Julie Gossett BSN, RN NURVN 413 Chapter 18 Health Care System:
Financing, Issues, and Trends Slide 2 Health Care System Rankings
U.S. ranked #1 in honoring the dignity of individuals, choice of
provider, timely care, and confidentiality U.S. ranked #37 in
overall performance in relating outcomes to expenditures in health
care U.S. has the highest health care spending (deductibles,
copayments, coinsurance, and premiums for private insurance) of
industrialized countries Slide 3 United States # 54 out of 191
countries in fairness in financing health care U.S. spends $7026
per capita on health care However of the spending was on 5% of the
population. In European Union ever person is based on premise that
every resident is guaranteed the same quality of healthcare Slide 4
Canada Federally funded national health insurance Coverage is
portable (not lost when a person moves) Universal (all residents of
Canada are insured) Accessible (reasonably available) Free from
extra charges for core services Slide 5 Two Major Ways to Finance
Health Care Fee-for-Service Traditional method of paying health
care bills Physicians paid by the patient for each service
Physician has an agreement with Insurance agency can be paid
directly Some Insurance companies will not pay for tests to keep
people healthy or identify illness in early stage Slide 6 Two Major
Ways to Finance Health Care Capitation Set monthly fee charged by
the provider for each member of the insurance group for a specific
set of services If health care services are more than the monthly
fee, the provider absorbs the cost of the services At the end of
year, if money is left over, the health care provider keeps the
profit Slide 7 Basic Health Insurance Terms Elsevier items and
derived items 2009, 2005 Saunders, an imprint of Elsevier, Inc. All
rights reserved. 7 Premium Monthly fee a person must pay for
health-care insurance coverage Deductible Yearly amount an insured
person must spend out-of-pocket for health care services before a
health insurance policy will begin to pay its share Slide 8 Basic
Health Insurance Terms Elsevier items and derived items 2009, 2005
Saunders, an imprint of Elsevier, Inc. All rights reserved. 8
Copayment Amount an insured person must pay at the time of an
office visit, when picking up a prescription, or before a hospital
service Coinsurance Percentage of the total bill paid by the
insured person Health Care Provider A licensed health care person
whose health care services are covered by a health insurance plan
Slide 9 How Patients Pay for Health Care Services Elsevier items
and derived items 2009, 2005 Saunders, an imprint of Elsevier, Inc.
All rights reserved. 9 Personal Payment (Private Pay) Payment
directly by the patient Some patients may use this method of
payment today. Cost of health care services discourages this method
to be used. Private pay patients may be able to negotiate a
discount with some health care agencies. Slide 10 How Patients Pay
for Health Care Services (contd) Elsevier items and derived items
2009, 2005 Saunders, an imprint of Elsevier, Inc. All rights
reserved. 10 Private Group Health Insurance Pools individual
contributions for a common group goal- protection from financial
disaster as a result of health care bills Offered by most employers
in the United States Private Nongroup Health Insurance Offered by
insurance companies to individuals who are not part of a group
Premiums are based on a persons health risk and age Slide 11 How
Patients Pay for Health Care Services Elsevier items and derived
items 2009, 2005 Saunders, an imprint of Elsevier, Inc. All rights
reserved. 11 Medicare: A Program of Social Security Federally
sponsored entitlement program and public health insurance plan
Helps finance health care for all persons older than age 65 (and
their spouses), Have at least a 10-year record in Medicare-covered
employment Must be a citizen or permanent resident of the United
States Slide 12 How Patients Pay for Health Care Services Elsevier
items and derived items 2009, 2005 Saunders, an imprint of
Elsevier, Inc. All rights reserved. 12 Components of Medicare Part
A: Hospital insurance for inpatient hospital care Part B: Medical
insurance for physician services, outpatient care, and diagnostic
tests Part C: Medicare Advantage Plan offered by private insurance
companies Part D: Medicare Drug Legislation: provides prescription
drug coverage Diagnosis-related groups (DRG) system Math formula
calculates the fee government pays for hospitalization Slide 13 How
Patients Pay for Health Care Services (contd) Elsevier items and
derived items 2009, 2005 Saunders, an imprint of Elsevier, Inc. All
rights reserved. 13 Medicaid (Medical Assistance) For eligible
families and individuals with low incomes and resources Each state
establishes its own program services and eligibility requirements.
Childrens Health Insurance Program (CHIP): covers uninsured
children up to 200% of the poverty level. Slide 14 Sources of
Funding Elsevier items and derived items 2009, 2005 Saunders, an
imprint of Elsevier, Inc. All rights reserved. 14 Private Health
Insurance: Individual contributions are pooled Government Health
Programs Medicare is funded by the federal government. Medicaid is
jointly financed by federal and state governments. Slide 15 Cost of
Health Care Elsevier items and derived items 2009, 2005 Saunders,
an imprint of Elsevier, Inc. All rights reserved. 15 Need for Cost
Containment The need to hold costs to within fixed limits Source of
Revenue (Income) for Government Health Care Income tax and payroll
tax When Federal Spending Exceeds Revenue Two ways to cut costs in
these programs Passing new laws to change eligibility Passing new
authorization bills to alter funding Health Care and the National
Economy The national economy plays a great deal into health care
economics. Slide 16 Cost of Health Insurance Elsevier items and
derived items 2009, 2005 Saunders, an imprint of Elsevier, Inc. All
rights reserved. 16 Cost of Prescription Drugs The cost of commonly
prescribed drugs in the United States has risen twice as much as
the rate of inflation. After decades of soaring drug prices,
employers and health plans expect employees to pay more for their
prescriptions. Drugs are expensive in the United States because
drug companies can charge full price for the drugs, which includes
the cost of research and development of new drugs. Slide 17 The
Uninsured Elsevier items and derived items 2009, 2005 Saunders, an
imprint of Elsevier, Inc. All rights reserved. 17 Two Classes Of
Employed Uninsured Low-wage employees Employed in low-wage jobs
that are less likely to offer insurance benefits Middle class
Workers are priced out of the health care insurance market by
rapidly rising health insurance premiums. Slide 18 Cost of Lack of
Health Insurance Elsevier items and derived items 2009, 2005
Saunders, an imprint of Elsevier, Inc. All rights reserved. 18
Alternatives to pay for health care include: Medicaid (if they
qualify) Private pay (if they can afford it) Charity care (if they
can find it) Face medical bankruptcy Lack of access to health care
prevents individuals from receiving preventive care and seeking
treatment when a health problem is developing. Many people rely on
Emergency Departments for all levels of health care due to lack of
insurance. Slide 19 Uncompensated Care Elsevier items and derived
items 2009, 2005 Saunders, an imprint of Elsevier, Inc. All rights
reserved. 19 Results in huge yearly deficits for health care
organizations Includes services for which hospitals did not receive
full payment Free care Free services that hospitals provide to
patients who show that they cannot afford to pay for their care.
Bad debt Services that hospitals provide for which they expect to
receive payment, but never receive it. For example, insurance
companies or patients who do not pay their bills Slide 20 Repairing
the Health Care System Elsevier items and derived items 2009, 2005
Saunders, an imprint of Elsevier, Inc. All rights reserved. 20
Incremental Changes Federal Level Health Insurance The Health
Insurance Portability and Accountability Act State Level The
Uninsured States are attempting to reduce their rising health care
costs and cover their uninsured. Local Level Retail Health Care
Retail stores such as Wal-Mart, Target, and CVS have added clinics
staffed by nurse practitioners or physician assistants to treat
common health conditions. Slide 21 Repairing the Health Care System
Elsevier items and derived items 2009, 2005 Saunders, an imprint of
Elsevier, Inc. All rights reserved. 21 Comprehensive Changes
Single-Payer System Payment for doctors, hospitals, and other
providers for comprehensive health care for everyone regardless of
past medical history comes from a single fund Health Savings
Accounts Involves a medical savings account that allows persons to
save for medical expenses on a tax-free basis Linked with high
deductible health plans that have lower monthly premiums Slide 22
Changes in Health Care Facilities Elsevier items and derived items
2009, 2005 Saunders, an imprint of Elsevier, Inc. All rights
reserved. 22 Minimum Nurse-to-Patient Ratios Mandating
nurse-to-patient ratios is an attempt to improve quality and
service. Voluntary Versus Mandatory Overtime Asking and requiring
nursing staff to work beyond an 8-hour shift has been the method
some facilities use to attempt to provide patient coverage during
the nursing shortage. Slide 23 Health Care Alliances, Networks, and
Consolidation Elsevier items and derived items 2009, 2005 Saunders,
an imprint of Elsevier, Inc. All rights reserved. 23 Alliances
Partnerships among hospitals, clinics, laboratories, health care
systems, and physicians Networking By joining together, these
alliances can coordinate the delivery of care and contain costs
among providers of health care services. Consolidated systems of
healthcare Include hospital systems found nationwide Slide 24
Restructuring the Health Care System Elsevier items and derived
items 2009, 2005 Saunders, an imprint of Elsevier, Inc. All rights
reserved. 24 Health care alliances, networks, and consolidation
Alternatives in insurance coverage Managed care Health maintenance
organizations (HMOs) Open access plans Preferred provider
organizations Changes in health care facilities Slide 25 Changes in
Health Care Facilities Elsevier items and derived items 2009, 2005
Saunders, an imprint of Elsevier, Inc. All rights reserved. 25
Unlicensed Assistive Personnel One survival strategy for acute care
facilities continues to be the use of UAPs. Cross Training Allows
staff to be assigned from units with low census to units that have
staffing needs caused by absences or increased patient census.
Slide 26 Changes in Health Care Facilities Elsevier items and
derived items 2009, 2005 Saunders, an imprint of Elsevier, Inc. All
rights reserved. 26 Minimum Nurse-to-Patient Ratios Mandating
nurse-to-patient ratios is an attempt to improve quality and
service. Voluntary Versus Mandatory Overtime Asking and requiring
nursing staff to work beyond an 8-hour shift has been the method
some facilities use to attempt to provide patient coverage during
the nursing shortage. Slide 27 Methods of Delivering Health Care
Elsevier items and derived items 2009, 2005 Saunders, an imprint of
Elsevier, Inc. All rights reserved. 27 Patient-Focused Care
Electronic Medical Records Involve recording all patient data in a
computer Increases efficiency by reducing/eliminating the need for
paper records, medical history forms, test request forms, drug
prescriptions, written physician comments, etc. Critical Pathways
This cost-effective method helps the patient reach discharge in the
fastest time possible. Slide 28 Quality Improvement Elsevier items
and derived items 2009, 2005 Saunders, an imprint of Elsevier, Inc.
All rights reserved. 28 Stresses the need to search continually for
new ways to improve the process of patient care, prevent errors,
and identify and fix problems Formulation of nursing care plans by
the RN, assisted by the LPN/LVN Providers of care must be able to
demonstrate competency throughout their careers. Slide 29 Dealing
with Change Elsevier items and derived items 2009, 2005 Saunders,
an imprint of Elsevier, Inc. All rights reserved. 29 Ways to Look
at Change Victims Look at change in a negative way Fear the worst
will happen because of the proposed change and feel helpless in the
situation Do not willingly participate in the change process,
allowing change to control them Slide 30 Dealing with Change
Elsevier items and derived items 2009, 2005 Saunders, an imprint of
Elsevier, Inc. All rights reserved. 30 Ways to Look at Change
Survivors Resist change but go along for the ride Claim the change
will never work, and if their prediction comes true, they will be
heard to say, I told you so. Slide 31 Dealing with Change Elsevier
items and derived items 2009, 2005 Saunders, an imprint of
Elsevier, Inc. All rights reserved. 31 Ways to Look at Change
Navigators Feel in control of the situation Feel confident and
excited about the possibility of being part of the solution to a
problem Believe they have some control over change rather than
being controlled by the change Slide 32 Personal Plan for Change
Elsevier items and derived items 2009, 2005 Saunders, an imprint of
Elsevier, Inc. All rights reserved. 32 LVNs must present themselves
as valuable to the health care agency. Be self-directed, motivated,
and a problem solver. Identify what needs to be done and do it.
Respond flexibly to changes that are presented. Identify tasks or
protocols that could be done more efficiently. Be a role model for
vocational nurses.
