Health Care DeliveryMary Beth Vogel, BSN RN-C

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A Little History…

Hippocrates: Father of Medicine

Michelangelo and DaVinci: dissection for accurate drawings

Anthony Leeuwenhoek: Father of Microscopy

1714: Fahrenheit: thermometer

1796: Jenner: smallpox vaccine

Ben Franklin: bifocals, catheters

Florence Nightingale: Founder of nursing

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

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)

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

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

Current Trends

1. Cost Containment

Focus: max benefit for every $

Causes of current high costs in US?

Technology

Aging population

Litigation

Poor health habits

# uninsured

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

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?

3. Geriatric Care

Rising elderly population will challenge US hc delivery

Assisted living and adult day care

SNF

4. Developing technology

Marks US hc as best in the world?

Comes with an expensive pricetag

5. Emphasis on prevention

Helps contain cost but is also a trend

Cheaper to prevent illness than tx it

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?

Health Care Delivery in the US

1. Hospitals

Acute care

Categorized by pop tx, affiliations, and/or funding

Types:

General

Specialty

Government

University

Religious

Funding:

Private/proprietary

Non-profit

2. Outpatient Services Wide range of careers/svcs

Clinics, physician offices, surgical svcs

Private, local, university, county/state

3. LTC SNF, assisted living, rehab

Tx: chronic illness, disabled, elderly

Long-term care, rather than acute care

4. EMS

Paramedics / EMT

Ambulance/transport services, urgent care, ED, flight services

5. Diagnostic Svcs Techs, equip operators

Labs, radiology

Free standing, hosp assoc

6. Home Health Svcs

HHA / CNA, LPN / RN, specialty services

Private agencies, hosp assoc

Nursing care

Personal care

Therapy ( PT, OT, Speech, RT)

Homemaking

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

8. Mental Health Services

Psychiatrist / psychologist

Specialized hosp or designated units in general hosp, psych clinics, tx ctrs for specific disorders

9. Rehabilitation Services

Hospital or free standing

Services inc PT, OT, SLP

10. Occupational Health

Industrial health

Company or assoc w/ hosp/med office

Wrkrs comp ins

Safety/prevention

MA

11. Optical Services Opticians, optometrists, ophthalmologists

Wide range of vision services from glasses to surgery

12. School Health Services

Emergency care, education, counseling, screenings

Health Insurance

Protection against med costs

Contract btwn insurer and individ/grp

In US, often is a benefit of employment

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

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

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

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

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

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

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

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

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

Organizational Structure

Chain of command

Streamlines prob solv, improve overall comm

Most efficient operation

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/