PHHE 295. Chapter 13. Health Care Delivery in the United States

PHHE 295

Chapter 13: Health Care Delivery in the United States

Chapter Objectives

1)      Define the term health care system.

2)      Trace the history of health care delivery in the United States from colonial times to the present.

3)      Discuss and explain the concept of the spectrum of health care delivery.

4)      Distinguish between the different kinds of health care, including population-based public health practice, medical practice, long-term practice, and end-of-life practice.

5)      List and describe the different levels of medical practice.

6)      List and characterize the various groups of health care providers.

7)      Explain the differences among allopathic, osteopathic, and non-allopathic providers.

8)      Define complementary  and alternative medicine.

9)      Explain why there is a need for health care providers.

10)  Prepare a list of the different types of facilities in which health care is delivered.

11)  Explain the differences among private, public, and voluntary hospitals.

12)  Explain the difference between inpatient and outpatient care facilities.

13)  Briefly discuss the options for long-term care.

14)  Explain what the Joint Commission does.

15)  Identify the major concerns with the health care system in the United States.

16)  Explain the various means of reimbursing health care providers.

Key Terms

·         Providers: Health care facilities or health professionals that provide health care services.

·         Hospital Survey and Construction Act of 1946: Federal legislation that provided substantial funds for hospital construction.

·         Third-Party Payment System: A health insurance term indicating that bills will be paid by the insurer and not the patient or the health care provider.

·         American Health Security Act of 1993: The comprehensive health care reform introduced by President Clinton, but never enacted.

·         Managed Care: A system of health care delivery that:

o   1) Seeks to achieve efficiency by integrating the basic functions of health care delivery

o   2) Employs mechanisms to control utilization of medical services

o   3) Determines the price at which the services are purchased and how much the providers get paid.

·         Population-Based Public Health Practice: Incorporates interventions aimed at disease prevention and health promotion, specific protection, and a good share of case findings.

·         Primary Care: Clinical preventative services, first-contact treatment services, and ongoing care for commonly encountered medical conditions.

·         Secondary Medical Care: Specialized attention and ongoing management for common and less frequently encountered medical conditions, including support services for people with special challenges due to chronic or long-term conditions.

·         Tertiary Medical Care: Specialized and technologically sophisticated medical and surgical care for those with unusual or complex conditions.

·         Restorative Care: Care provide after successful treatment or when the progress of an incurable disease has been arrested.

·         Long-Term Care: Different kinds of help that people with chronic illness, disabilities, or other conditions that limit them physically or mentally need.

·         End-Of-Life Practice: Health care services provided to individuals shortly before death.

·         Hospice Care: A cluster of special services for the dying that blends medical, spiritual, legal, financial, and family support services.

·         Independent Providers: Health care professionals with the education and legal authority to treat any health problem.

·         Allopathic Providers: Independent providers whose remedies for illnesses produce effects different from those of the disease.

·         Osteopathic Providers: Independent health care providers whose remedies emphasize the interrelationships of the body’s systems in prevention, diagnosis, and treatment.

·         Intern: A first-year resident.

·         Resident: A physician who is training in a specialty.

·         Non-Allopathic Providers: Independent providers who provide non-traditional forms of health care.

·         Chiropractor: A non-allopathic independent health care provider who treats health problems by adjusting the spinal column.

·         Complementary/Alternative Medicine: A group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine.

·         Limited (Restricted) Care Providers: Health care providers who provide care for a specific part of the body.

·         Licensed Practical Nurse: Those prepared in 1- to 2-year programs to provide non-technical bedside nursing care under the supervision of physicians or registered nurses.

·         Registered Nurse: One who has successfully completed an accredited academic program and a state licensing examination.

·         Professsional Nurse: A registered nurse holding a bachelor of science degree in nursing.

·         Non-Physician Practitioners: Clinical professionals who practice in many of the areas similar to those in which physicians practice, but do not have an MD or DO degree.

·         Allied Health Care Professionals: Health care workers who provide services that assist, facilitate, and complement the work of physicians and other health care specialists.

·         Public Health Professional: A health care worker who works in a public health organization.

·         Private or Investor Owned Hospital: For-profit hospitals.

·         Specialty Hospital: A hospital that provides mainly one type of medicine, is for-profit, and is owned at least in part by the physicians who practice in it.

·         Public Hospitals: Hospitals that are supported and managed by governmental jurisdictions.

·         Voluntary Hospitals: Nonprofit hospitals administered by not-for-profit  corporations or charitable community organizations.

·         Full-Service Hospitals: Hospitals that offer services in all or most of the levels of care defined by the spectrum of health care delivery.

·         Limited-Service Hospitals: Hospitals that offer only the specific services needed by the population served.

·         Medically Indigent: Those lacking the financial ability to pay for their own medical care.

·         Rehabilitation Center: A facility in which restorative care is provided following injury, disease, or surgery.

·         Home Health Care: Care that is provided in the patient’s residence for the purpose of promoting, maintaining, or restoring health.

·         Accreditation: The process by which an agency or organization evaluates and recognizes an institution as meeting certain predetermined standards.

·         Joint Commission: The predominant organization responsible for accrediting health care facilities.

·         Reimbursement: Payments made by the third-party payers to providers.

·         Fee-For-Service: A method of paying for health care in which after the service is rendered, a fee is paid.

·         Packaged Pricing: Several related health services are included in one price.

·         Resource-Based Relative Value Scale: Reimbursement to physicians according to the relative value of the service provided.

·         Prepaid Health Care: A method of paying for covered health care services on a per-person premium basis for a specific time period prior to the service being rendered.

·         Prospective Reimbursement: Uses pre-established criteria to determine in advance the amount of reimbursement.

·         Deductible: The amount of expenses that the beneficiary must incur before the insurance company begins to pay for covered services.

·         Co-Insurance: The portion of the insurance company’s approved amounts for covered services that a beneficiary is responsible for paying.

·         Copayment: A negotiated set amount that a patient pays for certain services.

·         Fixed Indemnity: The maximum amount an insurer will pay for a certain service.

·         Exclusion: A health condition written into the health insurance policy indicating what is not covered by the policy.

·         Preexisting Condition: A medical condition that had been diagnosed or treated usually within the 6 months before the date a health insurance policy goes into effect.

·         Self-Funded Insurance Programs: One that pays the health care costs of its employees with the premiums collected from the employees and the contributions made by the employer.

·         Medicare: A national health insurance program for people 65 years of age and older, certain younger disabled people, and people with permanent kidney failure.

·         Medicaid: A jointly funded federal-state health insurance program for low-income Americans.

·         Children’s Health Insurance Program: A title insurance program under the Social Security Act that provides health insurance to uninsured children.

·         Medigap: Private health insurance that supplements Medicare benefits.

·         Quality Management and Utilization Review: The analysis of provided health care for its appropriateness by someone other than the patient and provider.

·         Preferred Provider Organization: An organization that buys fixed-rate health services from providers and sells them to consumers.

·         Exclusive Provider Organization: Like a PPO but with fewer providers and stronger financial incentives.

·         Health Maintenance Organizations: Groups that supply prepaid comprehensive health care with an emphasis on prevention.

·         Mixed Model HMO: A hybrid form of health maintenance organization.

·         Staff Model HMO: A health maintenance organization that hires its own staff of health care providers.

·         Independent Practice Associations: Legal entities separate from the HMO that are physician organizations composed of community-based independent physicians in solo or group practices who provide services to HMO members.

·         Group Model HMO: One that contracts with a multispecialty group practice.

·         Network Model HMO: One that contracts with more than one medical group practice.

·         Direct Contract HMO: One that contracts with individual physicians as opposed to group practices.

·         Point-Of-Service Option:  An option of an HMO plan that enables enrollees to be at least partially reimbursed for selecting a health care provider outside the plan.

·         Consumer-Directed Health Plans: Health plan options that combine more consumer responsibility for decisions with a tax-sheltered account to pay for out-of-pocket costs for health care and a high-deductible health insurance policy.

Chapter Summary

·         The concept of a health care system has been and continues to be questioned in the United States. Is it really a system or is treatment provided in an informal, cooperative manner?

·         Health care in the United States has evolved from home and folk remedies to the modest services of the independent country doctor who often visited the sick in their homes to a highly complex 2 trillion plus industry.

·         There are medical specialists and health care facilities for almost every type of illness and health problem.

·         The spectrum of health care includes four domains of practice—population-based public health practice, medical practice, long-term practice, and end-of-life practice.

·         Within the medical practice domain of health care are the following types of health care providers:

o   Independent Providers

§  Allopathic

§  Osteopathic

§  Non-Allopathic

o   Limited Care Providers

o   Nurses

o   Non-Physician Practitioners

o   Allied Health Care Professionals

o   Public Health Professionals

·         Complementary and alternative medicine is a group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine.

·         Health care providers perform services in both inpatient and outpatient care facilities.

·         Inpatient care facilities include hospitals, nursing homes, and assisted living facilities.

·         The types of outpatient care facilities found in communities are health care practitioners’ offices, clinics, primary care centers, retail clinic, urgent/emergent care centers, ambulatory surgery centers, and freestanding service facilities.

·         Long-term care options include traditional institutional residential care as well as special units within these residential facilities, halfway houses, group homes, assisted-living facilities, transitional care in a hospital, day care facilities for patients, and personal  home health.

·         The predominant organization responsible for accrediting health care facilities in the Joint Commission.

·         The major issues of concern with the health care system in the United States can be summed up by the cost containment, access, and quality triangle.

·         Some of the barriers to access to health care in the United States have been the lack of health insurance, inadequate insurance, and poverty.

·         There are a number of different methods by which the amount of reimbursement to health care providers is determined. They include fee-for-service, packaged pricing, resource-based relative value scale, prepaid health care, and prospective reimbursement.

·         Most health care in the United States is paid for via third-party payment.

·         The two largest government-administered health insurance programs in the United States are Medicare and Medicaid.

·         The government’s Children’s Health Insurance Program is for many children who were previously uninsured.

·         Two major supplemental insurance programs in the United States are Medigap and long-term care insurance.

·         A significant portion of Americans today are covered by some form of managed care.

·         The more common forms of managed care include:

o   Health Maintenance Organizations (HMOs)

o   Preferred Provider Organizations (PPOs)

o   Exclusive Provider Organizations (EPOs)

o   Point-Of-Service (POS)

·         The United States is the only developed country in the world without national health insurance.

·         Consumer-directed health plans, including health savings accounts, high-deductible health plans, health reimbursement arrangements, flexible spending accounts, and Archer Medical Savings Accounts, are becoming more popular health plan options.

·         Health care reform in the United States did not come easily, but the Affordable Care Act will significantly increase the number of Americans who have health insurance.