Understanding Health Care Systems

Health Care Providers

It is the responsibility of every health care worker to help patients/clients solve their health problems. Since the health care industry has many delivery systems, it is important for future health care workers to be aware of health care agencies and facilities, their delivery systems, their organization, and some of their major services. When you understand how health care facilities and agencies serve the public, you will become a resource person for members of your community.

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Match key terms with their correct meanings. Research a volunteer agency. Define managed care. Define ambulatory care. Evaluate how managed care and ambulatory care meet

the needs of the changing health care system. Understand the role of government agencies in providing

health care. List six types of outpatient care and the type of treatment

given.

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Define wellness and preventive care. Contrast the current trends with health care in the

twentieth century. Be able to use or read an organizational chart. Give two reasons why the organization of health care

facilities is important. Explain a chain of command. List and define the major services in health care. Identify two departments in each major service.

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General hospitals Patients stay for a short period of time

Specialty hospitals Provide longer term care for those with complex or

chronic conditions Convalescent care

Geriatric care or long-term convalescence Nursing homes

Residences for those who require constant care Physician and dental facilities

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Rehabilitation centers Outpatient care for physical or occupational therapies

Industrial health care centers School health services Health Maintenance Organizations (HMOs) Home health care agencies Senior day care World Health Organization (WHO) Hospices

End-of-life care for terminally ill patients (life expectancy is 6 months or less)

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Veteran’s Administration hospitals U.S. Public Health Department State psychiatric hospitals State university medical centers State public health services U.S. Department of Health and Human Services

(USDHHS) National Institute of Health (NIC) Centers for Disease Control (CDC)

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Food and Drug Administration (FDA) Occupational and Safety Health Administration

(OSHA) Agency for Health Care Policy and Research

(AHCPR) County hospitals Laboratories

May be government or private facilities Local public health departments Senior centers

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Receive money from donations, endowments, membership and fundraising efforts Use funds for research and public education

Often support a specific disease or medical condition, such as: American Cancer Society National Foundation of the March of Dimes American Red Cross American Heart Association …and many others

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Goal is to provide quality care at reasonable costs

Policies include: Focus on preventive care, such as routine physicals

and well-baby care Use of primary care providers─the “family doctor”─as

first contact in undiagnosed illness Can refer patients to specialist, as needed Use of emergency and urgent care facilities Require preadmission authorization requirement for

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Part of trend to provide managed care Uses non-hospital facilities for care, whenever

possible, including: Rehabilitation centers Outpatient surgery Outpatient medical centers/clinics Physicians’ offices Day care

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Efficient health care centers are well organized Organization chart:

shows how each department fits into the system Identifies the line of authority

Chain of command is critical Tells you to take questions and problems to your

immediate supervisor Provides efficient problem-solving structure

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Therapeutic services Provide care over time

Diagnostic services Such as x-rays or blood tests Used to identify a particular condition or illness

Informational services Document and process information

Environmental services Help to create a relaxing and healing environment for

patients

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ambulatory audiology chiropractic chronic communicable convalescence diagnostic endowments environmental

sanitation facilities

geriatric hydroptherapy hypertension immunizations licensing managed care maternal obstetrics occupational therapyorthopedics

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outpatients podiatry prosthetics psychiatric radiology recreational therapy refer

rehabilitation specialties surgical therapeutic trend urology

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Health Care Systems

The cost of health care has increased significantly over the years. It is important to understand the causes for the increase as well as methods providers use to help contain the costs. Every health care worker should also know the health care systems that help patients/clients afford the services they need. When patients/clients receive regular and complete care, they live healthier and happier lives.

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Match key terms with their correct meanings. Explain how health care providers have modified their

practices to provide patients quality health care at a lower cost.

Explain the purpose of the Health Plan Employer Data and Information Set.

Identify and differentiate the various health care systems. Compare and contrast health maintenance organizations

and preferred provider organizations. Analyze and predict where and how certain factors such as

cost, managed care, technology, an aging population, etc. may affect various health care delivery system models.

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Costs driven up by: Technological advances Health-related lawsuits Aging population New equipment

Cost containment: Government legislation passed in 1983 to regulate

health costs▪ Developed DRGs―Diagnostic-related groupings―with

standard treatment and reasonable costs for each

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Health Plan Employer Data Information Set (HEDIS) provides guidelines and a report card that: Measures health care performance Identifies physicians who provide high quality medical

care to their patients Helps to identify physicians who do not meet health

care guidelines

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Health insurance―third party payers Each insurer determines how much it will pay for

specific services▪ Co-payments▪ Deductibles▪ Co-insurance

HMOs―must use a member physician or service provider and pay a co-pay

PPO―physicians and hospitals that band together to provide lower cost services to various large companies

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Medicaid Provided by state and federal government to disabled

and low income people Medicare

Health insurance for those over 65 TRICARE

Health care for active duty service members, retirees, and their families

Workers’ Compensation Employees who are injured, have workplace-related

illness or die covered by state worker’s compensationCopyright (c) 2009 Pearson Education 23

Because of increasing number of uninsured people, a national health plan is under discussion

Goal is to provide good, comprehensive health care to everyone

Emphasis on preventive care, immunizations, education and behavior modification (such as stopping smoking)

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benefits bulk co-insurance compensation co-payment deductible eligibility

intervention lawsuits legislations premium preventative systems

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