ch 12
societal beliefs
* People still expect the health care system to cure them when ill, but now there is an increase in: -Preventive care interest -Health education -Health promotion -Behavioral changes Research into barriers and lifestyle changes has increased. U.S. spends a lot of money on healthcare but has a lower quality of healthcare than other countries.
lifestyle and health behaviors
** Five leading causes of death and illness can be positively affected by changes in lifestyle. To prevent many chronic diseases -Low-fat diet -Exercise -Maintaining optimal body weight -Smoking cessation. decrease in lung cancer dt smoking cessation -Stress reduction
historical perspective
*Until 1930s individual health care financing in the United States was self-pay. Health care providers charged a fee, patients paid fees out of pocket. 1980s federal government made first efforts to curtail health care costs. Prospective Payment System (PPS) Despite containment efforts, costs of health care and, health insurance have continued to rise. * Until recently little to no incentive existed to prevent illness or promote health. Curative measures have been the focus. Now with rising costs, the public is more aware of health promotion/ prevention
prospective payment system
-A pre-determined about of payment for Medicare and Medicaid patients to the hospital for a specific diagnosis. This goes off of Diagnosis Related Groups. The hospital is not reimbursed for the total cost of the patient's care. They are reimbursed for the specific diagnosis. -Hospital reimbursement for Medicare patients based on diagnosis-related groups, classification system that identified cost according to diagnosis and client characteristics
roles of the public health nurse in the economics of healthcare
...* Advocate oNurses need to become more involved in economics of health care. oLarge number of nurses gives our occupation potential political clout. oAdvocate for health promotion/disease prevention funding from both public/private sectors oNeed to plan programs, seek funding, and evaluate program effectiveness oConstantly seek sources of funding for heath programs through any available sources
health care financing reform
...* Lack of insurance is a major factor associated with lack of access to medical care. * Uninsured adults more than 3× as likely as insured adults to go without needed medical care * 40% of overall decline in number of uninsured, resulted from ACA allowing young adults until age 26 to remain on their parent's health plan * * Health literacy and communication will be key factors in success as consumers try to figure out the key elements in the ACA and to use exchanges to obtain insurance if not provided by employer.
private insurance
...High costs Costs of plans vary based on cost-sharing levels selected and other actuarial factors. Plans are subsidized through tax credits or other mechanisms. This type of insurance is offered through your employer or business owners buy this for their insurance.
point of service POS
...oCombine elements of HMO and PPO oIf individual goes outside the network, he or she will be responsible for most costs unless referred by the PCP.
aging of society
...ØHealth care expenditures rise with age dramatically as people live longer. ØBaby boomers living longer
prospective reimbursement
Alternative to cost-based reimbursement introduced by federal government for Medicare in 1983 with an immediate savings noted. No matter what provider's cost is reimbursement to hospitals is from a predetermined amount Amount paid to provider determined by primary and secondary diagnosis's, age, gender, and complications. Reduced Medicare costs not overall health care costs. Hospitals developed cost shifting as a means of supplementing the loss of Medicare funding. Hospitals were able to include the loss from caring for Medicare patients in their cost. Actuarial classification ensured adequate premiums were charged for the projected health care needs of those enrolled and other means of cost control emerged. Managed care groups negotiated with health care providers to render care for specified amount of reimbursement based on community ratings modified by group-specific demographics Prospective reimbursement created incentives to control costs but also led to undertreatment and underuse of system. Physician services are given current procedural terminology (CPT) codes, which determines reimbursement from the patient's illness.
premium
Amount paid periodically to purchase health insurance benefits.
cost containment
Capitated reimbursement -Prospective reimbursement for services Access limitation -Primary care provider as gatekeeper. The primary acting as a gatekeeper. Can't see a specialist without a referral -Managed care plans—preauthorization requirements for additional services Rationing -Determining the most appropriate use of health care or directing the health care where it can do the most good
cost sharing definitions
Coinsurance—Cost sharing required by a health plan whereby the individual is responsible for a set percentage of the charge for each service. Copayment—Cost sharing required by the health plan whereby the individual must pay a fixed dollar amount for each service. Deductible—Cost sharing whereby the individual pays a specified amount before the health plan pays for covered services.
trends in health financing: ACA changes
Eligibility for Medicaid-States determine whether to expand eligibility. Not all states did, Ohio expanded! Covered services Ambulatory care Emergency services Hospitalization Pregnancy/maternity and newborn care Mental health and substance use disorder services Preventative measures Despite implementation of the ACA health care costs continue to increase. Major changes are still needed. More Americans have health care but there are concerns over evolving demographics such as -Aging Baby Boomers -Expansion of Medicare costs More policy and interventions need to take place.
high deductible health plans HDHP
Encourage employees to select plans with lower premiums but more pronounced up-front cost sharing Had health care consumer shop around for lower costs Health savings account (HSAs) The HDHP plans are more popular with the healthy and younger population. Put money in an HAS to pay for healthcare expenses.
health care fraud and abuse
Federal Bureau of Investigation (FBI) estimates health care fraud costs the United States tens of billions of dollars annually Billing for services not received Billing for other services Telemarketers targeting elderly. Calling and stating they are from Medicare Medicare used to be the patient's social security number. All patients should be advised to review their EOB or statements.
Medicare qualifications
Federal entitlement program to provide health care to the growing population of those 65 years of age or older, people who are disabled or have end stage renal disease.Another disease that qualifies you for Medicare is ALS or Amyotrophic Lateral Sclerosis
medicaid services
Federal government sets baseline services, but state governments may provide more services. -Must include inpatient and outpatient hospital care, pregnancy-related care, Vaccines For Children, family planning services, rural health clinics, home health care, laboratory and x-ray services, and EPSDT (Early and Periodic Screening Diagnosis and Treatment) are by pediatric and family nurse practitioners is covered. Children's Health Insurance Program (CHIP) is for low socioeconomic family who doesn't qualify for Medicaid, children under 18 some states will cover vision services
private healthcare insurance
First established in 1930s Blue Cross/Blue Shield -Enrollees paid monthly fee for health care Throughout the depression and World War II -Prices and wages frozen -Industries began to offer health insurance as "fringe benefit" to employees 1953 money spent on health care was declared tax-exempt. Union groups negotiated for health care insurance Private employer-based insurance became the model in the United States
medicare part a
Includes inpatient care in hospitals/skilled nursing facilities, hospice care, some home health care Must pay a deductible for health services Does not pay for all health care costs of enrollees Co-payments required after 60 days Part A does not pay for long-term care or any unskilled care. This would be out of pocket.
pharmaceuticals
Influence health care with both prescription and over the counter medications *New drugs improve health care outcomes and quality of life but increase cost. (? Market justice ?) Medicare Part D alleviates the costs of prescriptions for seniors. Does this increase their out of pocket costs?? -Eligible to purchase insurance coverage to offset costs of prescription drugs
part d
Initiated in 2006 to help defray costs of prescription drugs Optional; must enroll in an approved prescription drug plan at additional cost Monthly premium, deductibles, and co-payments Must pay 100% of costs when costs reach "coverage gap" or "donut hole"
part c
Medicare Advantage Plans Optional "gap" coverage Provided by private insurance companies approved by, and under contract with, Medicare May include HMOs and PPOs May include vision, hearing, dental care, and other services not covered by Medicare Parts A, B, or D Supplemental Medicare insurance that can be purchased by patients. Gives an extended coverage. Example: Humana
health maintenance organizations (HMO)
More comprehensive care Lacked enrollees freedom of choice Preventative care covered Specialty care restricted Encouraged to reduce costs by only providing most necessary services starting to evolve in the 1990s not really popular
preferred provider organization PPO
Negotiated with health care providers for services at reduced rate in exchange for guaranteed increase in consumers Negotiated reimbursement rate allows cost of plan to be somewhat controlled. Enrollees offered incentives for choosing health care from within the plan's network. More flexible than HMOs Must use the in-network providers. If go out of network, pay more out of pocket.
types of hospitals
Public hospitals—received public funds and served health care needs of entire population. operated by government funding Private hospitals—cared mainly for those whose ability to pay was greater than the general population For-profit hospitals—limited in numbers, received funds from investors, and cared for those who could definitely pay
part b
Purchased by monthly fee Helps pay for out-of-pocket costs for physician services, hospital outpatient care, durable medical equipment (wheelchair, shower chair, walker, hospital beds,etc), and other services, including some home health care Premiums prorated based on income Enrollees must pay deductibles and coinsurance
medicaid
Title XIX of the Social Security Act—a public welfare assistance program Provides universal health care coverage for the indigent (severe population), children, women, the disabled, and impoverished elders and adults below poverty line in some states A joint state and federal venture Eligibility for this program depends on the size and income of the family. Some states have expanded Medicaid to allow more people to quality. Ohio did this
reimbursement or health promotion and disease prevention
Until recent years reimbursement for health promotion and disease prevention has been limited. ACA mandated preventative services such as: -Counseling for management of obesity -Prevention of sexually transmitted diseases -Tobacco cessation
covered services
When employee fringe benefits included health care coverage, expanded benefit packages were developed. (*used to attract employees!) Costs increased, employers passed cost to employees, then insurance companies limited covered services to curtail escalating costs. Providers modified delivery of health care to accommodate changes. Hospitalization rates declined and outpatient services increased.
health savings account
employee determines amount to be spent during year and this amount is deducted from his or her paycheck, which is "pretax" when services are incurred the employee pays them from this acct
cost sharing
employee may opt to pay higher premium for freedom to choose provider or eliminate gatekeepers
indemnity plan
ex. blue cross/blue shield Paid all costs of covered services Free choice of provider and services Allowed persons to manage own health care Became costly, no incentives for cost containment These plans were known as the Cadillac plans. Good coverage of medical and prescriptions were next to nothing. Some plans paid everything except for $2.00. No cost containment as the patient had great coverage.
2 things of great concern for healthcare future
increase in obesity and overweight pt opioid
SSA amended in 1965
oCreated Medicare •Federal-administered health plan •Provides care to those over age 65 years o* Created Medicaid •State-administered health plan •Provides source of financing health care for some of the poor and the disabled Medicare for elderly and disabled. Federal government administers Medicaid for indigent. Federal government funds, but state administers States can expand Medicaid under ACA. This way working poor can receive services while working. Not all states did this.
self-insurance
organizations administer their own health care plan and purchase health care services from an est plan
access to health care
think about HBM and barriers to care Inadequate access to health care leads to unnecessary illness. Private insurance coverage or participation in government programs is largely responsible for accessibility. Physical and geographic barriers Rural areas and transportation issues Sociological barriers among the poor and ethnic Americans Language barriers and fear of reprisals for being in country illegally
