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Health Care DeliveryMary Beth Vogel, BSN RN-C
B
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A Little History…
Hippocrates: Father of Medicine
Michelangelo and DaVinci: dissection for accurate drawings
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Anthony Leeuwenhoek: Father of Microscopy
1714: Fahrenheit: thermometer
1796: Jenner: smallpox vaccine
Ben Franklin: bifocals, catheters
Florence Nightingale: Founder of nursing
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Joseph Lister: disinfectant/antiseptics
Louis Pasteur: germ theory/pasteurization
Elizabeth Blackwell: first woman to graduate from med school in 1849
Clara Barton: Founder of Red Cross
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20th Century Flemming: penicillin (1928)
Jonas Salk: polio vaccine (1952)
Crick and Watson: identified DNA (1953); Nobel Prize awarded in 1962
1975: amniocentesis dev and ability to remove life support (Karen Quinlan case)
Louise Brown: 1st in-vitro baby (1978)
AIDS identified (1984)
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Bureau of Labor Statistics:
Largest industry in US: 13.5 million jobs
8 out of 20 occup projected to grow the fastest are in hc
More new jobs (about 19 percent, or 3.6 million created between 2004 and 2014) will be in health care than in any other industry
About 545,000 establishments make up the hc industry
Hospitals constitute only 2% of all hc establishments; they employ 40% of all HCW
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HCW also are more likely to remain employed in the same occup. Why?
High level of educ, training, $ required for many health careers
Job opportunities will remain excellent in all hc settings because job turnover d/t retiring baby boomers
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Current Trends
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1. Cost Containment
Focus: max benefit for every $
Causes of current high costs in US?
Technology
Aging population
Litigation
Poor health habits
# uninsured
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Methods to Contain Costs: 1. DRGs (diagnostic related groups)
2. Combining services/eliminate dupl
3. Outpatient, home care
4. Preventative care
5. Bulk purchasing/procurement
6. Conservation of supplies, energy
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2. Home Health Care
A trend and a method to contain costs
Increasing number of disciplines can deliver care at home
House calls making a comeback?
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3. Geriatric Care
Rising elderly population will challenge US hc delivery
Assisted living and adult day care
SNF
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4. Developing technology
Marks US hc as best in the world?
Comes with an expensive pricetag
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5. Emphasis on prevention
Helps contain cost but is also a trend
Cheaper to prevent illness than tx it
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6. Alternative/Complimentary Tx
Alternative Tx: in place of traditional Complimentary Tx: in addition to trad Holistic care or Integrative Medicine may incorporate both NIH: Office of Alt Med (OAM) to research new therapies and
est standards Why is it important to be aware of alt/comp tx?
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Health Care Delivery in the US
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1. Hospitals
Acute care
Categorized by pop tx, affiliations, and/or funding
Types:
General
Specialty
Government
University
Religious
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Funding:
Private/proprietary
Non-profit
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2. Outpatient Services Wide range of careers/svcs
Clinics, physician offices, surgical svcs
Private, local, university, county/state
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3. LTC SNF, assisted living, rehab
Tx: chronic illness, disabled, elderly
Long-term care, rather than acute care
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4. EMS
Paramedics / EMT
Ambulance/transport services, urgent care, ED, flight services
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5. Diagnostic Svcs Techs, equip operators
Labs, radiology
Free standing, hosp assoc
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6. Home Health Svcs
HHA / CNA, LPN / RN, specialty services
Private agencies, hosp assoc
Nursing care
Personal care
Therapy ( PT, OT, Speech, RT)
Homemaking
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7. Hospice Care
Focus moves from curative to comfort care
Palliative/hospice
Home, hospital or specialized facility
Goal of Hospice Care: allow a person to die with dignity and in comfort.
Psychological, social, spiritual, physical
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8. Mental Health Services
Psychiatrist / psychologist
Specialized hosp or designated units in general hosp, psych clinics, tx ctrs for specific disorders
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9. Rehabilitation Services
Hospital or free standing
Services inc PT, OT, SLP
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10. Occupational Health
Industrial health
Company or assoc w/ hosp/med office
Wrkrs comp ins
Safety/prevention
MA
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11. Optical Services Opticians, optometrists, ophthalmologists
Wide range of vision services from glasses to surgery
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12. School Health Services
Emergency care, education, counseling, screenings
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Health Insurance
Protection against med costs
Contract btwn insurer and individ/grp
In US, often is a benefit of employment
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Managed Care
Integrates cost and delivery of healthcare
Goal: elim wasteful spending
All health care must have a purpose
Involves 2nd opinions, networks, pre-certification, case management
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Insurance Terms
Premium: cost of the plan
Deductible: fixed dollar amt payed before insurance begins to pay
Coinsurance: insured pays fixed %
Co-payment: flat fee/fixed dollar amt
Pre-certification/preauthorization
Referral
Network
Exclusions
PCP
2nd surgical opinion
Terms of policy often negotiated btwn emplyrs/ins carriers
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Types of health insurance
1. HMO (health maintenance org)
Selected network
PCP, referrals, pre-certs
Least expensive (historically)
Advantages: low out of pocket costs, may not have a lifetime max, focus on wellness
Disadvantages: non network may be denied or high co-ins%, “gatekeeper”, referrals; pre-authoriz for most proced
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2. PPO
More flexibility
No PCP/referrals but incentives for in-network
Advantages: low out of pocket expense, lgr network, usually no gatekeeper or referrals; limited pre-authoriz
Disadvantages: limitations for out of network, may be somewhat more expensive
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Variations of 1 and 2:
Point of Service: PCP in-netwk but care out of netwk is cov. May need referrals
Fee for Service: most freedom, no netwks, no PCP. Providers receive fee for each scv. Most expensive
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3. Medicare: elderly (65+), SS for >2 years
Part A: hospital
Part B: outpatient/physician
Part C (Medicare advantage): expanded benefits
Part D: prescription drug
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4. Medicaid: hosp/med expense coverage for low-income
Varies by state
5. CHIP: for uninsured children < 19
6. TRICARE: military & families; admin by priv contractors; VA
7. Civilian Health and Medical Program of the Uniformed Services (CHAMPUS): inactive military/families
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Government Agencies
WHO – UN sponsored, stats/info, addresses serious health prob in world
USDHHS – health probs in US
NIH – part of USDHHS, disease research
CDC – part of USDHHS, causes/spread/control of diseases
OSHA – standards, prev job-rel injuries
FDA – regulates food & drug products
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Non-Profits
Support from member fees, donations, fed/state grants
May focus on single disease or grp
Emphasis on research, educ, local services
Red Cross, AHA
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Organizational Structure
Chain of command
Streamlines prob solv, improve overall comm
Most efficient operation
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Health Care Reform What is wrong with our current system?
US spends more on hc than any other nation
But…
US is 23nd in life expectancy
US is 26th in infant mortality
Yet we spend more on hc than any other nation (WHO)
46 million are uninsured
Here’s how other countries take care of their citizens: (pbs.org)
http://video.pbs.org/video/1050712790/