chapter 1 - higher ed ebooks & digital learning solutions ...€¢dagins &osi treatment of...

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© 2007 Thomson - Wadsworth

Chapter 1

Health Care Systems and Reimbursement

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Overview

• Health Care Facilities in the U.S.Preventive & Primary Health Care ServicesSecondary & Tertiary CareRestorative CareLong-Term Care

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Overview continued

• Financing the Health Care IndustryPrivate Insurance• Traditional Fee-for-Service Plans• Group Contract Insurance

Public Insurance• The Medicare Program

– Medicare Part A– Medicare Part B– Coverage Gaps

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Overview continued

The UninsuredDemographic Trends in Health CareThe Need for Health Care Reform• The High Cost of Health Care• Efforts at Cost Containment• Equity & Access as Issues in Health Care• Racial & Ethnic Disparities in Health

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Overview continued

Health Care Reform in the United States• Nutrition as a Component of Health Care

Reform• The Cost-Effectiveness of Nutrition

Services

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Preventive & Primary Health Care Services

• Prevention of illness & chronic disease

• Nutrition• Facilities

Health departmentsClinics & physician’s officesSchoolsProfessional, nonprofit & volunteer organizations

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Secondary & Tertiary Care

• Diagnosis & treatment of illness

• Acute care• Tertiary care

ExpertTechnicalHighly specialized

• FacilitiesTraditionally hospitalsPhysicians’ officesOutpatient facilitiesUrgent careSurgical unitsEmergency rooms

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Hospital Classifications

• See Box 1-2• Public not-for-profit• Private not-for-profit• Private profit• Veterans’ and military

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Nutrition in Secondary & Tertiary Care

• Examples:Celiac diseaseHypertensionArtherosclerosisMyocardial infarctionCongestive heart failure

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Restorative Care

• Care for recovery from acute or chronic illness

• Nutrition• Facilities

Long-term careRehabilitation facilitiesOutpatient clinicsHome health services

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Long-Term Care

• Maintenance, custodial & health services for the chronically ill or disabled

• Nutrition

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Health Insurance

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Private Insurance

• Traditional fee-for-serviceFee per service rendered10% of insurance coverage today

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Private Insurance continued

• Group contract insuranceManaged care system• Health maintenance organizations

(HMOs)– Capitation– General HMO models

» Staff model» Group model» Network model» Independent practice association

• Preferred provide organizations (PPOs)

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Public Insurance

• Medicare• Medicaid• SCHIP• HIPAA• Workers’ compensation

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Providers of Public Insurance

• Centers of Medicare & Medicaid Services• Department of Veterans Affairs• Public Health Services

Indian Health Service• Department of Defense

Civilian Health & Medical Program of the Uniformed ServicesCHAMPUS

• Public hospitals & community health centers• State & local public health programs

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Medicare

• 1965 Title XVIII of Social Security Act

• Administered by CMS of Department of Health & Human Services

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Eligibility

• 65 years of age or older• Any age with end-stage renal disease• Eligible for Social Security or Railroad

Retirement Board disability benefits up to 24 months

• Medicare-covered government employment prior to retirement

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Medicare Part A

• Hospital InsuranceInpatient hospital, skilled nursing facility, & some home healthDeductibles & coinsurance feesHospital inpatient charges reimbursed according to prospective payment system (PPS)• Diagnosis-related groups (DRGs)

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Medicare Part B

• Medical insurance• Optional program• Provides benefits for

Eligible physician servicesOutpatient hospital servicesCertain home health servicesDurable medical equipment

• NutritionMedical Nutrition TherapyCurrent procedural terminology (CMT)Enrolled Medicare MNT providers bill for

• Diabetes mellitus• Nondialysis kidney

disease• Post-kidney

transplant

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Medicare savings after 3 years of reimbursement of nutrition services

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Coverage Gaps

• Prescription drug coverage• Skilled nursing & long-term institutional

care > 100 days• Medicare Modernization Act of 2003

Optional coverageDrug discount cards/prescription drug plansAdditional preventive benefits

• Medigap PolicySupplemental policy from private insurance companies

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Medicaid

• Entitlement program• Joint state & federal program• 1965 Title XIX of the Social Security

Act

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Eligibility

• Low incomes• Certain pregnant women & children

with low incomes• Older adults, the blind & people with

disabilities• Members of families with dependent

children in which one parent is absent, incapacitated or unemployed

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Eligibility continued

• Determined by states• Three criteria

Income• Below federal poverty guidelines

Categorical• Member of family with dependent children• Older adult• Blind• Disability

Resource

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Coverage

• Inpatient & outpatient hospital services• Physician, pediatric/family nurse practitioner• Nurse-midwife services• Selected health center & rural health clinic services• Prenatal care & family planning• Child vaccination & services for those under 21 years

of age• Laboratory & X-ray services• Skilled nursing home & home health services

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• State Children’s Health Insurance Program

• Title XXI in the Balanced Budget Act of 1997

• Children of working families with incomes too high to qualify for Medicaid but too low to afford private health insurance

SCHIP

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SCHIP Enrollment

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Coverage

• Inpatient & outpatient hospital services

• Physicians’ surgical & medical services

• Laboratory • X-ray services• Well baby/child care services

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The Uninsured

• Employed uninsured• Nonworking uninsured• Emergency room• Resulting cost shift to the insured by

the increase in overall medical costs

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Percentage of Uninsured in U.S.

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Demographic trends in health care

• Aging population of baby boomersRequire care for greater number of yearsRise in amount of medical care required

• Increase in Hispanic population

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Elderly needing long-term care

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Health Care Reform

• Success of health care systemCostQualityAccess

• ChallengesAccessible to allContain costsProvide nursing home careEnsure that Medicare & Medicaid can serve eligible people

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High costs of health care

• Aging population• Increased demand• Medical advances• Administrative costs of insurance

process• Professional liability costs

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National health expenditures in billions of dollars, 1960-2002

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Cost Containment Efforts

• Slowing hospital construction• Modifying reimbursement • Reducing length of stays• Increasing co-payments &

deductibles• Challenging eligibility requirements

for Medicaid

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Cost Containment Efforts

• Requiring second opinions to reduce unnecessary surgery

• Restricting access to new technology• Encouraging alternative delivery

systems• Emphasizing prevention• Generic drugs

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Resulting Trends

• Movement away from traditional fee-for-service

• Companies choosing self-insured health plans to avoid cost shifting

• Payers setting reimbursement restrictions & limitations

Prospective payment system (PPS)• Diagnosis Related Groups (DRGs)• ICD-9-CM

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Racial & Ethnic Disparities in Health

• Healthy People Initiative

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Health Care Reform in the U.S.

• Health insurance reform• Physician malpractice reform• Incentives to induce businesses to

include health promotion initiatives in their insurance plans

• Preventive component vs. chronic disease as typical focus of allopathic medicine

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Nutrition in Health Care Reform

• Good health does not exist without proper nutrition.

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Cost Effectiveness of Nutrition Services

• Well documented• Develop guidelines or protocols that

specify appropriate care for conditions or diseases

• Measure outcomes• Documentation

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chapter 1 - higher ed ebooks & digital learning solutions ...€¢dagins &osi treatment of...

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