Chapter 1- Health Care Systems

History of Health Care

Pertinent questions

When did most of the most significant changes in health care occur?

Why were the greatest advances made in this time period?

What are some possibilities for the future of health care?

Health Care Systems1. Many different types deliver

health care

2. Largest & fastest growing industry

3. Employs over 10 million workers in over 200 careers

4. $2,000,000,000 per day industry

Hospitals – vary in size & type of services General hospitals – varied services Specialty hospitals – certain conditions or

ages (burns, pediatrics, cancer, heart, etc) Government hospitals – fed, state, local (VA,

military, state rehab or psychiatric) University or college medical centers –

provide services, RESEARCH, education

Classification – based on funding sources Private or proprietary – for profit (pt.

fees & organizational support) Religious – religious support, pt. fees Non-profit or voluntary – pt. fees,

donations Government – taxes, pt. fees

Long Term Care Facilities (LTC)

Provide care for elderly, physical or mental disabilities, chronic or long term illnesses

Pts are usually called residents Nursing homes or geriatric homes – provide

ADLs for those unable to care for themselves, provide a safe environment, & promote social interactions

Extended Care or Skilled Care Facilities Provide skilled nursing & rehab care Prepare resident for return to home environment Subacute units – rehab for surgery, cancer tx,

dialysis Independent or assisted living facilities –

individuals receive the help they need (meals, transportation, housekeeping, etc)

Many are associated with LTC facilities, enabling the individual to move from facility to facility as need arises

Medical Offices

Privately owned offices to large corporations

Services: diagnosis, treatment, examinations, basic lab tests, minor surgery

Some treat wide variety of illness/ages & others specialize

Dental Offices

Private offices to dental clinics Can be found in major retail stores Can provide general or specialized

dental care

Clinics

Can refer to a group of medical/dental professionals who share a facility & staff

Others specialized – surgery, emergency care clinics, rehab clinics, diabetes or oncology clinics

Can be affiliated with a hospital Health department – pediatrics, sexually

transmitted diseases, immunizations, other special services

Medical centers at universities – frequently free or reduced cost care to provide learning experiences

Optical Centers

May be individually owned or part of a large chain

Provide vision examinations, prescribe eyeglasses or contacts, check for eye diseases

Emergency Care Services

Provide special care for accidents or sudden illness

Examples – ambulance, rescue squads, emergency care clinics, emergency rooms in hospitals, helicopter or airplane

Laboratories

Can be part of another facility or separate health care service

Medical labs – perform diagnostic tests Dental labs – prepare dentures and

other devices

Home Health Care

Provides care in patient’s home Examples – nursing, personal cares,

therapy, homemaking Offered by health departments,

hospitals, private agencies, government agencies, nonprofit agencies, volunteer groups

Hospice

Provides care for terminally ill persons with a life expectancy of 6 months or less

Care provided in home or hospice facility

Allows death with dignity & comfort Provides psychological, social, spiritual,

& financial counseling for pt. & family

Mental Health Facilities

Deal with mental diseases and disorders

Examples – guidance/counseling centers, psychiatric clinics/hospitals, chemical abuse treatment centers for alcohol or drug abuse, physical abuse treatment centers

Genetic Counseling Centers Can be independent or affiliated Works with couples or individuals who are pregnant

or considering pregnancy Performs prenatal screening, check for genetic

abnormalities & birth defects, explains test results, identify medical options when defect is present, help individuals cope with psychological issues caused by genetic disorder

Used especially for older women, family history of genetic disease, specific race/nationality where genetic disease is prevalent

Rehabilitation Facilities

Care directed at helping pt. with mental or physical disability obtain maximum function

Includes hospitals, clinics, private centers

Services – physical, occupational, recreational, speech, & hearing tx

Health Maintenance Organizations Provide total health care directed

toward preventive care Services: examinations, basic medical

services, health education, hospitalization, rehabilitation

Mode of operation – large industry/corp, private agencies, uses services of other health care facilities

Industrial Health Care Centers or Occupational Health Clinics Located in large industries or

companies Provides health care for employees Services – basic exams, teach accident

prevention/safety, provide emergency care

School Health Services

Found in schools & colleges Services – emergency care for

accidents & sudden illnesses, speech/vision/hearing screenings, promote health education, maintain safe & sanitary school environment, counseling

Government Agencies

Offered at international, federal, state, local levels – most tax supported

World Health Organization (WHO) – international agency supported by United Nations that provides statistics & information about disease, publishes health information, & investigates & deals with serious health problems throughout the world

United States Department of Health & Human Services (USDHHS)

National Institute of Health (NIH) – researching disease

Centers for Disease Control & Prevention (CDC) – researches causes, spread, & control of diseases in populations

Food & Drug Administration (FDA) – regulates food & drug products sold to the public

USDHHS (cont)

Agency for Health Care Policy & Research (AHCPR) – established in 1990 to research quality of health care delivery & identify standards of treatment

Occupational Safety & Health Administration (OSHA) – establishes & enforces standards protecting workers from job-related injuries & illnesses

State & Local Health Departments Provides health services as directed by

USDHHS Provides specific needed services –

immunizations, inspections for environmental health & sanitation, communicable disease control, collection of statistics & health records, health education, clinics for health care & prevention

Volunteer or Nonprofit Agencies Supported by donations, membership fees,

fundraisers, & grants Provides health services at national, state, or local

levels Examples – American Cancer Society, American

Heart Association, American Diabetes Association, American Red Cross, March of Dimes, etc.

Many deal with one disease or group of diseases to study, provide funding for research, promote education, purchase medical equipment, provide treatment centers, & supply information

Health Insurance Plans

Cost of health care a major concern Cost of health care is >12% of gross national

product Health care costs are increasing faster than

other costs of living Most people rely on health insurance plans to

pay for health care costs Without insurance, cost of illness disastrous

Health Insurance Plans

Different plans offered by thousands of agencies

Pay a premium to purchase insurance If insured person has expenses covered

by the plan, the insurance company pays for them

Amount of payment and services vary from plan to plan

Insurance terminology

Deductibles – amounts that must be paid by the insured individual before policy begins to pay

Co-insurance – requires specific percentage of expenses to be shared by individual & company (80-20 80% paid by company, 20% paid by individual)

Co-payment – specific amount of money patient pays for a particular service (example - $20 per doctor’s appointment regardless of total cost)

Insurance Plans

Many people have insurance from place of employment

Private policies can be purchased by individuals

Health Maintenance Organizations Special type of insurance plan Monthly fee is paid for membership & price

remains same, regardless of number of visits Premium paid either by employer or individual Most pay for total health care – routine visits

& exams & preventive health care (not usually covered by private insurance)

Health Maintenance Organizations Advantages – provides ready access to

health care, early detection & treatment of disease, individual usually maintains better health

Disadvantages – individual can only use HMO affiliated providers for health care. If choose a provider outside of HMO, individual pays for all costs

Preferred Provider Organizations (PPO) Usually provided by large company Company contracts with health care

agency Employee must use specific health care

agency Industry/company can provide health

care at lower rates

Medicare

Federal government health care plan Provides health care to those over 65 years of

age or persons with a disability who have had social security benefits for at least 2 years

Type A coverage – hospital services & LTC facility after hospitalization

Type B coverage – Dr. services, outpatient therapy, other health care. Individual pays premium for this coverage. 80-20 co-insurance – Medicare pays 80%, individual or insurance pays 20%

Medicaid (MediCal)

Medical assistance program offered by states (vary from state to state)

Covers individuals with low incomes, children who qualify for public assistance, the physically disabled or blind

State Children’s Health Insurance Program (SCHIP) – established 1997 to provide health care to uninsured children of working families who earn too much to qualify for Medicaid

Worker’s Compensation

Provides treatment for workers injured on the job

Administered by the state Payments made by employers & state Provides payment for health care & lost

wages

United States Government Plans

Provides health care for all military personnel TRICARE Cares for all active duty members & families Cares for survivors of military personnel &

retirees & their families Veteran’s Administration provides for military

veterans with service connected disability

Managed Care

Developed because of rising health care costs & need to spend money efficiently

All health care must have a purpose Second opinion or verification of need often

required Includes preventive care, physical exams, well-

baby care, immunizations, wellness education (good nutrition, exercise, weight control, healthy living)

Usually provided by HMOs & PPOs by setting up network of providers – restricted usage

Organizational Structure

Often called line of authority or chain of command

Indicates area of responsibility Leads to efficient operation of facility

Hospital Organizational Chart

Shows organization by departments Notes various divisions of departments Each department can have an individual

organization

Medical Office Organizational Chart Simpler organizational chart Even with fewer people, lines of

authority are clearly shown & easy to follow

Summary

In both cases, chain of command is clearly indicated

Health care workers must identify & understand their position in the organizational structure

Allows workers to know the line of authority & understand who is their immediate supervisor

Questions/concerns/problems – go to immediate supervisor

If supervisor is unable to solve the problem, go to the next level in the chain.

Trends in Health Care

Many events lead to changes in health care (example AIDS)

Changes occur almost daily 1st trend is cost containment

Methods Used to Contain Costs

Diagnostic related groups – DRGs– Attempt by Congress to control costs– Payment based on diagnosis– Certain amount paid for each

disease/condition– Agencies that provide care for less keep

the money– Agencies accept loss if care costs exceed

payment allowed

Combination of Services

Agencies combine services to avoid duplication

Share clinics, labs, etc HMO & PPO examples Provides care to larger number of

people at a decrease in cost per person

Outpatient Services

Patients receive care without being admitted to hospitals

Reducing length of stay or decreasing need for hospitalization lowers costs

Often use less expensive home care or skilled nursing care

Examples – outpatient surgery, xrays, diagnostic tests

Mass or Bulk Purchasing

Buying equipment & supplies in larger quantities at reduced prices

Often combines department or agency orders

Computerized inventories can be used to determine when supplies are needed & to prevent overstocking & waste

Early Intervention & Preventive Services Providing care before acute or chronic

disease occurs Prevention is ALWAYS more cost effective Methods – immunization, patient education,

regular physical exams, easy access to health care, incentives for prevention

Studies show people with limited access to health care use emergency departments

Energy Conservation

Monitoring use of energy to control costs & conserve resources

Electricity, water, gas Energy efficient buildings Recycling

Agency for Health Care Policy & Research (AHCPR)

Federal agency developed in 1990 Purpose – to research quality of health care

delivery & identify standards of treatment that should be provided

Quality of health care should not be lowered simply to contain costs

Need to provide quality care while be attentive to avoiding waste & controlling costs

Consumers need to be responsible as well

Home Health Care

Rapidly growing field due to insurance regulating hospital stays

Less expensive to perform All aspects involved – nursing, physical

& occupational therapy, respiratory therapy, social services, nutritional services, homemaking services

What are advantages to home care?

Geriatric Care

Care of the elderly Rapid growth due to longer life spans &

“baby boomers” Lead to growth of facilities – adult day

care, retirement communities, assisted & independent living facilities, LTC facilities

Geriatric Care

Omnibus Budget Reconciliation Act (OBRA) of 1987– Federal law creating regs regarding LTC and

home health– Requires state to establish training & competency

programs for assistants– Requires nursing assistants to:

• Complete mandatory state-approved training• Pass written & competency exams• Obtain certificate or registration

Geriatric Care

Other OBRA requirements– Continuing education– Periodic performance evaluations– Retraining/retesting if CNA does not work

in a facility for more than 2 years States must maintain registry Requires compliance with patients’

rights to ensure certain standards of care

Telemedicine

Uses video, audio, & computer systems to provide health care services

Allows interaction even though workers are in different locations– EMTs at scene of accident– Surgeons using remote control arms– Watching procedures by video

May allow people to receive tx in homes

Wellness

State of being in optimum health with balanced relationship between physical, mental, & social health

Recognizes importance of– Good nutrition– Exercise– Weight control– Healthy living habits

What are examples of facilities stressing this?

5 Ways to Promote Wellness

Physical wellness – Well-balanced diet– Regular exercise– Routine physical exams/immunizations– Regular dental/vision care– Avoidance of alcohol, tobacco, caffeine,

drugs, environmental contaminants, & risky sexual behaviors

5 Ways to Promote Wellness

Emotional Wellness– Understanding feelings & expressing them

appropriately– Accepting one’s limitations– Adjusting to change– Coping with stress– Enjoying life– Remaining optimistic

5 Ways to Promote Wellness

Social Wellness– Showing concern, fairness, affection,

tolerance, & respect for others– Communicating & interacting well– Sharing thoughts & ideas– Practicing honesty & loyalty

5 Ways to Promote Wellness

Mental & Intellectual Wellness– Being creative, logical, curious, & open-

minded– Using common sense– Obtaining continual learning– Questions/evaluating information &

situations– Learning from life experiences– Using flexibility & creativity to problem solve

5 Ways to Promote Wellness

Spiritual Wellness– Using values, ethics & morals to find

meaning, direction, & purpose in life

Alternative & Complementary Methods of Health Care

Most health care in the U.S. is biomedical or “Western” system– Based on evaluating physical signs &

symptoms, determining cause of disease, & treatment

Major trend towards other methods– Alternative therapy – in place of biomedical– Complementary – Used with biomedical

Holistic Health Care

Part of alternative/complementary tx Consider the whole person &

recognizes that the health of each part has an effect on total health status

Life force or energy helps with healing Many therapies based on culture Skilled practitioners, rituals, specialized

practices part of therapy

Examples of Alternative or Complementary Practitioners

Ayurvedic practitioners – Indian philosophy to maintain harmony by diet, exercise, yoga, & living practices

Chinese medicine – Life energy flows through the person through pathways that link the organs together: use acupressure & accupuncture, tai chi, herbs to maintain energy flow

Examples continued

Chiropractors – brain sends vital energy through nerves in spinal cord, misalignment causes pain: use spinal manipulation, massage, & exercise

Homeopaths – body has ability to heal itself through the immune system: use drugs from plants, animals, & minerals to cause symptoms & activate immunity

Examples cont.

Hypnotists – help people achieve a trance-like state to become receptive to verbal suggestions to change behaviors

Naturopaths – use only natural therapies like fasting, special diets, lifestyle changes & avoid surgery or medicine

Alternative/Complementary Medicine

Most therapies are holistic & noninvasive Most are less expensive than traditional

treatments Office of Alternative Medicine (OAM) –

established by NIH to research therapies & determine standards of quality care. Practioners may required education or licenses before practicing. Also labels therapy as experimental.

Remember

Patients have the right to choose their own type of care

Be non-judgmental Important for health care providers to be

aware of alternative treatments

National Health Care Plan

High costs of health care + large number of uninsured people = need for this plan

No current plan, many have been proposed

Problems – cost of creating, who pays more, lack of free choice, new regulations need to be created

Past & Current Trends

Polio vaccine Antibiotic development Cancer & AIDS drugs Computers Test tube babies Cloning Health care will continue to change – be

aware!