Before 1980 the primary type of payment for HC was through
Indemnity
Minimal controls placed on doctors an facilities. Cost began to sky rocket
Indeminity
To make money and contain cost large health care corporations have purchased smaller, local hospitals to develop statewide or nationwide health care networks
Conglomerates
Provides care across various health care settings at all care levels
Integrated health care
Focal point is no longer the hospital
Primary care
Three goals of primary care
1- keep client healthy
2-treating then in a less costly setting
3-reducing expensive hospital costs
Offers health care services to a group of individuals for a fixed fee. Members save when they go to an in network doctor
Managed care
Built in incentives to physicians for providing least amount of care possible by limiting referrals and preventing overuse of plan
Managed care
Profits from services are paid to stockholders
For-profit
Profits from services are re-invested back into the facility
Non-profit
How do clients access health care
1-physical distance
2-client age
3-ethnicity
4-lifestyle
5-military service
6-frequency of access guided by: funding, health benefits package, and rules an regulations of the program
Which country spends the most on HC
US
Individual impact
1- double digit increases in health insurance premiums every year
2- increased deductibles an co-pays
3-employees of employer-sponsored insurance to drop their coverage in order to pay their bills
4- employers to drop health insurance benefits
Clients pay from their personal resources when the receive care
Self-pay
Purchased by the consumer, very costly to consumer
Individual or private insurance
Offered at a discount to groups of individuals
Group insurance
Employee pays some or all of the premiums, insurance is most affordable
Employer insurance
Provided through a trade, professional organization,affiliation with religious or community group. Cheaper rates than what's available through private insurance
Association- based
Those with serious medical conditions, pre-existing conditions. Very expansive. Many opt out
High-risk pools
Duties of the health department
1- focuses on the general health of citizens within the state
2- food handling
3- licensing
4- vaccinations
5- free aids/std testing
Combines HMO and PPO
POS (point of services)
Members offered a choice each time they seek health care, more expensive but flexible
POS
Increasing group due to more part-time workers, self employed workers, contract laborer, and positions without insurance
Employed and Uninsured
Rely on government provided insurance, if they don't qualify they go without
Unemployed and disabled
Do not contribute via taxation, can't pay, many states serve millions. Expenses come from other sources
Undocumented imigrants
Enhances efficiency, contains cost and provides medically necessary services within a reasonable timeframe
Goals of managed care
Client services regularly reviewed by a board to ensure that they are medically necessary an appropriate to meet the client needs
Authorization of services
Pays a physician a " fixed fee" to care for groups of clients. Limits services the physician can offer
Managed care.
Physicians have the choice to contract with managed care organizations. When the physician leaves the clients must find a new one
Managed care
Critical thinking will impact your career by
1- helps you gain control of the situations
2- keeps you organized and effective instead of going through the motions
3-continually evaluating the care vs cost containment
Provides nurses with the experience of more than one job function. Nurses can more effectively answer questions an provide pt teaching
Cross training
Documentation can
1- provide evidence of each aspect of care being necessary: medication, treatments, equipment
2- captures initial complications
3- avoids more serious illnesses
4- minimizes expenses
Greater focus on preventive measures to keep clients from progressing illness, nurses focus on prevention and client teaching
Clinical instruction
Clients are no longer passive recipients of health care they choose to be active participants
Clinical instruction
Three types of nursing
1- team nursing
2- modular nursing
3- functional nursing
Provides total client care to a group of clients. May be made up of different staff members. Team is efficient an effective
Team nursing
Focus is on assigning a team to a limited area or speciality. Leader is an RN
Modular nursing
Lpn provides the direct patient care
Modular nursing
Requires excessive time for communication. Continuity of care may be diminished. Holistic view is lost
Disadvantages of modular nursing
Needs of the groups of clients is broken down into tasks. Skills are divided between members so that skill and scope of practice is utilized effectively.
Functional nursking
Three examples of functional nursing members
1- shower aides
2- treatment nurse
3- med pass nurse
Uneven continuity of care and follow up problems. Lack of holistic view. More time spent on communication to achieve intended outcomes
Disadvantages of functional nursing
People living longer, research provides more comprehensive data and tools
Current trends
Based on accurate, scientifically sound data. Data collected during experimental studies
Current trends
Distance and culture no longer barriers. Providers benefit from sharing information. More avenues for pandemic outbreaks
Telenursing, telemedicine, and globalization
Global warming, terrorism, epidemics. Plan for impact of human and natural disasters
Response preparedness
Reimbursement and incentives given for better than expected outcomes
Pay for performance
People 65 and over. For younger disabled persons or chronic health issues
Medicare
Has deductibles, co-pays, and monthly premiums. Does not cover all expenses or LTC
Medicare
Eligible for low income, medically if physically disabled
Medicaid
Supervises Medicaid an medicare
Social security
Federal program but state sets the limits
Medicaid
Acts as principle health care advocate for national Americans and Alaska natives
Indian health services (IHS)
Vets qualify for a variety of programs/services at any VA provider. Largest integrated health care system.
Veterans Affairs (VA)
The insured person pays premiums and the annual deductible amount. Consumer files claim. Most flexible
Indemnity insurance
Health Maintenance Organization
HMO
Limits choice to specific doctors and hospitals. Need referrals for specialists. Small monthly premiums, small co-pays. No yearly deductible an no forms
HMO
Out of pocket expense is actually less than indemnity insurance but patients have fewer choices
HMO
Members may use specialist within the plan with out referral from PCP
Open access plans
Focus on preventive care so treatment starts early and avoid long-term illness
HMO
Need referral and only to approved specialist. Must have prior approval. ER must notify,usually within 24 hrs
HMO