Concepts of health care systems

Before 1980 the primary type of payment for HC was through


Minimal controls placed on doctors an facilities. Cost began to sky rocket


To make money and contain cost large health care corporations have purchased smaller, local hospitals to develop statewide or nationwide health care networks


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


Profits from services are re-invested back into the facility


How do clients access health care

1-physical distance
2-client age
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


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


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


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


Has deductibles, co-pays, and monthly premiums. Does not cover all expenses or LTC


Eligible for low income, medically if physically disabled


Supervises Medicaid an medicare

Social security

Federal program but state sets the limits


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


Limits choice to specific doctors and hospitals. Need referrals for specialists. Small monthly premiums, small co-pays. No yearly deductible an no forms


Out of pocket expense is actually less than indemnity insurance but patients have fewer choices


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


Need referral and only to approved specialist. Must have prior approval. ER must notify,usually within 24 hrs