Exam 1

Largest Public Health Insurance Program in the US

Medicaid

Occupational Safety and Health Administration (OSHA) responsibility

OSHA develops and enforces regulations for all employers including: help for employers, workers' rights, fall prevention, heat, personal protective equipment, record keeping, trenching & excavation. This regulation spans several sectors including: agriculture, construction, federal agencies, health care, maritime, and oil & gas

US Centers for Disease Control and Prevention functions

One of the major operating components of the Department of Health and Human Services. · Detect and respond to new and emerging health threats · Tackle the biggest health problems causing death and disability for Americans · Put science and advanced technology into action to prevent disease · Promote healthy and safe behaviors, communities and environment · Develop leaders and training the public health workforce, including disease detectives · Taking the health pulse of our nation (collect data and constantly assess health/well-being)

US Food and Drug Administration responsibility

The FDA regulates: · Food · Drugs · Medical devices · Radiation-emitting products · Vaccines, blood, & biologicals · Animal & veterinary products · Cosmetics · Tobacco products

Policy

The authoritative decisions made in the legislative, executive, or judicial branches of government

Social Determinants of Health

The conditions in which people are born, grow, live, work, and age, shaped by the distribution of money, power, and resources at global, national, and local levels

quality

The degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

10 Essential Services

1. Assess & Monitor health 2. Investigate, diagnose, & address health hazards and root causes 3. Communicate effectively to inform and educate 4. Strengthen, support, & mobilize communities & partnerships 5. Create, champion, & implement policies, plans, & laws 6. Utilize legal & regulatory action 7. Enable equitable access 8. Build a diverse & skilled workforce 9. Improve & innovate through evaluation, research, & quality improvement 10. Build & maintain a strong organizational infrastructure for PH

3 core functions of public health

1. Assessment 2. Policy Development 3. Assurance

Out of Pocket Max

The maximum amount you will pay annually for medical care

access

The timely use of health services to achieve the best health outcomes. This includes: insurance coverage, geographic availability, and personal relationships (Institute of Medicine).

Essential Health Benefits of Affordable Care Act (ACA)

Those benefits that MUST be provided under law (preventative care without co-pay, contraceptive management, etc..)

Medicaid enrollment

Through the state's Department of Health and Human Services

Nurses participate in policy

To advance a healthier society To promote a safer healthcare system To support nursing's ability to care for people with equity & skill

US Centers for Medicaid and Medicare Services (CMS) responsibility

CMS administers and regulates all aspects of Medicare, Medicaid/CHIP, and the ACA. Distributes funds to the states as appropriate. CMS collects and analyzes data, produces research reports, and works to eliminate instances of fraud and abuse within the healthcare system.

what does the Affordable Care Act (ACA) say about coverage

Cannot be denied for pre-existing conditions, children can remain on parent's insurance until age 26

Public Health Finance

Complex system determines how public health infrastructure, services, etc. are financed

Management

Health and Human Services (state & federal) Health Insurance •State Health Insurance Regulations •Federal Health Insurance Regulations

Regulatory

Influence actions, behaviors, and decisions of individuals or groups to ensure that a public objective is met

Medicaid eligibility

Insurance for low-income populations •Children (under the age of majority) •Adults (in some states) •Seniors (dual eligibility) •Disabled persons Long term care services •Nursing home coverage for long term care residents

US Agency for Healthcare Research and Quality function

Lead Federal agency charged with improving the safety and quality of America's health care system. AHRQ develops the knowledge, tools, and data needed to improve the health care system and help Americans, health care professionals, and policymakers make informed health decisions. · Invests in research on the Nation's health delivery system that goes beyond the "what" of health care to understand "how" to make health care safer and improve quality. · Creates materials to teach and train health care systems and professionals to put the results of research into practice. · Generates measures and data used by providers and policymakers.

Low income

below 100% of the poverty level

Focus must shift to addressing

upstream factors in and outside of health care systems

Health Policy

when the intent of public policy is to influence health or health care all policy is health policy

Health policy determines

who gets what type of health care - when, how, from whom & at what cost

co-insurance

your shared responsibility for medical costs with the insurance company. Applies after the deductible has been met

Commercial/Private Insurance

many options for this •Each will include a premium, deductible, network, co-pay/co-insurance, out of pocket max. •Each will have special riders that are specific to that particular plan •Each is required to cover preventative care - because of the ACA

advisory agencies

organization that collects and analyzes data and information and makes recommendations no authority for enforcement

Broad range of issues

other than health care that influence health and wellbeing

Affordable Care Act

private/commercial insurance

Employer Provided Insurance

private/commercial insurance

3 Dimensions of the American Healthcare System

quality cost access

The CDC

recommends not regulates

US Centers for Medicaid and Medicare Services (CMS)

regulatory agency Situated as part of the US Department of Health and Human Services. Oversees administration of Medicare, Medicaid/CHIP, and the Affordable Care Act.

US Environmental Protection Agency (EPA)

regulatory agency The mission of EPA is to protect human health and the environment

Occupational Safety and Health Administration (OSHA)

regulatory agency The mission of OSHA is to ensure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance.

The Joint Commission (TJC)

regulatory agency The mission of The Joint Commission is to continuously improve health care 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. Its vision is that all people always experience the safest, highest quality, best-value health care across all settings.

US Food and Drug Administration

regulatory agency The FDA is responsible for protecting the public health by ensuring the safety, efficacy, and security of food, drugs, tobacco products, and medical products.

Medicaid

state insurance

cost

the actual cost of providing services related to the delivery of healthcare, including the cost of procedures, therapies and medications. This does NOT include expenditure costs such as money paid for services or fees (National Institute of Health)

deductible

the amount of money you must pay out of pocket, before insurance coverage kicks in

upstream factors

the factors in the social environment that influence health and illness

Public Health Policy is connected to

the health care system, values, and philosophies about the place of government

Public Health Policy is grounded in

the health planning process

Premium

the monthly or annual amount you pay in order to have health insurance coverage

two types of public policy

Allocative Regulatory

US National Institute for Occupational Safety and Health functions

A research agency focused on the study of worker safety and health, and empowering employers and workers to create safe and healthy workplaces. Part of the U.S. Centers for Disease Control and Prevention, in the U.S. Department of Health and Human Services. It has the mandate to assure "every man and woman in the Nation safe and healthful working conditions and to preserve our human resources." NIOSH has more than 1,300 employees from a diverse set of fields including epidemiology, medicine, nursing, industrial hygiene, safety, psychology, chemistry, statistics, economics, and many branches of engineering. · Conduct research to reduce worker illness and injury, and to advance worker well-being. · Promote safe and healthy workers through interventions, recommendations and capacity building. · Enhance worker safety and health through global collaborations (information sharing).

US Environmental Protection Agency (EPA) responsibilities

EPA develops and enforces regulations that span many environmental topics including: air, emergency management, land & clean-up, pesticides, toxic substances, waster, water, and issues that cut across these areas like asbestos & lead. This regulation spans several sectors including: agriculture, automotive, construction, electric utilities, oil & gas, and transportation.

policy in government

Enacted at all 3 levels of government

at the center of all the core functions

Equity

The Joint Commission (TJC) responsibility

Establishes standards that are the basis of an objective evaluation process to help health care organizations measure, assess and improve performance. The standards focus on important patient, individual, or resident care and organization functions that are essential to providing safe, high quality care. The Joint Commission's state-of-the-art standards set expectations for organization performance that are reasonable, achievable and surveyable. Provides accreditation and certification for a wide array of health care facilities and organizations.

US National Institutes of Health functions

One of the world's foremost medical research centers. An agency of the Department of Health and Human Services, the NIH is the Federal focal point for health research. NIH is the steward of medical and behavioral research for the Nation. · Foster fundamental creative discoveries, innovative research strategies, and their applications as a basis for ultimately protecting and improving health · Develop, maintain, and renew scientific human and physical resources that will ensure the Nation's capability to prevent disease · Expand the knowledge base in medical and associated sciences in order to enhance the Nation's economic well-being and ensure a continued high return on the public investment in research · Exemplify and promote the highest level of scientific integrity, public accountability, and social responsibility in the conduct of science · Provide leadership and direction to programs designed to improve the health of the Nation by conducting and supporting research (in the causes, diagnosis, prevention, and cure of human diseases; in the processes of human growth and development; in the biological effects of environmental contaminants; in the understanding of mental, addictive and physical disorders; and in directing programs for the collection, dissemination, and exchange of information in medicine and health, including the development and support of medical libraries and the training of medical librarians and other health information specialists.)

National Academy of Medicine functions

One of three academies that make up the National Academies of Sciences, Engineering, and Medicine (the National Academies) in the United States. The National Academies are private, nonprofit institutions that work outside of government to provide objective advice on matters of science, technology, and health. · Respond to Critical and Pressing Issues (Clinician well-being, opioid crisis, climate change, gene-editing. · Advise the Nation and World on the Future of Health and Health Care (Health equity, vital directions for health and health care · Lead and Inspire for the Future (Emerging science, technology, and information)

One World

Operate on sliding scale fee for prescriptions and medical care

___________ is a community based alternative to nursing home care for the elderly. Patients must be eligible for ___________.

PACE, medicare and medicade

#1 reason Americans file for bankruptcy

People have the option of paying cash outright for medical expenses

Allocative

Provides benefits for a distinct group of individuals or organizations (at the expense of others) to achieve a public objective (may be redistribution of wealth)

Federally Qualified Health Centers

Safety net providers such as community health clinics and public housing centers that provide health services regardless of the ability to pay and are funded by the federal government. Charles Drew

the prevention fund

U.S. first and only mandatory funding stream dedicated to improving the public's health. -3% of U.S. health spending is on prevention and public health

Commercial/Private Insurance will stay in place for

a year Only eligible to change plans for "qualifying life events" (marriage, child, adoption, etc)

Public Health Policy directed towards

influencing actions, behaviors, or decisions influencing population health

US National Institute for Occupational Safety and Health

advisory agency Develop new knowledge in the field of occupational safety and health and to transfer that knowledge into practice

National Academy of Medicine

advisory agency Improve health for all by advancing science, accelerating health equity, and providing independent, authoritative, and trusted advice nationally and globally

US Agency for Healthcare Research and Quality

advisory agency Produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used

US National Institutes of Health

advisory agency Seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability

US Centers for Disease Control and Prevention

advisory agency Works 24/7 to protect America from health, safety and security threats, both foreign and in the U.S. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same Increases the health security of our nation. As the nation's health protection agency, CDC saves lives and protects people from health threats. To accomplish our mission, CDC conducts critical science and provides health information that protects our nation against expensive and dangerous health threats, and responds when these arise

Charity Care

care written off by healthcare systems for those unable to pay

Health is determined in a large part by

conditions where people live, work, and play

Public policy

crafted by governments -Health Policy -Social Policy

Private Policy

crafted by nongovernmental entities - health care organizations, insurers, or others

Public Health Policy should be based on

evidence and support determinants of health

Advisory Agency part of

executive branch

Medicare

federal insurance

co-pay

flat fee you pay toward cost of medical care. May start before or after the deductible phase. May or may not apply to the deductible amount

Medicaid is

government sponsored insureance

Social policy

identifies course of action to deal with social problems - typically addressing the social determinants of health

Can be Independent advisory agency

independent from the government

intention of policy

influence the actions, behaviors or decision of citizens

Medicaid: Nebraska eligibility

•65 years of age or older •An individual under 65 years of age who has a disability, or is visually impaired according to Social Security guidelines •An individual 18 years of age or younger •A pregnant woman •A parent or caretaker •A former foster care youth

Medicare - coverage

•A: Hospital, Skilled, Home Health, Hospice Coverage •B: Outpatient, Labs, Durable Medical Equipment (DME) Coverage •D: Prescription Coverage •C: Medicare Advantage •F-N: Supplement/ Medigap Plans

Medicare - eligability

•Age 65 or older •Disabled (for at least 24 months) •End Stage Renal Disease (ESRD) •Amyotrophic Lateral Sclerosis (ALS)

Income Requirements for medicaid in Nebraska

•Annual Income less that 100% FPL - 12,140 for a single person •Savings/Assets (including home, cars, bank accounts) must be less than $4000

Basic Provisions of the Affordable Care Act (ACA)

•Creation of Health Exchanges •Premium Subsidies •Medicaid Expansion •Medicare Reform •Lifetime Spending Limits Erased

Sick Care

•Hospital •Clinic •Federally Qualified Health Centers •Free Clinics •Pharmacy

Medicaid coverage

•Hospital, Skilled, Home Health, Hospice •Outpatient, Labs, Durable Medical Equipment •Prescriptions

Medicare - enrollment

•Initial: 3 months before, month of, 3 months after (65th birthday or 25th month of disability) Coverage begins the first full month after enrollment. •General: 1/1 - 3/31 annually. Coverage begins July 1, penalty is assessed.

Medicare - assistance

•Medicare Savings Program (premiums, deductibles, co-insurance) •Low Income Subsidy (LIS) / Extra Help •Program of All Inclusive Care for the Elderly (PACE) •Medicaid (Dual Eligibility)

Medicare - cost

•Premiums (A, B, & D), supplements or C •Deductibles (A, B & D), supplements or C •Traditional covers only 80% cost, no out of pocket max •Prescription stages 1-4 (Deductible: $435, Initial Coverage: $4020, Coverage Gap: $9719, Catastrophic: > $9719) •Medicare Advantage usually applies co-pays, does have out of pocket max, prescription stages still apply

Advisory Agency

•Provide information and recommendations about course of action •Developed around a specific mission and responsible for providing guidance on certain issues and/or industries

Well Care

•Public Health Programs •Community Events

Medicaid cost

•Small insured co-pay for prescriptions ($3 - $10) •Financed in conjunction with the Federal Government. Feds pay an average of 63% cost. State taxes make up the difference.