3: United States Health Care System

Affordable Care Act

Proposed incremental changes to services, public oversight, and increased emphasis on prevention in health care delivery in the US.

Health Care System

The organizational structure in which health care is delivered to a population

Primary Prevention

The promotion of healthy behaviors and reduction of health risks

Obama Administration's Affordable Care Act

Intended to increase number of persons covered by some type of health insurance, increased the accountability of providers, & improved the quality of health care services

Features of US Health Care System

Highly decentralized governance, a strong emphasis on a laissez-faire philosophy, and an abundance of economic resources

Decentralization

Local communities, the states, and the federal government all share the responsibilities for the regulation & provision of services to the population

Laissez-Faire Approach

No centralized planning structure; consider health care a privilege, rather than a right, & would not support government intervention to ensure health care for those who cannot pay.

Free Market

Private enterprise is allowed to develop goods & services as it chooses & to offer them to the clientele, or market, it selects.

Health Care Service Market

Private individuals, groups, or corporations can plan, offer, and deliver health care to target groups they wish to serve

Gross Domestic Product (GDP)

A measure of all goods and services sold in the United States

State Children's Health Insurance Program (CHIP)

Both federal and state funding & oversight; health care services that the children receive come from physicians, hospitals, managed care organizations, & other health care providers-they must conform to Medicaid

Health Care Resources

1. Health Care Professionals 2. Facilities (hospitals, etc) 3. Health Care supplies and equipment

Nonphysician Practitioners

Professionals trained to provide primary care in place of physicians; either Physician's assistant or Advanced Nurse Practitioner

Ambulatory Care Clinics

Set up to attract middle-class consumers rather than clients from low-income groups or those receiving public assistance

Out-of-pocket expenses

Expenses paid for directly by the consumer

Wellness Centers (Health Promotion Centers/Alternative Medicine)

Promote healthy behaviors and assist consumers in eliminating or reducing risky behavior; geared toward niche markets, primarily middle-class and wealthy individuals who can afford to pay

Home Care

Care of the client in his/her own home

Consumer

The recipient of services delivered by system; most vulnerable component and is the most likely to be hurt by ineffective functioning of the system j

Direct Care Services

Health services delivered to an individual;provided in a variety of setting- physical therapy, nursing care, & doctor's visits

Direct Care Providers

The personnel who provide direct care services

Indirect Care Services

Health care services not personally received by the individual, although they influence health and welfare-health planning, monitor/regulation of environmental hazards, inspection of public use facilities, etc.

Private Sector

Composed of private organizations, both for-profit businesses & nonprofit organizations; provides direct services to Americans that can pay, either out of pocket or through third-party payers

Public Sector

Consists of services provided by public funds & public organizations (some type of governmental agency)-provides both direct & indirect services.

U.S Department of Health & Human Services (USDHHS)

Federal agency with the most health-related responsibility; responsible for some direct services, but mostly indirect care-carry out these services or delegates the responsibility & funding for services to other public/private organizations

National Institutes of Health (NIH)

Funds and collects research, including nursing research, which is financed through the National Center for Nursing Research; used as referral source for clients who require experimental care

U.S Food and Drug Administration (FDA)

Establishes & enforces safety standards for food, drugs, and cosmetics

Health Resource and Services Administration (HRSA)

Conducts health care resource planning & provides access to essential health care services for people who are poor or uninsured, or live in rural/urban neighborhoods without health care services; provides primary/preventive services through community-base

Substance Abuse and Mental Health Services Administration (SAMHSA)

Coordinates and funds programs in both areas

Agency for Toxic Substance and Disease Registry (ATSDR)

Responsible for preventing health-related problems associated with toxic substances

Indian Health Service (IHS)

Provides direct health care services to the American Indian and Alaskan Native populations & oversight of health care services administered by the American Indian tribes.

Centers for Disease Control and Prevention (CDC)

Primary source of information on communicable diseases and is vital resource for all public health personnel

Agency for Healthcare Research and Quality (AHRQ)

Lead agency for sponsoring and conducting research to improve the quality of health care, reduce costs, improve patient safety, and increase access to essential services

Centers for Medicare and Medicaid Services (CMS)

Oversight of the Medicare and Medicaid programs; administers CHIP

Administration for Children and Families (ACF)

Administers state and federal welfare programs for children and families

Administration on Aging (AoA)

Advocates for older Americans; administers federal programs under Older American Act-Meals on Wheels/ home residency assistance programs

Public Health Service (PHS)

A reorganization of the USDHHS established all the agencies as independent agencies

State Health Agency

Principal agency for health care services for that state- personal health, community health, environmental health, health resources, health education, health planning/policy development, enforcement of public health laws, laboratory services, general admi

Department of Education

Responsible for school health programs and health education policy

National Commission on Community Health Services

Recommended consolidation of all official health services into a single agency to streamline bureaucracy, reduce duplication of efforts, and potentially cut costs.

Third Party Reimbursement

Financing of health care by an insurance company rather than an individual

Managed Care

Combines two functions: health insurance and delivery of health care services

Health Maintenance Organizations (HMOs)

Networks or groups of providers who agree to provide certain basic health care services for a single year fee; consumer pays same amount for coverage regardless of amount/type of services provided.

Preferred Provider Organizations (PPOs)

Contract with a network of providers to provide services at a discounted rate to members; there is a fixed premium (insurance cost)

Point of Service (POS)

Hybrid of PPO concept; networks for providers; consumers selects primary care physician from network providers to act as primary care physician; physician acts as gatekeeper who determines consumer's needs for specialized health care services/referrals

Health Care Networks

Corporations with a consolidated set of facilities and services for which consumers/employers pay a specific monthly fee; services intended to be comprehensive, and consumers are expected to receive all care within network or from providers arranged by ne

Voluntary Agency

Originate through some sort of private initiative & not compelled by government sanction to organize/provide health care services; Creativity & Advocacy

Secondary Prevention

Treating Illness

Tertiary Prevention

Eliminating or reducing the long-term effects of an illness or disability

Medicare

Health care services paid for- for older adults

Medicaid

Health care services paid for-for the poor

Vested Interests

Groups who professional practices or finances might be affected by decisions of the boards

Universal Health Coverage

State law that provides health care access to all residents (only exists in 4 states)

Joint Commission

Hospital data required as part of accreditation process include quality outcome measures such as number of hospital deaths and readmission rates

Single-Payer System

The government is sole funder of health care; all citizens are covered & private health insurance is unnecessary; financed by income/sales taxes & health care service fees are set by government

All-Payer System

Health care is financed by a number of sources, public and private; all citizens covered but control would be more decentralized;

provide services primarily through indirect care

The Federal agencies involved with U. S. health care...

Managed care ensures maximum value received from resources used.

A client has been informed that his health care plan will be changing to a managed care model. How would the nurse best explain the goal of this model?

The political influence held by those with a strong interest in maintaining the current system has prevented this change.

A community/public health nurse discusses the current health care system with a class of finance students. A student asks why the U.S. government has not moved to a single-payer system. Which of the following statements would be an appropriate response by

Managing third-party reimbursement

Which of the following is considered to be a responsibility of an insurance company?

Action plans are focused on changing lifestyles to reduce risks and prevent problems.

A community/public health nurse educated a community group about the development of the national goals. Which of the following information would the nurse have included in this presentation?

As being in the midst of ongoing change that offers real opportunities.

A community/public health nurse is describing the American health care system to a group of young adults entering their first fulltime job. How would the nurse best describe this system?

It is decentralized and expensive.

Which of the following best describes the U.S. health care system?

The health of the population served

A public health nurse is examining the effectiveness of a health care system. Which of the following data would be the most appropriate for the nurse to use?

Private system for those who can pay and public system for some of the poor

What are the two systems of health care that exist in the United States?

Helps students understand health behaviors

A community/public health nursing faculty member discusses with students the significant changes in the U.S. health care system. Why is this information important to discuss with this population?