of state insurance pools Provides tax benefits for some health care expenses

41. Application and Enforcement of Group Health Plan Requirements: Establishes standards that require group health care plans to offer portability, access, & renewability to all members of the group Revenue Offsets: Provides changes to the Internal Revenue Code for HIPAA expenses

42. Compliance with all HIPAA regulations was required by April 2004 for all health care agencies. Regulations haven’t solved all problems of health care insurance, but they have provided consumers with more access to insurance & greater confidentiality in regard to medical records. In addition, health care costs have been reduced due to: - standardization of electronic health care records - reductions in administrative costs - increased tax benefits - decreasing fraud & abuse

43. Patient Protection and Affordable Care Act

44. Patient Protection and Affordable Care Act Commonly called “Affordable Care Act” or “Obamacare” AUnited States federal statute signed into law by President Barack Obama on March 23, 2010 By 2014 most of the provisions of the act were in place Enacted with the goals of: - increasing the quality and affordability of health insurance - lowering the uninsured rate by expanding public and private insurance coverage - reducing the costs of healthcare for individuals and the government

45. Patient Protection and Affordable Care Act The law and its implementation have continued to face challenges in Congress and federal courts, and from some state governments, conservative advocacy groups, labor unions, and small business organizations.

46. 2:5 Organizational Structure

47. Organizational Structure All health care facilities must have some type of organizational structure Structure may be complex (larger facilities) or simple (smaller facilities) Always encompasses a line of authority or chain of command Organizational structure should indicate areas of responsibility and lead to the most efficient operation of the facility It is important for health care workers to identify and understand their respective positions in a given facility’s organizational to: - know their line of authority - understand who their immediate supervisor is in charge of their work