© 2009 delmar, cengage learning chapter 2 health care systems

© 2009 Delmar, Cengage Learning

Chapter 2

Health Care Systems


Health Care Facilities

• Growth—one of the largest and fastest growing industries in the United States

• Employment opportunities—employs over 17 million workers in over 200 careers

• Expenditures—it is a four-billion-dollar-per-day business and growing

• By 2020 employment will exceed 5.6 jobs with 22.7 million workers

• Healthcare expenditure 2012 2.7 trillion dollars • 2020 4.6 trillion dollars

(continues)


Private Health Care Facilities(continued)• Hospitals

– General hospitals• Vary in size

• Treat wide variety of

• Provide diagnostics, treatments, surgery, ER care

– Specialty hospital• Provide care for specific conditions

– Government • Operated by local, state or federal governments

• Include VA and state psychiatric hospitals

– University/ College Medical Centers• Provide service, research and education

• Can be publicly or privately funded


Private Health Care Facilities• Long-term care facilities (LTC or LTCF)

– Provide care and assistance for the elderly, handicap and disabled

– Common types of LTC include: residential, extended care skilled nursing care facility

• Independent living and assisted living

– Rent or purchase apartments with assistance available if needed

• Medical offices

– Single or multi physician owned and operated

– Provide: diagnosis, treatment, examination, labs, minor surgery

• Dental offices– single or multiple dentist, to clinic setting

– Provide dental exams, and treatment many dental conditions

• Clinics or satellite centers– Surgicenters, urgent care, rehab clinics, substance abuse clinics, specialty clinics,

outpatient clinics, health department clinics and medical center clinics.

•


Private Health Care Facilities(continued)

• Emergency care services

• Optical centers

• Laboratories

• Home health care

• Hospice agencies

• Mental health facilities

• Genetic counseling centers

• Rehabilitation facilities (continues)


Private Health Care Facilities(continued)

• Health maintenance organizations (HMOs)– Services directed at preventative care

– Fees are fixed and prepaid

• Industrial health care centers or occupational health clinics– Found in large companies- geared at employee health

• School health services– Found in school districts and colleges-provide care for

sudden illness, screenings, ER care for accidents and for students with chronic conditions


2:2 Government Agencies• Government services are tax supported

• World Health Organization (WHO)

– International health agency sponsored by UN for global health issues

• U.S. Department of Health and Human Services (USDHHS)

– Deals with health issued in the USA

• National Institutes of Health (NIH)

– A division of USDHHS- involved in disease research

• Centers for Disease Control and Prevention (CDC)

– Division of USDHHS- deals with spread, cause and control of disease in the USA

(continues)


Government Agencies(continued)

• Food and Drug Administration (FDA)– Responsible for regulating food & drug products

• Agency for Health Care Policy and Research (AHCPR)– Federal agency which deals with improving quality, safety, efficiency

and effectiveness of HC in the USA

• Occupational Safety and Health Administration (OSHA)– Establish and enforce standard that protect workers from job related

injury and illness

• Health Departments– Provide health services as directed by the USDHHS


2:3 Voluntary or Nonprofit Agencies

• Supported by donations, membership fees, fundraisers and grants

• Health services are provided at national, state, and local levels

• Examples include the American Cancer Society, March of Dimes, American Red Cross and many more

(continues)


Voluntary or Nonprofit Agencies(continued)

• Organizations focus on specific diseases

• Educate the public

• Provide special services

• Purchase medical equipment

• Staffed by many health care workers

and volunteers


2:4 Health Insurance Plans

• Health care costs are rising faster than other costs of living

• Most people rely on health insurance plans to pay for health care costs

• Without insurance, the cost of an illness can become a financial disaster


Insurance Terminology

• Deductible– Amount that must be paid by the patient for medical

services before insurance begins to pay

• Co-insurance– A specific amount of expenses that must be shared by

the patient and insurance company• Ex; 80:20

• Co-payment– A specific amount a patient pays for service

• Ex: $10.00 co-pay for office visit


Types of Health Insurance Plans• Health maintenance organization (HMO)

– Managed care with predetermined monthly rates

– Focus is on prevention- if care is rendered outside HMO- the patient will incur all costs

• Preferred provider organization (PPO)

– Managed care plan which contracts with a health care agency to provide care at reduced rates

– Require copays and deductibles

• Must use in network provides or will have to pay greater fees (continues)


Types of Health Insurance Plans• Medicare

– Federal government insurance for 65 and over – Has 3 parts– A,B,D

• A is hospital insurance coverage• B offers additional coverage for outpatient, therapy, clinical

labs, and other health care• D offers medication coverage

• Medigap– A Medicare supplement (Medigap) insurance, sold by private

companies, can help pay some of the health care costs that Original Medicare doesn't cover, like copayments, coinsurance, and deductibles


Types of Plans(continued)

• Medicaid– Medicaid is a joint federal and state program that helps

with medical costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, like nursing home care and personal care services.

• The State Children’s Health Insurance Program (SCHIP)– The Children's Health Insurance Program (CHIP)

provides free or low-cost health coverage for more than 7 million children up to age 19. CHIP covers U.S. citizens and eligible immigrants


Types of Plans

• Worker’s Compensation

– Health insurance plan providing treatment for workers injured on the job

• U.S. government plans for all military personnel and their families

– TRICARE-Health Insurance plan for military personnel


Types of Plans(continued)

• Managed care plans are a type of health insurance. They have contracts with health care providers and medical facilities to provide care for members at reduced costs. These providers make up the plan's network


WHAT IS HIPAA?

•HIPAA is the federal Health Insurance Portability and Accountability Act of 19961.The primary goal of the law is to make it easier for people to keep health insurance

2.protect the confidentiality and security of healthcare information

3.help the healthcare industry control administrative costs.


Portability

• This section allows individuals to carry their health insurance from one job to another so that they do not have a lapse in coverage.

• It also restricts health plans from requiring pre-existing conditions on individuals who switch from one health plan to another


Administrative Simplification

• This section is the establishment of a set of standards for receiving, transmitting and maintaining healthcare information and ensuring the privacy and security of individual identifiable information.


Privacy

• HIPAA provides for the protection of individually identifiable health information that is transmitted or maintained in any form or medium. The privacy rules affect the day-to-day business operations of all organizations that provide medical care and maintain personal health information


What Health Information is Protected?

• Names• Dates relating to a patient , i.e. birthdates, dates of medical

treatment, admission and discharge dates, and dates of death• Telephone numbers, addresses (including city, county, or

zip code) fax numbers and other contact information• Social Security numbers• Medical records numbers• Photographs• Finger and voice prints• Any other unique identifying number


Who Must Comply?• Health Care Providers: Any provider of

medical or other health Services that bills or is paid for healthcare in the normal course of business.

• Health Care Clearinghouse: It includes groups such as physician and hospital billing services.Health Plans: Individuals or group plans that provide or pay the cost of medical care and includes both Medicare and Medicaid programs


WHAT ARE A PATIENT’S RIGHTS UNDER HIPAA’S PRIVACY STANDARDS?

• Patients have a right to:– receive a notice of the privacy practices of any health care

provider.

– see their PHI and get a copy.

– that changes be made to correct errors in their records or to add information that ha been omitted.

– to see a list of some of the disclosures that have been made of their PHI.

– request that you give special treatment to their PHI.

– request confidential communications.

– to complain


HIPAA (1996)

Compliance of HIPAA regulations was required by April 2004


Affordable Care Actsigned March 2010 / 2014

• AKA---OBAMACARE

• Provisions in place • Requires all insurers to charge the same premium to

all applicants of gender, age, geographic location- regardless of pre-existing conditions

• Can not deny converge if premiums are paid• Expand Medicaid coverage to include families with

incomes of 133% the poverty rate• Creates affordable insurance exchanges in all states


Affordable Care Actsigned March 2010 / 2014

• Mandates all must purchase insurance • Provides subsides for low income families, small

business• Young adults can be covered up to 26 years old by

parent• Improve enrollment for Medicaid and CHIP• Enforces shared responsibly payment for employers• Improves Medicare & prescription drug coverage • Allow restructuring of Medicare reimbursement from

fee for service to bundled payments


VIDEO

• Obamacare Video


What do you think?• Divide into 4 groups of 4-5 and answer the following questions?

1. Does the Patient Protection and Affordable Care Act provide health care insurance to every individual in the USA? Why or Why not?

2. Will Affordable Care Act impact quality of care and how doctors practice medicine? Will care improve or deteriorate? Explain with specific examples.

3. Will Obamacare worsen the physician shortage? Explain / What are some solutions?

4. Opponents of the individual mandate insist that they are only defending individual freedom. What do you think?

•


Organizational Structure of Hospitals


2:5 Organizational Structure

• Line of authority or chain of command

• Indicates areas of responsibility

• Goal: most efficient operation of facility

• Complex or simple structure determined by size and needs of organization

• Sample organizational charts (See Figure 2-4 and 2-5 in text)

(continues)


Organizational Structure(continued)

• The line of authority must be clearly indicated in any organizational structure

• Workers must identify and understand their position in the structure

• To follow proper channels of communication, workers must take problems, reports, and questions to their immediate supervisor


Acute Care Hospitals

•Acute Care Hospitals

Organizational Structure

and

Regulatory Agencies


Organizational Chart• Board of Trustees

•• Administrator

•• Nursing Management

•• Medical Director

•• Ancillary Services

•• Management

•• Business Management

•• Patient Care

•• Unit Leadership

•– Respiratory Therapy

•– Physical Therapy, etc


Lines of Authority- Chain of Command PCT

•• Licensed Nurse (LVN/RN)– who takes direction from:

•• The Charge Nurse-– who takes direction from

•• The Nurse Manager– who takes direction from

•• Nursing Supervisor-– who takes direction from

•• Chief Nursing Officer– who takes direction from

•• The Administrator (CEO)– who takes direction from

•• The Board of Trustees


Hospital Organization • Governing Board- Board of Trustees or Board of Directors

– Persons from business/professional

• communities and all socioeconomic groups.

• Duty is to establish policies, provide financing, oversee personnel standards.

• • CEO – Chief Executive Officer

– directly in charge of hospital and answers to board.

• • COO – Chief Operating Officer

– answers to CEO and is responsible for day to day operations.

• • Vice President or Director of each service:

• reports to COO


Lines of Authority on Nursing Units• • Chief Nursing Officer

– Assistant Director of Nursing – House Supervisor– Unit Managers

– ER, OB, OR, RT, PT, Peds, ect• • Staff Nurses

– Nursing Assistants– Patient Care Technicians

• Unit Secretaries


Accreditation of Acute Care Hospitals

• Joint Commission on Accreditation of Health Care Organizations (JCAHO)

– JCAHO accredited means hospital has been surveyed, graded, and approved by the Joint Commission

– Participation in JCAHO is voluntary.

•Department of Health Services – License to operate is granted by the Department of

Health Services of each individual state.


Regulatory Agencies

• Occupational Safety and Health Administration ( OSHA)

• • Board of Registered Nurses (BRN)

• • Licensed Vocational Nurses/Psychiatric Technicians

• • Medical Board

• • Department of Consumer Affairs


Hospital Departments/Services• Business Services

• The Admitting Department

• Purchasing

• Diagnostic & Therapeutic Services

• Support Services

• Operational Services


Hospital Mission Statements


What is a Mission/Vision Statement

• Definition:

• A sentence describing a company's function, markets and competitive advantages; a short written statement of your business goals and philosophies


Assignment• First “Test Grade”- Due Wednesday 9/3

– Create a concept map of: • B) Typical hospital organizational structure

– Name your hospital & create a meaningful Mission Statement

– At a minimum it must include the following departments with examples of healthcare professionals specific to the grouping:

• Board

• Administration

• Nursing Services

• Information Services

• Therapeutic Services

• Diagnostic Services

• Support Services

© 2009 delmar, cengage learning chapter 2 health care systems

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