Objectives of Health Care Delivery? (2)
1. Enable citizens to receive health care when needed
2. care should be cost effective and meet standards of quality
What are the major components of the health care system?
1. Insurance
2. Financing
3. Delivery
4. Payments
Health Care System - Definition
The act of providing health care to patients
How is the United States health care system different than other countries?
1. More complex, messy
2. Is NOT a system
3. Lack of universal access
4. We do access care during an emergency (ENTALA)
5. No entitlement
6. Critical issues of cost, access and quality
What is our entitlement policy?
Citizenship guarantees rights in health care.
Ex: Medicare (65<)
What is the Quad Function Model?
The four componets of Health Care. (Financing, insurance, payment, delivery)
Define Financing in Health Care
To buy insurance or to pay directly for the health care services.
For an individual to buy insurance it's extremely EXPENSIVE
Define Insurance in Health Care
Protects insured agents against risk.
There are specifics how/where health care services may be received
Distributes funds to health care providers
Define Delivery in Health Care
Provision of health care services by various providers.
Define a provider
Any entity that delivers health care services and can independently bill for those services or is tax supported
Define Payment in Health Care
Deals w/ reinburstments to providers for services delivered. The insurer determines how much is paid
What is a premium
Month (amount $) paid to insurance
What is a Co-Pay
(10%) of the visit is paid out of pocket
What is a deductible
Pays out of pocket before the insurance covers any cost
What is a prospective payment
Hospitals are told what they will be paid
What is managed care? & their functions? (4)
A system of health care delivery that:
1. Seeks to achieve efficiences by integrating the four functions of hc delivery
2. Employs mechanisms to control utilizations of medical service
3. Determines how much providers get paid
Is also the dominant system
HMO?
Health maintenance organization. When the organization is the hospital, doctor, and insurance.
Kasier is the biggest
PPO
Preferred provider organization. Insurer has some choice, can see someone out of network, just pay more.
What are the subsystems within Health Care?
1. Managed care
2. Military
3. Vulnerable populations
4. Integrated systems
5. Long term care
6. Public Health
Military subsystem
Care is avaliable mostly free of charge to active duty military personnel
Families & Non Actives: Tri-care, VA health care system
Vulnerable populations subsystem
Safety net providers and insurance mechanisms.
Ex: Medicaid, medicare, SCHIP, FQSC, CAH,
What is FQSC & CAH
FQSC - Federally qualified health center
Primary care physicans
Low income families
Favorable reinburstment
Apply for grants
ex: Hopewell
CAH - Critical Access Hospital
Small (less than 25 beds)
25 miles away from any hospital
has to have an emergency room
favorable reinburstments
Integrated Systems subsystem
A network of organizations and providers to provide a coordinates continuum of services to defined populations.
1. Medical home model (primary care)
2. Accountable care org.
Long term care subsystem
#NAME?
Public Health Subsystem
To improve and protect community health population based approach to Health Care
What are the ten characteristics of Health Care
1. Little integration or coordination
2. Technology driven delivery system w/ the focus on acute care
3. Cost, quality, access
4. Imperfect market conditions
5. Government as subsidiary of private sector
6. Fusion of market justice and social justice
7. Balance of power
8. Seeking accountability and integration
9.Partial access
10. Our litigious (likely to sue) society
Define Market Justice
Places responsibility for fair distribution of health care on market focus
Define Social Justice
Emphasizes the well-being of the community over that of the individual, inability to obtain healthcare due to lack of resources
Define value
High quality, low cost
What is defensive medicine?
Excessive medical test and procedures performed as a protection against malpractice lawsuit, otherwise regarded as unnecessary
Current trends and direction of the health care system:
Illness -->
Acute care --->
Inpatient -->
Individual health -->
Fragmented care -->
Service duplication -->
Wellness
Primary care
Outpatient
Community well being
Managed care
Integrated systems
Continuum of services
What is national health insurance?
Example
Government finances health care, but then it is delivered by private providers
Canada
What is National Health System?
Example
Government manages infrastructure for the delivery of medical care, in addition to financing
United Kingdom
What is a socialized health insurance
Example
Health care is finances through government mandated contributions by employers and employees
Germany
What is a Hybrid and who is an example?
When a healthcare system takes elements of all three and creates our own type of "system" from that.
United States is an example
Canada's Health Care System
National Health Insurance.
Delayed care, higher taxes, tighter financing by the gov
United Kingdom's HC System
National Health System
Medical institutions are ran by the government, providers are government employees, tax supported national health insurance program
Germany's HC System
Socialized Health Insurance.
Mandated, sickness fund collected, HC is delivered by private providers
Wha are the foundations (4) of the system?
1. Historical
2. Culture
3. Social
5. Economic
What are the resources (2) of the system?
1. Human (staff, DR's)
2. Non-human (materials, supplies, money)
System processes?
Carried out through the health care delivery infrastructure
System outcomes?
Critical issues and concerns surrounding what the health system services is able to accomplish, or not able to accomplish.
System outlook?
To project into the future in views of social, culture, economic and other forces of change.
What is the ACA's objective? Known as what?
Also known as PPACA, Obama care
To increase access to health care and health insurance
Known as a stool
3 Parts of the stool
1. Guarenteed Issue - Insurance can't deny coverage because someone is ill
2. Mandate - Making insurance mandatory
3. Subsidies - Looking at income, if you aren't able to pay then the government will help you '
ACA Today:
How much has the uninsured changed by?
How many STILL lack insurance?
What did Ohio do w/ Medicaid
1. Declined by about 20 million
2. 24 million people still lack
3. Expanded medicaid
Why are people still uninsured?
1. ACA exclusion of undocumented immigrants from coverage expansions
2. Lack of medicaid expansions in 19 states
3. Less aware of market place by some demographics
4. Concerns of plan affordability
5. Difficulty selecting plans / lack of assistance
*Many people are unaware / uneducated that they are eligible
Two LESSER known truths about HC?
1. Curative medicine has been the primary focus of the US health industry
2. Strong forces exist against fundamental changes to the financing and delivery of hc (Countervailing powers)
What is the medical model?
Delivery of the health care that places primary emphasis on treatment of diseases and relief of systems instead of prevention of disease and promotion of health
Sick role
;
Who & Year
Rights & Obligations
Parsons 1951
Rights: Exempt from normal social roles & not responsible for condition
Obligations: Try to get well, seek technically competent help and cooperate
Define health
Complete state of physical, mental, and social well being, not merely the absence of disease or infirmity
What is holistic medicine?
Integrated medicine.
They aim to treat the whole person and incorporate alternative therapies (CAM)
What is CAM & Examples
Complementary and Alternative Medicine
Ex: Weed, massage therapy
Define Illness
Identified by a persons perception and self evaluation
Define disease
Based on a professional evaluation
Contested disease
Going to a doctor only to get diagnosed for medicine.
Define a patient
Person under the care of a medical professional determined thru formal diagnosis
Acute
Relatively severe, espisodic, treatable
ex: flu
Subacute
Has acute features, postacute treatment after discharge
ex: head trauma
Chronic
Not as severe, long and continuous, controlled; but if not if can lead to complications
ex: diabetes
Quality of life?
Overall satisfaction w/ life during / following a persons encounter w the health care system
(Independence)
What are health determinants?
Factors that influence an idividiual and a populations health
Examples of health determinants
Genetic makeup, individual behaviors, medical practice, social environment
How does heredity charc. effect someones health?
Individuals genetic makeup, family history, physical and mental health problems acquired during life
How does physical environment charc. effect someones health?
That which can be seen, toouched, heard, smelled, and tasted
How does social environment charc. effect someones health?
Interactions w/ family, friends, coworkers, and others in the community
Capital in social environment?
Economics (money), human (continued education), cultural (arts, travel), social
How does behavior / lifestyle effect someones health
#NAME?
Food desert
Within so many miles from fresh produce
Medical care
Expanding access to services could eliminate health disparities and increase the quality of life
Define a health disparity
Sig. difference in the overall rate of disease incidence, prevalance, morbidity, mortality or surivial rate in the population as compared to the health of the general population
Health inequality
subjective value judgment of injustice
Define market justice
market forces in a free economy can best achieve a fair distribution
How does hc have market justice (5)
1. Health care is an economic good
2. Free market conditions
3. Markets are most capable at allocation
4. Production based on demand
5. Care distributed based on their ability to pay
Are health resources scarce?
Artifically scarce
Define social justice
Equitable distribution of health is a societal responsibility
Chararc. defining social justice (6)
1. Views health care as a social resource
2. Health care should be based on need and not cost
3. Requires active government involvement
4. Assumes government is more efficient in allocating
5. Medical resources allocation is determined by planning
6. Ability to pay is inconsequential
7. Equal access viewed as a right
What are two criticisms of how we do things?
1. individual health issues can have negative consequences for society
2. Does NOT work well for health care delivery
How can we improve health? (3)
1. Healthy people 2020
2. Public health
3. Focus directly on determinants
What are four examples of determinants that can help improve health?
1. Social determinants
2. Medical care determinants
3. Policy interventions
4. Community based interventions