CH 3 8th Edition

The Patient Protection and Affordable Care Act (PPACA)New health care federal reform law signed in 2010 requiring the largest change in the financing of the American health care system since the enactment of Medicare and Medicaid Designed to address the issues of affordability, accessibility, and financing of health careFocus efforts on meeting the needs of vulnerable populations US Supreme Court upheld the ACA in June 2012Will be fully enacted by 2018*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


The Health of the NationMeasuring the nations healthHealth, United States reportInforms policymakers of trends in nations healthHealthy People 2020Goal is to increase quality and years of healthy life, and eliminate health disparitiesWorld Health Organization (WHO) statisticsMorbidity dataCompares United States with other countries*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


US Health TrendsSuccesses in infection, other diseasesConcerns: Sedentary lifestyle, obesity, chronic illnessHealth disparities persistentContribute to unfavorable US health indicatorsCompromise progress in world health Vulnerable populations due to age, education, language, locationWork environment changes identified for a safer US health care system*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


A Safer SystemThe health care delivery system in the United States is experiencing changes sparked by health care reform, recommendations from large organizations involved in forming health policy.The Institute of Medicine (IOM) conducts research from a systems approach to advise the nation in improving health.*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


Global Health

The World Health Organizations (WHO) overriding objective is to influence health opportunities and outcomes for all people so that they can attain the highest possible level of health.



History of Health CareEarly influences (through Middle Ages)Holistic; Illness understood in mystical terms or as part of religious worldviewInfectious disease epidemics (e.g., bubonic plague, smallpox): Health meant the survival/absence of diseaseIndustrial influences (1600s and on)Increased longevity Adequate food supplySanitary engineeringdecreased infectious diseaseSocioeconomic (SES) influences1834 philosophy: Pauperism among the able-bodied indicated a moral failingAttitude towards poor: PunitivePeople held individually responsible for SES standing and health maintenance



History of Health Care (Cont.)Public health influencesEdwin Chadwick (1800-1890), father of British and American public healthEnvironmental sanitationImproved health of masses for economic reasonsLinked health/welfare policiesLemuel ShattuckUS public health Modeled British systemPuritan ethic influence re: Work, attitude toward poorScientific influences1800s: Public health change from sanitation to biological control of communicable diseaseMid-20th century: Antibiotics decreased infectious disease; more chronic disease with agingNow: New emphasis on infectious disease due to antibiotic-resistant organisms; bioterrorism *Copyright 2014 by Mosby, an imprint of Elsevier Inc.


History of Health Care (Cont.)Influences of special populationsVulnerable populations: Greatest riskMinoritieslower quality care (even when insured)Health: Related to SES, education, lifestyle Political/economic influencesPolicy: Determine desired outcomesEconomics: How/to whom resources distributedGovernmental programs: Social Security Act, Medicare, Medicaid*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


Split Between Preventative and Curative MeasuresEarly preventionWithin medical practiceFocus on poorDevelopment of preventative servicesWithin public healthIncorporated clinical medicine (immunizations, screenings)Evolution: Emphasis on societal valuesGovernment involvement in financingHealth care reform efforts to address health care barriers*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


Organization of the Delivery System:Private SectorIndependent practiceFee for service; choice of providerPrimary carecomprehensive, prevention emphasisNursing-managed centers Advanced Practice Nurse as primary care provider (PCP)Multidisciplinary collaborative approachFocus: Vulnerable populations*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


Organization of the Delivery System:Private Sector (Cont.)Managed health care/health maintenance organizations (HMOs)Groups of providers, contract with HMOsComprehensive care for prepaid feeManaged care characteristicsControl costs, regulate health care utilizationPCP gatekeeper to system; coordinate carePayment amount dependent on provider (within/outside of network) *Copyright 2014 by Mosby, an imprint of Elsevier Inc.


Organization of the Delivery System:Private Sector (Cont.)Independent practice associations (IPAs)Physician organizationsCare for HMO members in private officeSeveral models availableConcierge medical practicesMembership fee for enhanced health careFewer patients; more time/patientFocus: Personalized care for upper SES*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


Organization of the Delivery System:Private Sector (Cont.)Hospitalist movementPhysicians: Care for hospitalized patientPoint-of-service plans (POS)Additional fee for providers outside of networkIncreases consumer choice*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


Organization of the Delivery System:Private Sector (Cont.)High-Deductible health insurance plans Feature a very high annual out-of-pocket deductible of $1000 to $2000 for individual coverage with a low monthly premiumStructured similar to traditional managed care plans and fee-for-service plans Preferred provider organizations (PPOs)Contracted providers provide services for discounted priceAdditional consumer cost if non-PPO provider*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


Organization of the Delivery System:Public Sector Source of powershared federal/stateFederal: Tax/spend general welfareState: Health authority based on 10th AmendmentInfluence of political philosophyPower shifts between federal and state/local government with changes in federal administrationNational health care debateFuture health policyLack of political consensus Major factors: Cost, access, quality Selected initiatives: Health savings accounts (HSA) and electronic recordsNurses role in health care reformANA: Advocate for single-payer systemFocus on primary care, prevention*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


Official Health Care Agencies*Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Type of AgencyKey CharacteristicsLocalLocal health departmentDirect services to publicStateState health departmentPolicy, planning, program coordinationFederalRun by executive and legislative branchesdetermine health policyUSHHSadministers policy


Official Health Care Agencies (Cont.)*Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Type of Agency/ PersonnelKey CharacteristicsChief Nursing OfficerServes in US Public Health ServiceWorks with US Surgeon General on nursing and public health policyMilitary Health SystemsDepartment of Defense health systemActive duty personnel, dependents, retireesWounded Warrior CareExtensive rehabilitation to return soldiers to active duty or transition to VA health system


Health Care Legislation and Agencies


Legislation/ AgenciesKey InformationAmericans with DisabilitiesProhibit job discrimination and require services to people with disabilitiesPatient Self-Determination ActAdvanced directives for health careFederal Health Information PrivacySafeguards security/confidentiality of health information International-WHOWorldwide guidance in promoting world health through standards, programming, and collaborationVoluntary (not-for-profit) Influence policy/legislationPhilanthropic (nongovernmental)


Financing Health CareCostsIncreasing due to multiple factorsLess time in system for health promotionSourcesGovernment (Medicare, Medicaid)Third-party payment (insurance)Independent sourcesOut-of-pocket: deductibles, co-pays, health savings accountsMechanismsIndependent nursing practice (APNs)PaymentSalaryset amount for services in time frameCapitationflat fee regardless of services used*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


Financing Health Care (Cont.)

Cost-containment initiatives Prospective payment system, limits on provider payments, Medicare Advantage (MA) plansCare managementDetermines and coordinates careAcross continuum of health care servicesReduce waste, improve quality, control costsManaged care issuesQuality of care vs. cost controlPCP as gatekeeper*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


Financing Health Care (Cont.)Health insurancePrivate insuranceTraditional insurance companies (BC/BS)PPOsbrokers between insurers/providersHMOsprepayment plansPOScombination of HMOs and PPOsSelf-insurance/self-fundedPublic insurance/assistanceMedicareMedicaid*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


MedicareTitle XVIII, Social Security ActFederal programPaid through taxesFinances medical care for:People over 65 DisabledPeople with end-stage renal diseaseHospice*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


MedicareTitle XVIII, Social Security Act (Cont.)Part AInpatient care in hospitals, skilled nursing facilities, home health care, hospicePart BSupplementary voluntary coveragePays doctors visitsPart DPharmaceutical costsmultiple plans availableChallengesGrowth in elderly populationDepletion of Medicare resources (trust fund)Uncovered services (glasses, hearing aids)*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


MedicaidTitle XIX, Social Security ActAssistance program managed jointly by federal and state fundsState-determined eligibilityCosts up to 50% of state budgetsopen-ended programBenefits vary by stateAvailable to:Certain low-income individualsNo age requirementsFamilies with children: 5-year lifetime limit*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


The UninsuredOf all developed countries, the United States has the highest proportion of population with no health insurance2008: 46 million uninsured younger than age 65Most uninsured individuals live in families in which there is at least one full-time worker Groups at most riskPersons of Mexican originYoung adultsWorking uninsuredIllegal aliens*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


The Uninsured (Cont.)The Affordable Care Act is expected to reduce the number of uninsured people by 60% through the use of the following measuresExpansion of Medicaid Subsidies to pay premiums in health insurance exchanges A federal mandate requiring most legal citizens to enroll in an insurance plan or face tax penalties for noncompliance A provision allowing children to remain on employer family insurance until the age of 26Health Insurance Portability and Accountability Act (HIPAA)Provisions for maintaining coverage if lose/leave job*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


Health Care Systems in Other CountriesCanadian health care systemUniversal coverage; social insurance planPrivate plans available for unpaid servicesIssues: 2-tiered system, shortage of providers, delays in serviceGerman health care systemNearly universal access (87%), but private insurance (10%) pays providers betterIssues: 2-tiered system, weakening public system, increased costUnited Kingdom health care systemNational health insurancespends least on health care per capita*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


Influencing Health PolicyNurses roleAdvocateIndividualJustice in health care systemParticipating in policy decision makingVoting Communicating with legislatorsRunning for political officeLobbying though professional organizations*Copyright 2014 by Mosby, an imprint of Elsevier Inc.


Documents

CH 3 8th Edition