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NU 401 Health Care Delivery Systems & Economics

Terms in this set (117)

What are some factors that are stimulating change in the demand for health care?
-Rising Labor Costs
-Cost of Fuel
-Recession in 2008
-Unemployment Rate
-Patient Protection & Affordable Care Act (ACA)
When it comes to analyzing what effects healthcare, there are 5 main trends that can be broken down.

What are these trends?
-Demographic Trends
-Social Trends
-Economic Trends
-Health Work Force Trends
-Technological Trends
What are some demographic trends that affect healthcare?
- Increased population in 3rd world countries but decreased in 1st world countries like US
- Increased Hispanic population in US
- Increased age in Americans (prevention/treatment of AIDS, cancer, etc.)
- Leading causes of death have changed
In the United States, we see an (increase/decrease) in population meanwhile we see an (increase/decrease) in the population of third world countries.
Decrease; Increase
The population among the world is changing as a result of changing fertility.

What are some things that might change fertility for Americans?
-Abortion is more readily available
-Shift in the mentality of Americans (have fun now, families later)
-Birth Control is more readily available
Our demographic trend is also affected by diversity as well as an (increase/decrease) in the average age of Americans.
Increase
The increase in average age means Americans are living longer but with more....
Co-morbitities

*this means a longer and increased need for health care
What are some social trends that affect healthcare?
Shift from traditional work ethic to an improved quality of life
-Increased spending on nutrition, fitness and alternative therapies
-Mentality that health is an irreplaceable commodity
Social trends in healthcare:

What are some of the alternative therapies Americans are putting more funding toward?

*these are typically therapies that insurance does not cover
-Marijuana
-Essential Oils
-Chiropractors
-Acupuncture
-Etc.
What are some economic trends that affect healthcare today?
A shift in changes of income brackets and trends
- the average American's income has increased
- The gap between the richest 35% and poorest 25% is widening
- Increase in dual-income families
Social trends affecting healthcare:

the gap between the richest 25% and the poorest 25% is _____________.
Widening
Economic trends in healthcare:

We see an increase in _______-Income families.
Dual
What are some Health Work Force trends that are affecting healthcare?

What are some areas that make up the Health Work Force trend?
-Nursing shortages
-Bed capacity decreased as care becomes more community based
-Periodic shortages as more providers choose to become specialists
- Increase in minority nurses
What are some technological trends that are affecting healthcare?
Telehealth increasing
What are some positives for the increase in Telehealth?
- Decreased cost in long run bc of machines replacing people
- More convenient in terms of time and travel
- Paperwork decreased, implementation of the EHR
What are some negatives of the increase in Telehealth?
- Cost
- Increased legal liability
- Potential for decreased privacy
- Too much reliance on technology (i.e. power outages)
When it comes to trends affecting healthcare, what are the 3 major problem areas?
1. Cost
2. Access
3. Quality
So what are some factors that are driving the cost of healthcare up so high?
- Technology
- Prescription drugs

- shortages, chronic degenerative diseases
The largest share of healthcare expenditure is spent where?
acute care in hospital
When it comes to accessibility to healthcare, this comes by one of what two types of funding?
1. Private Funding
2. Public Funding
What is the difference between Private and Public funding of healthcare?
- Private: personal payments or insurance
- Public: government funded
When dealing with various types of funding, we also see a phenomenon called cost-shifting. What is this?
When people with insurance have higher rates to pay to cover costs of those who don't have money/insurance

*Medicare and Medicaid typically underpay resulting in the need for private insurances to overpay
And finally, when it comes to the quality of healthcare, some will argue that there is an increased focus on.... but with a decreased focus on improving the quality.
Increased focus on decreasing cost

*but not necessarily improve quality - something to be mindful of
What helps maintain a designated level of quality of healthcare?
Accreditation standards
Organization of Healthcare
...
There are major divisions when it comes to organizing healthcare. What are they?
1. Private/Personal Care
2. Public Health Care
Under Private Care, there are 2 subdivisions. What are they?
1. Primary Care
2. Primary Health Care
Characteristics of Primary Care:
- Individual care
- Emphasis on curative aspect of care
- Provided by generalists w/support of nurses/allied health providers
- Professional dominance
- Funded through individual client payments, health insurance, & sometimes federal grants
Characteristics of Primary Care:

A care in which it can be either _________ or ___________, but has an individual focus
Public; private
Characteristics of Primary Care:

Care in which there is an emphasis on the _____________ aspect of care.
curative
Characteristics of Primary Care:

Care in which it is provided by generalists with the support of...
Nurses and allied health providers
Characteristics of Primary Care:

Care in which there is a professional ________________.
Dominance
-because it is the healthcare workers that make people better
Characteristics of Primary Care:

Care that is funded through....
-Individual Client payments
-Health Insurance
-Occasionally Federal Grants
Primary care offices are things like...
Doctors offices and urgent cares
Within Primary Care, there is Managed Care. What is this?
A specific network of providers who agree to comply with the care that is established through managed care
- use of a gatekeeper to control access
Managed Care uses a __________________ to help control access to providers and services.
Gatekeeper
What are some of the various types of Primary Care Organizations?
-Health Maintenance Organization (HMO)
-Preferred Provider Organization (PPO)
-Exclusive Provider Organization (EPO)
-Medical Savings Account (MSA)
What is a Health Maintenance Organization (HMO)?
A form of care where:
- insurer collects a premium and pays a negotiated fee to a group of doctors to provide care
- Pts must stay in network
- Pts must select PCP, who will then refer to specialist if needed (can't go to specialist without referral)

*Lower cost plan but has most limitations
Generally speaking, a HMO has the lowest associated _______ with the most __________________.
Cost; limitations
Overview of an HMO:
-Must stay in the network
-Must select a primary care provider
-Must get a referral to see a specialist
What is a Preferred Provider Organization (PPO)
Form of healthcare that contracts with medical providers to create a network of participating providers. You pay less if you use providers that belong to the plan's network
- Not required to stay in network, but higher cost if you go outside network
- Don't need referral to see a specialist
- More expensive for employers, so you have a higher monthly premium
Within a PPO, can individuals chose providers outside of the network?
Yes - there is a network that is encouraged, but they can still choose a provider outside of it
-they may just have to pay a higher premium but a percentage will still be covered
Overview of a PPO:
- Can go outside of network but you have to pay more
- Do not need to choose PCP
- No referral needed for specialist
What is a EPO?
Exclusive Provider Organization

A compromise between an HMO and PPO in that:
- you have to stay in network (except for emergencies), but:
- don't have to select PCP, and:
- no referral necessary for a specialist
With these various primary care organizations, there is something called a MSA. What is this?
This is a tax exempt savings account that is available for individuals (typically part of a small company that can't provide full coverage) to allow them to save for future medical expenses
What are the 7 different areas of the Federal level from primary care?
-Department of Commerce
-Department of Defense
-Department of Labor
-Department of Agriculture
-Department of Justice
-Health and Human Services (HHS)
-Department of Homeland Security
Within the Federal level of the public health system in America, there is the Department of Commerce.

Give an example of the Department of Commerce.
The census bureau
Within the Federal level of the public health system in America, there is the Department of Defense.

Give an example of the Department of Defense.
Tri-care; healthcare for the military
Within the Federal level of the public health system in America, there is the Department of Labor.

Give an example of the Department of Labor.
OSHA - providing safety and health standards for work sites
Within the Federal level of the public health system in America, there is the Department of Agriculture.

Give an example(s) of the Department of Agriculture
-Funding for WIC (food stamps)
-Plant and animal inspections
Within the Federal level of the public health system in America, there is the Department of Justice.

Give an example of the Department of Justice.
Healthcare for federal prisoners
Within the Federal level of the public health system in America, there is the Department of Homeland Security.

Give an example of the Department of Homeland Security.
-Prevent and Deter terrorist attacks
-Prevent and Respond to threats and hazards for the nation
Within the Federal level of the public health system in America, there is Health & Human Services.

What are the 9 different sub-departments of HHS?
1. Center for Disease Control (CDC)
2. Food and Drug Administration (FDA)
3. Health Resources and Services Administration (HRSA)
4. National Institutes of Health (NIH)
5. Joint Commission on Accreditation of Healthcare Organization (JACHO)
6. Office of Public Health Preparedness
7. Center for Faith-Based and Neighborhood Partnerships
8. Office of Global Affairs
9. US Public Health Services Department
Describe what the CDC does:
Health Surveillance
-track morbidity and mortality rates
-immunizations
-bioterrorism
Describe what the FDA does.
Works to ensure the safety of:
-food
-drugs
-cosmetics
-biological products
-medical devices
-blood/plasma products
Describe what HRSA does.
This is the division of nursing works with education, legislation and interpretation of trends
the division of nursing falls under which sub-department of the Health & Human Services?
HRSA
Describe what the NIH does.
This is works premier medical research organization
Describe what JACHO does.
Accrediting body for hospitals
Describe what the Office of Public Health Preparedness does.
Prepares the US for bioterrorism

*added after 9/11
Describe what the Center for faith-based and Neighborhood Partnerships does
Allows for Faith communities to compete for federal money to support their community activities
Describe what the Office of Global Affairs does.
Promotes global health by coordinating the health and human service department - strategies and programs with other governments and international organizations
Describe what the US Public Health Services Department does.
Contains 8 different agencies including the Commissioned Corp
-the surgeon general is the head of the Commissioned Corp
Describe what the Department of Homeland Security does
protects against terrorist attacks
- created around 2003
Next, after the federal level, comes the state level of primary care. What is involved in the state level?
-Board of Examiners of Nurses
-State Health Departments (works with local health departments)
What does the Board of Examiners of Nurses do?
Determines the practice acts for each state and who can get what certification
What do the State Health Departments do?
Determine and administrate healthcare finances of Medicaid, provide mental health, education, health codes and regulate the industry within in the state
And lastly, what is involved with the local level of primary care?
Local health Departments
- direct responsibility to citizens in community
In contrast with Primary Care. We also have Primary Healthcare. Identify some of the characteristics of Primary Healthcare:
- Integration of public healthcare and primary care
- Ultimate goal: "to achieve better health for all"
- Community focus
- Emphasis is prevention/rehabilitation
- Conceptual point of view - essential care made universally accessible to all ppl
- Government funded
- Goal is to educate ppl to be self-reliant
Identify some of the characteristics of Primary Healthcare:

What are some of the different ways the government funds Primary Healthcare?
-Tax dollars
-Federal state grants
-Medicare and Medicaid
Identify some of the characteristics of Primary Healthcare:

________________ focused.
Community
Identify some of the characteristics of Primary Healthcare:

Provides care at a _______________ level.
Population

*not individual level
Identify some of the characteristics of Primary Healthcare:

There is an emphasis on what type of care?
Preventative and Rehabilitative

*not curative
Identify some of the characteristics of Primary Healthcare:

Has a Conceptual Point of View. What is this?
The idea that primary healthcare is made universally accessible to everyone regardless of their ability to pay
Identify some of the characteristics of Primary Healthcare:

How does the healthcare team differ with Primary Healthcare?
Wider variety of healthcare team members because it is more comprehensive
Identify some of the characteristics of Primary Healthcare:

Self-____________.
Reliance
- educating people to ensure that they are responsible that their own health needs are met
Under Primary Healthcare, what is the science-based 10 years national "caremap" containing the objectives for how improve the health of all Americans called?
Healthy People
-contains various benchmarks to see and monitor progress
Healthy People 2020 created 4 goals for the country. What are they?
1. Attain high quality, longer lives free of preventable disease, injury, and premature death
2. Achieve health equity, eliminate disparities, and improve the health of all groups
3. Create social and physical environments that promote good health for all
4. Promote quality of life, healthy development, and healthy behaviors across all life stages
Primary Healthcare also was involved with the ACA. What is this?
The Affordable Care Act; "Obamacare"
What did the ACA involve?
Health care reforms
- focus on cost, quality, and access to care
Healthcare Economics
...
What was the 1st national health insurance plan in the US?
Marine hospital service (1798)
- provided medical care to sick/disabled sailors
Medicare is "care for the _____________."
Elderly
Is Medicare or Medicaid care for the elderly?
Medicare
What is Medicare?
A federal funded program that provides hospital and medical insurance for:
- 65+
- permanently/totally disabled
- ALS pts
- ESRD pts
Medicare is comprised of many parts but what are the 4 main ones?
-A
-B
-C
-D
What does part A of Medicare entail?
This provides hospital insurance and social security
What does Part A pay for?
-Hospital services
-Home-care
-Hospice care
-Limited skilled nursing care
Part A of Medicare is available to elderly that paid into social security. However, if one did not pay SS, can they still access Part A?
Yes, for a monthly premium

*note that either way, Part A is not free
Is there a deductible required for Part A?
Yes
What does part B of Medicare entail?
Supplemental coverage;
- Has more premiums but covers more
- available for all ppl who have part A
What does Medicare part B pay for?
-Out-Patient Care
-Diagnostics
-Equipment of any kind
-Specific home healthcares

*this does not cover institutional care coverage (that is only part A)
Is there a premium or deductible for Part B?
Yes, there is a monthly premium and after that is paid, it covers 80% of reasonable medical charges
What does Part C of Medicare entail?
Medicare advantage
- Managed care plans; choices
- Additional plan; includes both A and B and additional coverage with high deductible
Is there a deductible required for Medicare part C?
Yes! Part C is a high deductible plan
What does Part D of Medicare entail?
This is coverage for medication and prescription drugs
Who is part D of Medicare available to?
Those 65+
Is there a monthly premium for Part D?
Yes; but often it's around $30-$60
As a part of Medicare, DRGs were created.

What does DRG stand for? What are DRGs?
Diagnosis-Related Groups;
- List of many different diagnoses that each have a fixed charge
The idea behind DRGs was to help reduce hospital costs by only treating the person for what is truly wrong with the pt while maintains access and quality of care.

But what is a major down side?
-Creates the want for hospitals to discharge people potentially quicker than they should

*because if there is a hospital-acquired complication, they are no longer covered
Medicaid is "aid for the _______."
Poor
What people are included in Medicare coverage?
-Aged Poor
-Blind
-Disabled
-Families with dependent children
Medicaid is funded by...
The government
Is there a monthly premium for Medicare?
No
What are some areas in which Medicaid covers?
In pt and out pt services
- Same things medicare covers (hospital care, lab and radiology, doctors, skilled nursing, essential screenings under 21 yrs, vaccines, family planning, etc.)

*some states may choose to add other areas like vision, dental, prescriptions, etc. but that varies by state
Another type of 3rd party payer is by private support. What are 3 different forms of private healthcare support?
1. Insurance Companies
2. Employers
3. Individuals
Employers may also provide insurance to __________ and _________ employees.
Attract; retain

*Employers and insurance companies will negotiate and determine the plans offered
Individuals (consumers) can also choose to privately support themselves by...
Paying out of pocket
-this way that have more of a choice on how to spend their money

*however, in most cases, the person receiving care is not the person paying for it
There are 2 main systems in which money is payed to healthcare systems. What are they?
1. Retrospective Reimbursement
2. Prospective Reimbursement
What is Retrospective Reimbursement?
When the HCP determines the amount the consumer pays after the services are given
Cost-shifting can happen with retrospective reimbursement. What is cost-shifting?
Organization will help balance for losses in one area (i.e. ppl can't pay) by charging more in other areas
What is Prospective Reimbursement?
3rd party payer establishes the amount of money paid for a service before the service is ever offered
Prospective Reimbursement involves the use of.... in compensating the provider on a case by case basis.
DRGs
With the use of DRGs, there is a...
Predetermined amount paid regardless of the time and money spent on one's care
Prospective Reimbursement does encourage companies to...
Only treat what is wrong with the pts however, as discussed before, this will decrease quality of care
What are two ways that healthcare practitioners are paid/reimbursed?
-Fee for Service (retrospective reimbursement)
-Capitation (prospective reimbursement) - caps off after a certain amount
Capitation is unique from fee for service in that it is...
Cut off after a certain point
Sets with similar terms