chapter 1 - higher ed ebooks & digital learning solutions ...€¢dagins &osi treatment of...
Post on 23-May-2018
221 Views
Preview:
TRANSCRIPT
1
© 2007 Thomson - Wadsworth
Chapter 1
Health Care Systems and Reimbursement
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2
© 2007 Thomson - Wadsworth
Overview
• Health Care Facilities in the U.S.Preventive & Primary Health Care ServicesSecondary & Tertiary CareRestorative CareLong-Term Care
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3
© 2007 Thomson - Wadsworth
Overview continued
• Financing the Health Care IndustryPrivate Insurance• Traditional Fee-for-Service Plans• Group Contract Insurance
Public Insurance• The Medicare Program
– Medicare Part A– Medicare Part B– Coverage Gaps
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4
© 2007 Thomson - Wadsworth
Overview continued
The UninsuredDemographic Trends in Health CareThe Need for Health Care Reform• The High Cost of Health Care• Efforts at Cost Containment• Equity & Access as Issues in Health Care• Racial & Ethnic Disparities in Health
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
5
© 2007 Thomson - Wadsworth
Overview continued
Health Care Reform in the United States• Nutrition as a Component of Health Care
Reform• The Cost-Effectiveness of Nutrition
Services
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
6
© 2007 Thomson - Wadsworth
Preventive & Primary Health Care Services
• Prevention of illness & chronic disease
• Nutrition• Facilities
Health departmentsClinics & physician’s officesSchoolsProfessional, nonprofit & volunteer organizations
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
7
© 2007 Thomson - Wadsworth
Secondary & Tertiary Care
• Diagnosis & treatment of illness
• Acute care• Tertiary care
ExpertTechnicalHighly specialized
• FacilitiesTraditionally hospitalsPhysicians’ officesOutpatient facilitiesUrgent careSurgical unitsEmergency rooms
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
8
© 2007 Thomson - Wadsworth
Hospital Classifications
• See Box 1-2• Public not-for-profit• Private not-for-profit• Private profit• Veterans’ and military
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
9
© 2007 Thomson - Wadsworth
Nutrition in Secondary & Tertiary Care
• Examples:Celiac diseaseHypertensionArtherosclerosisMyocardial infarctionCongestive heart failure
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
10
© 2007 Thomson - Wadsworth
Restorative Care
• Care for recovery from acute or chronic illness
• Nutrition• Facilities
Long-term careRehabilitation facilitiesOutpatient clinicsHome health services
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
11
© 2007 Thomson - Wadsworth
Long-Term Care
• Maintenance, custodial & health services for the chronically ill or disabled
• Nutrition
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
12
© 2007 Thomson - Wadsworth
Health Insurance
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
13
© 2007 Thomson - Wadsworth
Private Insurance
• Traditional fee-for-serviceFee per service rendered10% of insurance coverage today
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
14
© 2007 Thomson - Wadsworth
Private Insurance continued
• Group contract insuranceManaged care system• Health maintenance organizations
(HMOs)– Capitation– General HMO models
» Staff model» Group model» Network model» Independent practice association
• Preferred provide organizations (PPOs)
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
15
© 2007 Thomson - Wadsworth
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
16
© 2007 Thomson - Wadsworth
Public Insurance
• Medicare• Medicaid• SCHIP• HIPAA• Workers’ compensation
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
17
© 2007 Thomson - Wadsworth
Providers of Public Insurance
• Centers of Medicare & Medicaid Services• Department of Veterans Affairs• Public Health Services
Indian Health Service• Department of Defense
Civilian Health & Medical Program of the Uniformed ServicesCHAMPUS
• Public hospitals & community health centers• State & local public health programs
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
18
© 2007 Thomson - Wadsworth
Medicare
• 1965 Title XVIII of Social Security Act
• Administered by CMS of Department of Health & Human Services
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
19
© 2007 Thomson - Wadsworth
Eligibility
• 65 years of age or older• Any age with end-stage renal disease• Eligible for Social Security or Railroad
Retirement Board disability benefits up to 24 months
• Medicare-covered government employment prior to retirement
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
20
© 2007 Thomson - Wadsworth
Medicare Part A
• Hospital InsuranceInpatient hospital, skilled nursing facility, & some home healthDeductibles & coinsurance feesHospital inpatient charges reimbursed according to prospective payment system (PPS)• Diagnosis-related groups (DRGs)
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
21
© 2007 Thomson - Wadsworth
Medicare Part B
• Medical insurance• Optional program• Provides benefits for
Eligible physician servicesOutpatient hospital servicesCertain home health servicesDurable medical equipment
• NutritionMedical Nutrition TherapyCurrent procedural terminology (CMT)Enrolled Medicare MNT providers bill for
• Diabetes mellitus• Nondialysis kidney
disease• Post-kidney
transplant
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
22
© 2007 Thomson - Wadsworth
Medicare savings after 3 years of reimbursement of nutrition services
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
23
© 2007 Thomson - Wadsworth
Coverage Gaps
• Prescription drug coverage• Skilled nursing & long-term institutional
care > 100 days• Medicare Modernization Act of 2003
Optional coverageDrug discount cards/prescription drug plansAdditional preventive benefits
• Medigap PolicySupplemental policy from private insurance companies
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
24
© 2007 Thomson - Wadsworth
Medicaid
• Entitlement program• Joint state & federal program• 1965 Title XIX of the Social Security
Act
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
25
© 2007 Thomson - Wadsworth
Eligibility
• Low incomes• Certain pregnant women & children
with low incomes• Older adults, the blind & people with
disabilities• Members of families with dependent
children in which one parent is absent, incapacitated or unemployed
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
26
© 2007 Thomson - Wadsworth
Eligibility continued
• Determined by states• Three criteria
Income• Below federal poverty guidelines
Categorical• Member of family with dependent children• Older adult• Blind• Disability
Resource
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
27
© 2007 Thomson - Wadsworth
Coverage
• Inpatient & outpatient hospital services• Physician, pediatric/family nurse practitioner• Nurse-midwife services• Selected health center & rural health clinic services• Prenatal care & family planning• Child vaccination & services for those under 21 years
of age• Laboratory & X-ray services• Skilled nursing home & home health services
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
28
© 2007 Thomson - Wadsworth
• State Children’s Health Insurance Program
• Title XXI in the Balanced Budget Act of 1997
• Children of working families with incomes too high to qualify for Medicaid but too low to afford private health insurance
SCHIP
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
29
© 2007 Thomson - Wadsworth
SCHIP Enrollment
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
30
© 2007 Thomson - Wadsworth
Coverage
• Inpatient & outpatient hospital services
• Physicians’ surgical & medical services
• Laboratory • X-ray services• Well baby/child care services
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
31
© 2007 Thomson - Wadsworth
The Uninsured
• Employed uninsured• Nonworking uninsured• Emergency room• Resulting cost shift to the insured by
the increase in overall medical costs
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
32
© 2007 Thomson - Wadsworth
Percentage of Uninsured in U.S.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
33
© 2007 Thomson - Wadsworth
Demographic trends in health care
• Aging population of baby boomersRequire care for greater number of yearsRise in amount of medical care required
• Increase in Hispanic population
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
34
© 2007 Thomson - Wadsworth
Elderly needing long-term care
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
35
© 2007 Thomson - Wadsworth
Health Care Reform
• Success of health care systemCostQualityAccess
• ChallengesAccessible to allContain costsProvide nursing home careEnsure that Medicare & Medicaid can serve eligible people
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
36
© 2007 Thomson - Wadsworth
High costs of health care
• Aging population• Increased demand• Medical advances• Administrative costs of insurance
process• Professional liability costs
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
37
© 2007 Thomson - Wadsworth
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
38
© 2007 Thomson - Wadsworth
National health expenditures in billions of dollars, 1960-2002
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
39
© 2007 Thomson - Wadsworth
Cost Containment Efforts
• Slowing hospital construction• Modifying reimbursement • Reducing length of stays• Increasing co-payments &
deductibles• Challenging eligibility requirements
for Medicaid
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
40
© 2007 Thomson - Wadsworth
Cost Containment Efforts
• Requiring second opinions to reduce unnecessary surgery
• Restricting access to new technology• Encouraging alternative delivery
systems• Emphasizing prevention• Generic drugs
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
41
© 2007 Thomson - Wadsworth
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
42
© 2007 Thomson - Wadsworth
Resulting Trends
• Movement away from traditional fee-for-service
• Companies choosing self-insured health plans to avoid cost shifting
• Payers setting reimbursement restrictions & limitations
Prospective payment system (PPS)• Diagnosis Related Groups (DRGs)• ICD-9-CM
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
43
© 2007 Thomson - Wadsworth
Racial & Ethnic Disparities in Health
• Healthy People Initiative
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
44
© 2007 Thomson - Wadsworth
Health Care Reform in the U.S.
• Health insurance reform• Physician malpractice reform• Incentives to induce businesses to
include health promotion initiatives in their insurance plans
• Preventive component vs. chronic disease as typical focus of allopathic medicine
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
45
© 2007 Thomson - Wadsworth
Nutrition in Health Care Reform
• Good health does not exist without proper nutrition.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
46
© 2007 Thomson - Wadsworth
Cost Effectiveness of Nutrition Services
• Well documented• Develop guidelines or protocols that
specify appropriate care for conditions or diseases
• Measure outcomes• Documentation
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
47
© 2007 Thomson - Wadsworth
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
top related