Delivering Health Care in America – Flashcards

The primary objectives of any health delivery system are to enable all citizens to receive health careservices whenever needed, and to deliver health services that are cost-effective and meet pre-established standards of quality.

The United States does not have a universal health care system covering all citizens. Health insurance is primarily employer-based.

Managed care is a system of health care delivery that seeks to achieve efficiencies by integrating the basic functions of health care delivery, and employs mechanisms to control utilization of medicalservices and the price at which the services are purchased.

the insurance function introduces a third party into the transaction between the patient and the provider. Health insurance insulates the consumer from the cost of health care. Providers are sometimes restricted from delivering services that are non covered.

The key players in the system are the physicians, administrators of health service institutions, insurance executives, large employers, and the government. One positive effect of these opposing forces is that they prevent any single entity from dominating the system. On the other hand, they also make it difficult to achieve system wide reforms.

The government is a major financier of health care delivery through the Medicare and Medicaid programs. The government determines eligibility criteria as to who can receive services under these programs; it also determines the reimbursement rates that providers will receive for rendering services to Medicaid and Medicare patients. In order to render services to Medicare and Medicaid, these organizations must comply with the standards of participation formulated by the government.

In a socialized health insurance system, health care is financed through government-mandated contributions by employers and employees.

The first goal is to propose a holistic approach to health care delivery that focuses on curative medicine, health promotion, and disease prevention. The second goal is to further explore the issue of equity in the distribution of health services using the contrasting theories of market justice and social justice in U.S. Health Care Delivery.

Illness reflects what a person feels. Disease may or may not be present. On the other hand, disease reflects the physician's diagnosis. It requires therapeutic intervention. A person who is ill seeks health care with the objective of finding relief of symptoms and discomfort. A medical professional attempts to diagnose the illness and prescribes treatment if disease is present.

Acute condition: relatively severe, episodic and often treatable, Sub acute condition, and Chronic condition: less severe

Environment, Behavior and Lifestyle, Heredity, Medical Care

Public health is concerned with ensuring conditions that promote optimum health for society as a whole. Its main objectives are to prevent disease, prolong life, and promote health through organized community effort.

The first goal is to help individual of all ages increase life expectancy and improve their quality of life. The second goal is to eliminate health disparities among different segments of the population.

In the market justice system, health care services are rationed through prices and the ability to pay. The uninsured and those who lack sufficient income to pay privately cannot obtain the quantity and type of health care services when they want them. This is referred to as demand-side rationing, or price-rationing.

Health risk appraisal is the process of evaluating risk factors and their health consequences in individuals. Only when the risk factors and their health consequences are known can avenues be developed for motivating individuals to alter their behaviors to more healthful patterns.

Private, employer-based health insurance, mainly for middle-income Americans, falls under the heading of market justice.

Behavior can be modified through educational programs and incentives directed at specific high risk populations. For example cigarette smoking

During institutionalization, life domains such as comfort, ability to make decisions, respect and dignity, and attention to personal preferences are important indicators of quality of life. Self-perceptions of health, ability to function, and role limitations stemming from physical or emotional problems are important life domains after the patient has returned to the community.

The first objective is to provide an overview of the large array of health professionals employed in the vast assortment of health delivery settings. The second objective is to describe the differences and imbalances between primary and specialty care services characterized in the U.S. health care system.

The first reason is that there is a growth in population that now utilizes a greater amount of health services. This growth is mainly due to immigration. Another reason is the aging of the population. This particularly describes the baby boom generation that starts to hit retirement age in the year 2011 and beyond.

The development of health services professionals in the U.S. is closely related to population trends, advances in research and technology, disease and illness trends, and the changing environment of health care financing and delivery.

Primary care may be distinguished from specialty care by the time, focus, and scope of the services provided to the patients. Primary care is first-contact care or the portal to the health care system, whereas specialty care, if needed, generally follows primary care. Primary care focuses on the person as a whole, whereas specialty care centers on diseases or organ systems. Primary care is comprehensive in scope and includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis, and treatment of acute and chronic illnesses. Specialists are more narrowly focused.

Physicians are more likely to concentrate in metropolitan and suburban areas than in rural and inner-city areas because they're normally offered higher income, professional interaction, access to modern facilities and technology, continuing education and growth, high standards of living, and social amenities. The basic physician labor force problem in the United States is that while the supply of physicians is largely determined by population need, medical services are delivered in a market that links services to ability to pay, whether through insurance or out of pocket.

The principal determinant of need for primary care physicians is the demographics of the general population. The major driving force behind specialists is the development of medical technology. The rapid advance of medical technology expands the demand for specialty services. Specialists not only earn higher incomes, but they also have more predictable work hours and have higher prestige.

To alleviate the shortage of physicians, for example, new medical schools were instituted in the underserved areas (inner city and rural) Nurses in expanded roles (e.g., nurse practitioners) emerged as a viable option to remedy the health labor force problem. A combination of various policy options has also been initiated. These options include the regulation of health care professions, change in reimbursement policies, and targeting programs for underserved areas. Federal programs addressing specialty mal distribution include the National Health Service Corps, the Migrant and Community Health Programs, support of primary care training programs, and support of Area Health Education Centers. To achieve a better balance in the proportion of primary care physicians and specialists, continual efforts are needed to improve the specialty distribution of physician labor forces. Medical schools need to develop students' competencies in skills, values, and attitudes relevant to the practice of primary care. Their curricula can be oriented toward issues of special concern to generalists such as outpatient experience, public health concepts, disease prevention, and cultural, ethnic, and population specific knowledge. Medical programs can provide students with opportunities to work with the poor, minorities, and the uninsured and to practice in rural or underserved areas. The means of financing medical training and physician services can be improved. The system of graduate medical education payments through Medicare contributes to specialty-oriented training and creates disincentives for primary care training. A possible solution is to encourage and provide priority funding for primary care residency slots and primary care-related research. Hospitals whose graduates actually go into primary care in underserved areas should be rewarded. Reimbursement to providers and patients should emphasize preventive, primary care services and should stress the attributes of primary care. Since physicians tend to practice in affluent urban areas, it is necessary to differentially reward providers who practice in "less desirable" areas or care for socially disadvantaged populations. A more rational referral system may be established that achieves a reasonable division of work based on the frequency and severity of health problems in the populations. Disincentives for non-referred specialist care should also be established.

The major roles of physicians are to diagnose diseases and treat patients. Physicians must be licensed and graduated from a credited medical school and complete their residency. Physicians often work in hospitals or have their own private practice but also work in a spectrum of outpatient settings including group practices, surgi centers, diagnostic imaging centers, urgent care centers, and managed care organizations such as health maintenance organizations (HMOs).

Nurses are the major caregivers of sick and injured patients, serving their physical, mental, and emotional needs. All states require nurses to be licensed to practice as RNs. The licensure requirements include graduation from an approved nursing program that awards an associate degree (ADN), diploma, or baccalaureate degree (BSN), and successful completion of a national examination. ADN programs take about two years and are offered by community and junior colleges. Diploma programs take two to three years and are offered by hospitals. BSN programs take four to five years and are offered by colleges and universities. Nurses work in a variety of settings, including hospitals, nursing homes, private practices, surgi centers, community and migrant health centers, emergency medical centers, HMOs, worksites, government and private agencies, clinics, schools, retirement communities, rehabilitation centers, and patients' homes.

*Dentists are the major providers of dental care. The major roles of dentists are to diagnose and treat dental problems related to the teeth, gums, and tissues of the mouth. All dentists must be licensed to practice. The licensure requirements include graduation from an accredited dental school that awards a Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD) degree and successful completion of both written and practical examinations. Most dentists practice in private offices as solo or group practitioners. Some dentists work in dental clinics in private companies, retail stores, franchised dental outlets, or HMOs. The federal government also employs dentists, mainly in the hospitals and clinics of the Department of Veterans Affairs and the U.S. Public Health Service.

*The major roles of pharmacists are to dispense medicines prescribed by physicians, dentists, and podiatrists and to provide consultation on the proper selection and use of medicines. All states require a license to practice pharmacy. The licensure requirements include graduation from an accredited pharmacy program that awards a Bachelor of Pharmacy (BPharm) or Doctor of Pharmacy (PharmD)degree, successful completion of a state board examination, and practical experience or completion of a supervised internship. Most pharmacists hold salaried positions and work in community pharmacies that may be independently owned or are part of a national chain of drugstores, grocery stores, or department stores. Pharmacists also work in hospitals, managed care organizations, home health agencies, clinics, government health services organizations, and pharmaceutical manufacturing companies.

Physician assistants are licensed to perform medical procedures under the supervision of a physician. The supervising physician may be either on-site or offsite. The major services provided by PAs include evaluation, monitoring, diagnostics, therapeutics, counseling, and referral. They practice in offices, hospitals, HMOs, clinics, nursing homes, mental health facilities, rehabilitation centers, community and migrant health centers, and government institutions. As of 1995, there were 68 accredited PA training programs that awarded a certificate, an associate degree, a bachelor's degree, or a master's degree. Although the typical student has already completed a baccalaureate program in another discipline, most of the programs grant a baccalaureate degree upon graduation. PAs are certified by the National Commission on Certification of Physician Assistants. PAs have prescribing authority in most states.

Nurse practitioners are individuals who have completed a program of study leading to competence as registered nurses in an expanded role. The training of NPs may be a certificate program (at least nine months' training) or a master's degree program (two years' fulltime study). States vary with regard to licensure and accreditation requirements. There are more than 150 educational training programs nationwide. In addition, NPs complete clinical training in direct patient care. Certification examinations are offered by the American Nurses Credentialing Center, the American Academy of Nurse Practitioners, and specialty nursing organizations. The primary function of NPs is patient education. NPs spend considerable time with patients to make them understand the need to take personal responsibility. Nurse practitioners emphasize wellness promotion, illness prevention, early intervention, and illness management. NPs have statutory prescribing authority in 47 states, and 49 states allow direct Medicaid reimbursement for NP services.

Certified nurse midwives are registered nurses with additional training in midwifery, such as materna land fetal procedures, nursing, and patient assessment, from a nurse-midwifery program. They manage gynecological and obstetric care and can be used as substitutes for obstetricians/gynecologists. They are certified by the American College of Certified Nurse Midwives to provide care for normal expectant mothers, and they refer abnormal or high-risk patients to obstetricians or manage them jointly. Very few training programs exist for CNMs (9 certificate programs and 20 master's degree programs).

* Non-physician primary care providers include nurse practitioners, physician assistants, and certified nurse midwives. They play a critical role in the provision of health care, particularly primary care to underserved populations. NPs and PAs often give care equivalent to that provided by physicians. Moreover, NPs have been noted to have better communication and interviewing skills than physicians. Clients are more satisfied with NPs than with physicians because NPs generally spend more time with the patients, express greater personal interest in patients, and provide care at less cost. CNMs are considered to be effective in providing access to obstetrical and prenatal services in rural and poor communities. Among the issues that need to be resolved before non-physician primary care providers can be used fully are legal restrictions to practice, reimbursement policies, and relationships with physicians.

* Health services administrators are employed at the top, middle, and entry levels of various types of organizations that deliver health services. Top level administrators provide leadership and strategic direction, work closely with the governing board, and are responsible for an organization's long term success. They are responsible for operational, clinical, and financial outcomes of the entire organization. Middle level administrators may have leadership roles for major service centers such as outpatient, surgical services, nursing services, etc., or they may be departmental managers in-charge of single departments such as diagnostics, dietary, rehabilitation, social services, environmental services, or medical records. Their jobs involve major planning and coordinating functions, organizing human and physical resources, directing and supervising, operational and financial controls, and decision-making. They often have direct responsibility for implementing changes, creating efficiencies, and developing new procedures with respect to changes in the health care delivery system. Entry level administrators may function as assistants to mid-level managers. They may supervise a small number of operatives. Their main function may be to oversee and assist with operations critical to the efficient operation of a departmental unit.

*Allied health professionals can be divided into two broad categories: technicians/assistants and therapists/technologists. Assistants and technicians include physical therapy assistants (PTAs), certified occupational therapy assistants (COTAs), medical laboratory technicians, radiologic technicians, and respiratory therapy technicians. Technologists and therapists include physical therapists (PTs),occupational therapists (OTs) , medical dietetics, speech-language pathologists, and social workers. Allied health professionals constitute approximately 60 percent of the U.S. health care work force. They are an integral part of the health care delivery system and complements the physician and nursing workforce.

As a whole, medical technology has contributed to the increase in health care costs. Technology raises consumer expectations and leads to wasteful care especially because insured individuals do not bear the costs. It leads to overspecialization in medical practice.

A. Clinical information systems support patient care delivery, clinical decision making, and clinical reports. Electronic health records can provide quick and reliable information to guide clinical decision making. Telemedicine, based on integrated applications of telecommunications and information technologies, enables distant delivery of health care. Medical informatics uses IT applications that are designed to improve clinical efficiency, accuracy, and reliability. B Administrative information systems enable the organization to carry out financial and administrative support functions. C Decision support systems provide analytical tools for managerial decision making. D The Internet and e-health enable patients and practitioners to access information, facilitate interaction between consumers or between patients and providers, add certain conveniences for both physicians and patients, and enable the possibility of virtual visits

American beliefs in capitalism and lack of government intervention promote innovation because the developers of new technology reap financial rewards. On the other hand, Americans believe that it is absolutely essential that they get the most advanced tests, drugs, procedures, and equipment. Americans have high expectations of what the medical care system should do for them.

The proliferation of technology once it is developed is called technology diffusion. The FDA ensures the safety and effectiveness of drugs and medical devices. It also controls access by deciding which drugs need prescriptions and which ones can be obtained over the counter.

Class III devices support life or prevent health impairment. They require premarket approval from the FDA regarding their safety and effectiveness.

Ability to do things in spite of disablement, Ability to manage chronic conditions, Relief from pain and suffering, and Fast recovery and return to normal life

Technology has had a positive effect on access in rural and geographically remote areas. Mobile equipment can be transported to these sites. Telemedicine has enabled generalists to consult specialists located at a distance without having to transport the patient to a distant medical center. Technology has also made it possible for many patients to receive in-home care instead of being admitted to a healthcare facility.

Technology assessment is the evaluation of medical technology to determine its safety, effectiveness, and cost benefits. The main practical use of assessment is to determine whether new technology is appropriate for widespread use based on criteria such as safety, efficacy, and cost effectiveness.

Financing is any mechanism that gives people the ability to pay for health care services. Desirable effects: It enables people to obtain health care, and it compensates providers for the services they deliver.

Risk is unpredictable for an individual, Risk can be predicted with reasonable accuracy for a large group, Insurance shifts risk from the individual to the group, and Resources are pooled and losses are shared on some equitable basis by all members of the insured group

Employers and employees generally share in the cost of premiums. In addition, the insured pays out of pocket expenses referred to as deductibles and copayments. A deductible, paid annually, is the amount the insured must first pay before benefits are received. Copayment is the portion of total medical costs that the insured has to pay out of pocket each time health services are received.

Managed care plans are regarded as health insurance because they assume risk in exchange for an insurance premium. Unlike traditional insurance, managed care plans assume the responsibility for providing health care services to their enrollees by contracting with a network of providers.

Part A is the hospital insurance (HI) portion of Medicare. It is financed by a mandatory payroll tax. The employer contributes an equal amount. Part A covers hospital inpatient services, care in a skilled nursing facility (SNF), home health visits, and hospice care. A maximum of 90 days of inpatient hospital care is allowed per benefit period, Up to 100 days of care in a Medicare certified skilled nursing facility (SNF) are allowed, provided the beneficiary has been hospitalized for at least three consecutive days, not including the day of discharge. Admission to the SNF must occur within 30 days of hospital discharge, Home health care is covered when a person is homebound and requires intermittent or part time skilled nursing care or rehabilitation care, and For terminally ill patients, Medicare pays for care provided by a Medicare certified hospice.

Part B is the Supplementary Medical Insurance (SMI) portion of Medicare. It is a voluntary program financed partly by general tax revenues and partly by required premium contributions from the enrollees. The main services covered by SMI are outpatient services such as physician services, hospital outpatient services (outpatient surgery, diagnostic tests, radiology, etc.), emergency department visits, outpatient rehabilitation services, renal dialysis, prostheses and medical equipment, and supplies.

Medicaid finances health care services for the indigent. The program is jointly financed by the federal and state governments. The federal government provides matching funds to the states based on the per capita income in each state. Medicaid is a means tested program in which eligibility is based on the beneficiary's income and assets. Federal law requires that certain low income people be covered.Federal law also mandates that every state provide some specific health services. The main federally mandated services include hospital inpatient and outpatient care, physician services, laboratory and X-ray services, SNF care, home health services for those eligible for SNF services, prenatal care, and family planning services and supplies. In addition, states may elect to cover certain optional services such as prescription drugs, optometrists' services, eyeglasses, and dental care.

Under capitation, an HMO pays a provider a set fee per member per month. The provider is required to deliver whatever services the members need. Capitation shares risk with providers because if the cost of services exceeds the fixed payment, the additional costs have to be absorbed by the provider. Risk sharing makes the providers prudent in the delivery of services. It removes the incentive for provider induced demand.

Retrospective reimbursement is based on actual costs incurred by a provider during the previous year. In prospective reimbursement, certain pre-established criteria, not costs, are used to determine in advance the amount of reimbursement. Whereas the retrospective system encourages providers to increase their costs because the costs would be reimbursed, the prospective system eliminates such perverse incentives by rewarding providers for controlling costs.

The prospective payment system (PPS) under DRGs is used by Medicare to determine reimbursement rates for inpatient hospital care. The amount of payment is set per discharge rather than per diem. Hence, it is a rate established for bundled services. On admission, a patient is assigned a DRG category according to the principal diagnosis. Based on the patient's DRG classification, the hospital receives a set amount.

A network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population serviced.

A system that integrates the functions of financing, insurance, delivery, and payment and uses mechanisms to control costs and utilization of services.

A distributional principle according to which health care is most equitably distributed through the market forces of supply and demand, rather than government interventions. See social justice.

A joint federal state program of health insurance for the poor.

A federal program of health insurance for the elderly, certain disabled individuals, and people with end-stage disease.

A distribution principle, according to which health care is most equitably distributed by a government-run national health care program.

Any large-scale government sponsored expansion of health insurance or intrusion in the private practice of medicine

Provide- low income families with children with health insurance coverage that covers access to health care services

A program that is financed by the military. This insurance plan permits the beneficiaries to receive care for both private and military medical care facilities

Responsible for coordinating the activities of the hospitals, outpatient clinics, nursing homes, and other facilities located within its jurisdiction

Relatively severe, episodic (of short duration), and often treatable. It is subject to recovery and treatment is generally provided in a hospital

Individual lifestyles are also a key determinant of health. For example diet, exercise, a stress-free lifestyle, risky or unhealthy behaviors, and other individual choices have been found to play a major role in the most of significant health problems of today.

Less severe but of long and continuous duration. The patient may not fully recover. The disease may be kept under control through appropriate medical treatment, but if left untreated, the condition may lead to severe and life-threatening health problems. Examples include asthma, diabetes, and hypertension

Prices and ability to pay ration the quantity and type of health care services people consume

The leading determinants of health can be classified into four main categories: environment, behavior, and lifestyle, heredity, and medical care.

All of the activities aimed at promoting, restoring, or maintaining health

A complete state of physical, mental, and social well-being, and not merely the absence of disease or infirmity.

A philosophy of health care that emphasizes the well-being of every aspect of a person including the physical, mental, social, and spiritual aspects of health

Refers to government means to limit the availability of certain health care services by deciding how technology will be dispersed and who will be allowed access to certain types of high-tech services

Reflects an organized effort to deliver public health services within a jurisdiction with the goal of improving health and well-being of the population

A wide variety of activities undertaken by state and local governments to ensure conditions that promote optimum health for society as a whole

Between acute and chronic but has some acute features. Subacute conditions can be post acute requiring further treatment after a brief stay in the hospital. Examples include ventilator and head trauma care.

Presupposes the existence of illness or disease, thereby emphasizing clinical diagnosis and medical intervention in the treatment of disease or its symptoms.

A general name for nurses who have education and clinical experience beyond that required of a RN. APNs include four areas of specialization in nursing: clinical nurse practitioners (NPs) and certified nurse midwives (CNMs)

A broad category that includes services and professionals in many health-related technical areas. Allied health professionals include technicians, assistants, therapists, and technologists.

Views medical treatments as an active intervention to produce a counteracting reaction in an attempt to neutralize the effects of disease.

In the US physicians trained in family medicine/general practice, general internal medicine, and general pediatrics are considered primary care physicians or generalists

An imbalance of the distribution of health professionals such as physicians, needed to maintain the health status of given population at an optimum level. Geographic maldistribution refers to the surplus in some regions but shortage in other regions of needed health professionals. Specialty maldistribution refers to the surplus in some specialties but shortage in others.

Emphasized the musculoskeletal system of the body

A carefully designed research study in which human subjects participate under controlled observations

A step beyond the determination of efficacy. Whereas efficacy is concerned only with the benefit to be derived from the use of technology, cost-effectiveness weighs benefits against cost. Health care is cost-effective when benefits exceed the costs.

Computer based information and analytical tools to support managerial decision making in health care organization

refers to the health benefit to be derived from the use of technology

All forms of electronic health care delivered over the internet, ranging from informational, educational, and commercial products to direct services offered by professionals, non-professionals, businesses, or consumers themselves.

Publicly financed Medicaid and Medicare coverage for certain disadvantaged groups, and the workers' compensation program for those injured at work, fall under the heading of social justice.