Healthcare Delivery Systems PDF

Healthcare Delivery Systems  3.11 Compare healthcare delivery systems. Non-profit and for profit SYSTEMS Government Non-profit  9% of all jobs in America are in health care Healthcare Employment in healthcare...

Healthcare Delivery Systems  3.11 Compare healthcare delivery systems. Non-profit and for profit SYSTEMS Government Non-profit  9% of all jobs in America are in health care Healthcare Employment in healthcare occupations is projected to grow Delivery 19 percent from 2014 to 2024 Systems More than 200 different health careers Healthcare Delivery Systems Medical model (Western medicine) assumes that illness and disease require treatment Moving toward a wellness model the prevention of disease and maintenance of well-being  Non-profit Non-pr Company created for purpose other than profit Tax exempt if purpose is: ofit and charity, religion, public safety, education, prevention of cruelty to children or animals Private For receive most of their money from a few or one single donor Public Profit receive donations from the general public  For Profit Owner(s) obtain money from the FOR profits of the agency PROFIT Subject to taxation Likely to offer more profitable medical services Non-prof Hospitals Ambulatory facilities it and Long-term For care facilities Home health Profit Medical and Mental health Agencies dental offices services Hospitals The Joint Commission PUBLIC OR PRIVATE Can be public or private Formerly The Joint Commission on the Accreditation of Healthcare Organizations Private hospitals can be for profit or non-profit (JCAHO); founded in 1951 Many different types and classifications General hospitals treat a wide variety of Mission: To continuously improve health care illnesses and ages for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. Vision: All people always experience the safest, highest quality, best-value health care across all settings. SPECIALTY HOSPITALS Specific conditions, age groups, or other ways of grouping patients For example: Cancer hospitals Pediatric hospitals Psychiatric hospitals Rehabilitation centers Ambulatory Facilities Also called outpatient services – they often provide diagnostic and treatment services that were previously performed in hospitals Surgical clinics; outpatient surgery Urgent care centers Outpatient clinics Optical centers Genetic counseling centers (fertility clinics)  Mainly care for elderly Extended care facilities LONG TERM patients (residents) provide skilled nursing care CARE rehabilitation services FACILITIES May also care for any individual with disabilities or handicaps Assisted living facilities Independent living Residential care provide basic services Nursing Homes meals provide basic physical care housekeeping basic medical care  Began in1885; a time when 1990-Present; caring for sick Home Health most of the seriously ill were cared for at home due to Americans at home has assumed a significant place infectious diseases and high in the health care delivery Care death rates system 1955-1969; due to rising hospital costs, an increase in chronic illness and a rapidly Services are paid for by growing elderly population, the public and private insurance home regained status as a less or directly by patients and costly and more appropriate their families place for healthcare 1965; Medicare began to pay Home care and hospice for some services quality of continue to be the preferred care means of receiving quality health care services for nearly 5 million Americans MEDICAL AND DENTAL OFFICES AND MENTAL HEALTH SERVICES Medical and Dental Mental Health Vary from small (one doctor) to Counseling centers large complexes with multiple Psychiatric clinics and hospitals specialties and other healthcare professionals Chemical (drug and alcohol) abuse treatment centers Physical abuse treatment Some treat a wide variety of centers, dealing with child illnesses and conditions, others abuse, spouse abuse and elderly provide specialized services abuse  Provides palliative care to dying patients and their families Seeks to relieve symptoms but does not cure HOSPICE Involves healthcare professionals and volunteers Emphasis is to make patient’s last days as pain-free and meaningful as possible GOVERNMENT AGENCIES GOVERNMENT AGENCIES Center for Disease Control and Prevention (CDC) Food and Drug Administration (FDA) U.S. Department of Health and Federal agency; FDA Human Services; CDC Concerned with cause, spread Responsible for regulating food and control of disease, and and drug products sold to the other health and safety issues, in public populations GOVENRMENT AGENGIES CONTINUATION Occupational Safety and World Health Organization (WHO) Health Administration (OSHA) International agency; WHO Part of the U.S. Department of Sponsored by the United Labor; OSHA Nations Compile's disease statistics, Establishes and enforces promotes healthy living, and standards that protect workers investigates serious health from job-related injuries and problems throughout the world illnesses  Public Health System Part of the U.S. Department of Health and Human Services; Health Departments Provide services to states and local communities Examples of services Immunizations Environmental health and sanitation Collection of health statistics and records Health education Clinics for health care and prevention Systems Theory System – A group of individual parts that work together to form a unified whole. Systems Theory – A way of studying a system as one unit, instead of individual parts.  Components of the Systems Theory Input Throughput Output Feedback Loop Controls Environment Goals Mission  Evaluate the System The key to evaluating a system is to determine if the mission is fulfilled. To evaluate a system, look at the “big picture.” Systems Theory in Healthcare A healthcare system is made of many small systems They must be evaluated using systems theory to ensure that they are successful and efficient  Healthcare Systems National healthcare systems can be publicly or privately funded Nearly every industrialized country has a national healthcare system. Some countries have a system of publicly funded healthcare. Other countries use private funding to administer healthcare services. Neither system is entirely "right" or "wrong." However, every country must monitor its system carefully. Changes may be needed to ensure that the maximum number of citizens receive the healthcare they deserve. Public Healthcare Systems Mainly funded by taxes and social security insurance. Advantage – Every citizen is guaranteed healthcare regardless of economic status. Disadvantages – Healthcare is not always comprehensive, and taxes may be higher. Norway, France, the United Kingdom, and Canada Private Healthcare Systems Funded mainly by private insurance agencies and out-of-pocket payments. Advantages – Coverage is often comprehensive, taxes may be lower, and economic growth is stimulated. Disadvantage – Not every citizen is guaranteed healthcare. United States and Switzerland Mixed Systems Few countries contain a purely public system or a purely private system. Most countries create a mixed system by using various funding sources to cover healthcare expenses. Example: Canada and the United States Goals Three goals for national healthcare systems: 1. To provide quality healthcare to the entire population. 2. To be responsive to the citizens’ expectations. 3. To ensure financial protection and fair distribution of financing. These goals must be considered when evaluating any national healthcare system. Health Insurance The rising cost of healthcare is good for the economy, but the expenses are a burden for most individuals and families. In the 1920’s, the United States developed a system of health insurance to help cover the cost of medical expenses. The Patient Protection and Affordable Care Act (ACA) of 2010 was passed to reduce the number of uninsured in the U.S.  Premium – the amount paid to an insurance agency for a health insurance policy Deductible - the amount that must be paid by the patient before the insurance agency will begin to make payments Co-payment - an amount paid by the patient for a certain service Co-insurance: The co-insurance is the percentage of costs of a healthcare service that is paid by the patient after they have paid the deductible. For Health example, you have paid your deductible and have an $100 office visit with a co-insurance of 20%. You would be responsible for $20 and the health insurance agency would pay the rest ($80). Insurance Out-of-Pocket Expense: An out-of-pocket expense is a medical bill that must be paid by the patient. Many health insurance policies have a limit to the amount of out-of-pocket expenses to be paid by the patient during a year. Terms Cost-Sharing Reduction (CSR): This discount applies to deductibles, copayment and co-insurance for qualified health plans. It lowers out-of-pocket expenses Premium Tax Credit: Based on your annual income and household information, this credit lowers your monthly insurance premium payment on qualified health plans Health Insurance Portability and Accountability Act (HIPAA): This law protects patient health information and confidentiality. Signed into law in 1996, HIPAA makes it illegal to gain access to a patient’s health information without their permission. It also places strict permissions on the transfer of personal health information (PHI) between organizations.  Most healthcare payers use the CMS-1500 health insurance claim form for claims submitted by a provider or supplier. The medical assistant must have all the information needed to complete the form, including the patient’s and guarantor’s demographic and insurance information, diagnostic test, treatment, or procedure information and CMS-1500 billing information FORM The CMS-1500 forms has 33 blocks or items, which are divided into three sections. Section 1: Carrier block contains the address of the insurance carrier Section 2: contains information about the patient or insured includes boxes 1-13 Section 3: Physician/Supplier Section contains information about the physician or supplier: includes boxes 14-33 CMS-1500 FORM The Administrative Simplification Compliance Act (ASCA) requires that claims to Medicare be transmitted electronically. But if a provider uses a clearinghouse to submit claims, the draft sent to the clearinghouse may be completed on paper. For paper claims, the correct from to use is the CMS-1500, WHICH HAS BEEN REVISED BY THE ORGANIZATION THAT MAINTAINS IT. Any new version must be approved by the White House Office of Management and Budget. Healthcare Fraud Healthcare fraud is a crime. Examples of healthcare fraud include: Using someone’s health information as if it were your own Billing for medical services that were not provided Delivery of unnecessary medical services Misrepresentation of medical services provided for higher reimbursement Providing or receiving money for participating in any of the above fraud schemes  Health Insurance Then and Now The first broad coverage was Workers Compensation in 1914 and provided cash payments to injured workers with job related injuries or illnesses. Today, the Affordable Care Act requires health insurance companies to cover 10 essential health benefits: Outpatient care Emergency services Hospitalizations Pregnancy, maternity and newborn care Mental health and substance abuse treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventative health services Pediatrics services Individual and Group Insurance Individual insurance is when a person purchases a policy and agrees to pay the entire premium for health coverage. Group insurance is generally purchased through an employer. The premium is split between the employer and the person being insured. Indemnity Insurance In indemnity insurance, patients must pay for all healthcare expenses out of their own pockets. Afterward, the insurance agency will reimburse the patient for a percentage of the expenses. Indemnity insurance does not work for everyone. Many people cannot afford to pay for their medical expenses out-of-pocket.  Two primary concepts of managed care: To promote good health Managed Care To practice preventive medicine Managed care plans offer medical services through a system of healthcare providers. The system of providers offers services at reduced rates. Managed Care vs Indemnity Reimbursement Health insurance agencies do not always reimburse the full amount charged for services. Physicians will either “absorb” the loss, or they will charge the patient for the amount that was not paid by the insurance agency TYPES OF HEALTHCARE PLANS Managed Care Health Maintenance Organizations Preferred Provider Organizations Point of Service Health Maintenance Organizations Clients must pay a premium, deductible, and co-payments. Clients must visit in-network doctors and select a primary care physician. HMOs urge clients to practice healthy living and to receive preventive treatments Preferred Provider Organization Clients must pay a premium, deductible, and co-payments. Clients do not have to choose a primary care physician. Clients may visit non-network physicians, but coverage is greater with in-network physicians. PPOs often have other fees and co-payments. Exclusive Provider Organizations Coverage for healthcare services is limited to care from providers or hospitals in the plan’s network, except for emergencies. Referral is not required to see a specialist. No coverage for care from out-of-network providers POINT OF SERVICE Clients must pay a premium. Clients must choose a primary care physician. For in-network physicians, there is usually no deductible and co-payments are low. Specialists may be non-network physicians, but coverage may be limited.  MANAGE CARE COMPARISON GOVERNMENT HEALTHCARE PLANS Public Health Insurance Programs With public health insurance programs, the federal government finances healthcare services received by eligible groups of the population. Medicaid Medicare Military Health System TRICARE Veterans’ Health Administration Government Programs Public Medical Assistance: Medicaid Medicare Affordable Care Act (ACA) Expanded eligibility criteria for Medicaid Provided financial assistance for those who do not qualify for Medicaid or lack insurance from employer Medicaid Needs-based program Designed by the federal government, administered by state governments Provides medical assistance to individuals and families who the state determines to be “medically needy.”  Services typically include: Hospital services Prenatal care Child vaccines Medicaid Pediatric services Services Physician services Diagnostic testing and X-rays Rehabilitation and physical therapy Prescription drugs Home healthcare Medicaid The ACA provided the foundation for Medicaid expansion. Since it is a Expansion voluntary program and states may decide whether or not to participate, states also decide whether or not to expand Medicaid for their residents. As of May 2019, 37 states including Washington, DC, have elected to expand Medicaid. MEDICARE Entitlement program for any citizen age 65 or older Administered by the federal government After deductible, Medicare will cover 80% of all medical expenses This means that insured persons must pay the remaining 20%, similar to coinsurance. Many people cannot afford to pay the 20% charge. An additional form of insurance called Medigap may be purchased to help cover the remaining expenses.  MEDICAID SERVICES Part A: Hospital Care Hospitalization Skilled nursing facilities Home healthcare Hospice care Long-term care facilities Part B: Outpatient Services Medical expenses, including therapy, medical equipment, and testing Preventive Care  Healthcare for the Military The U.S. Department of Defense operates the Military Health System which provides medical services to active duty and retired military members of the armed forces and their families. TRICARE is the health insurance program of the Military Health System. The Veterans Health Administration (VHA) is the largest integrated health services system in the United States