CHAPTER 1 TEXTBOOK SUMMARY
CHAPTER 1 TEXTBOOK SUMMARY HSA 3111
Popular in Statistics for Biology Majors
Popular in Statistics
This 7 page Class Notes was uploaded by Sharon Stambouli on Wednesday September 7, 2016. The Class Notes belongs to HSA 3111 at Florida International University taught by Dr. Chanadra Whiting in Fall 2016. Since its upload, it has received 39 views. For similar materials see Statistics for Biology Majors in Statistics at Florida International University.
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Date Created: 09/07/16
HSA 3111 CHAPTER 1 STUDY GUIDE An Overview of US Health Care Delivery The US HealthCare delivery system: Broadly Defined: Major components of the system and processes that enable people to receive health care. Restricted definition: the act of providing health care to patients (i.e. in a hospital or a physician’s clinic) Primary objectives of the healthcare system: 1. To enable all citizens to receive health care services 2. To deliver services that are cost-effective and meet established standards of quality. The US Healthcare system: § It’s Unique § It’s not a system § No universal health care financed by taxes § No entitlement § No other country operates like the U.S. § Critical issues related to cost, access and quality § There’s little or no: o Networking o Interrelated components o Standardization o Coordination o Cost containment as a whole o Planning, direction It has duplication, overlap, inadequacy, inconsistency, waste, complexity, inefficiency, financial manipulation, and fragmentation. Leads the world in: § Medical technology § Medical training § Research § Sophisticated institutions, products and processes. Characteristics of the US Healthcare system: • Political climate • Economic development • Technological progress • Social and cultural values • Physical environment • Population characteristics (demographics, health trends) • Global influences Characteristics that differentiate the US Healthcare system: § No central agency governs a system o Most developed nations have a national health care program where every citizen is entitled to receive a set of service o To control costs, use global budget to determine total health care expenses o Government usually controls frequency of health care services, especially expensive medical technology use o The U.S. has mostly private financing and delivery o Private financing through employers at 55% and government at 45% o Private health care, hospitals, physicians are independent of government o No one monitors total expenses through global budgets and utilization o U.S. does determine public-sector expenses and reimbursement rates for Medicare and Medicaid o Government sets standards of participation through policy and regulations o Providers must comply with standards to be certified to provide Medicaid & Medicare patients o Regarded as minimum standards of quality § Access is selective based on insurance o Universal access: Health care is available to all citizens o Access: the ability to obtain health care when needed o In U.S., access restricted to those who: § Have health insurance through an employer § Are covered under a government health care plan § Can afford to buy insurance out of pocket § Can pay at time of service privately o Health insurance helps ensure access o Those unable to pay wait until a health problem arises then receive health care at the emergency room o Hospital does not receive payment o A form of catastrophic health care insurance? o Primary Care: basic and routine care o Lack of access to prim care a big reason for U.S.’ lag in population health (i.e. infant mortality, life expectancy) § Health care offered under imperfect market activity o In national health care, economic markets do not exist o Private health care consolidating, forming alliances and integrating delivery system o Networks of health care organizations o U.S. has a quasi-market where health care is partially managed by free markets § Patients (buyers) and providers (sellers) act independently § Prices set by interaction of supply and demand § Unrestrained competition on basis of price and quality § Patients must have info of availability of different services (technology too complicated, skills too advanced) § Patients have info on price and quality on each provider § Patients must bear cost of services received § Patients make decisions about the purchase of health care services o U.S. has a quasi-market where health care is partially managed by free markets § Patients have info on price and quality on each provider § Patients must bear cost of services received § Patients make decisions about the purchase of health care services o Item pricing § Obtain fees charged for service (surgeon’s price) § Services can’t be determined prior to procedure o Package pricing § Bundled fee for a group of related services o Capitation § All health care services include one set fee per person, more all-encompassing o Phantom providers § Bill for services separately § Anesthesiology, pathologist, supplies, hospital facility use o Supplier/provider-induced demand § Physicians have influence on creating demand for their financial benefit § Physicians receive care beyond what is necessary (i.e. follow-up visits, tests, unnecessary surgery) § Third party insurers are intermediaries between finance and delivery o Patient is first party o Provider is second party o Intermediary is third party § A wall of separation between financing and delivery § Quality of care is a secondary concern § Multiple payers are cumbersome o The U.S. has many payers, company can choose different plans § A billing and collection nightmare § System becomes more cumbersome o Single-payer system § A national health care system that is usually the primary payer-government § Balance of power, no domination o Multiple Players § Physicians, administration, insurance, government, employers o Fragmented self-interests § Prevents an entity from dominating § Legal risk affects practice behavior o The U.S. is a litigious society o Practioners engage in defensive medicine § Prescribe diagnostic tests, return checkups, documentation § New technology creates demand for its use o The U.S., a hotbed of research and innovations § Creates demand for new services despite high costs § With capital investments, must have utilization § Legal risks for providers denying new technology § New service settings along a continuum o Medical services has three broad categories: § Curative § Restorative § Preventative o Health care is not confined to the hospital § Quality is achievable o Continuous Quality Improvement o Higher expectations o Quality standards with compliance Government Roles in the US Healthcare system: • Major financier of health care delivery • Determine reimbursement rates to providers who render Medicare / Medicaid services • Regulates through licensing personnel and health care establishments • Health policy Blended and Private US Healthcare system: • The results: o Multi financial arrangements o Many insurance company with different risk mechanisms o Many payers with different determinates o Many consulting firms offering: • Planning, • Cost containment, • Quality, • Minimizing resources The Quad-Function Model Functional components of health care delivery: 1. Financing: To buy insurance or to pay for health care services consumed usually employer-based 2. Insurance: to protect against catastrophic risk and determine the package the individual is eligible to receive 3. Delivery: Provider: any entity that delivers health care services and receives insurance payment directly for those services 4. Payment There’s some overlap dependent on private, government-run, insurance or managed care a. Reimbursement: the determination of how much to pay for a service b. Funds come from premiums paid to insurance company c. Patient usually pays co-pay, and the insurance company pays remainder Major players in the US Healthcare system § Physicians § Administrators § Insurance executives § Large employers § Government The health care workforce employs over 16.4 million people • 838,000 active MDs • 70,480 DO’s • 2.6 million nurses • 5,795 hospitals • 15,700 nursing homes • 1,128 health centers • 300+ medical, dental and pharmacy schools • 1,500+ nursing programs Financing and ensurance mechanism: § Employer-based health insurance (private) • Privately-purchased health insurance (private) • Government programs (public) o State Employees Group … Employees o Medicare … Elderly and certain disabled people o Medicaid and CHIP … Indigent, poor (if they meet the eligibility criteria), children A disfranchised Segment • In the U.S., insurance is employer-based o The unemployed usually have no insurance • Even if employed, employees do not have insurance because: 1. Employers not mandated to offer insurance a. Premium Cost Sharing i. Rarely paid at 100% if at all ii. Benefit: group rate or availability of insurance 2. Participation in health insurance is voluntary National and Social Insurance and Systems • National Health Insurance (NHI) o Government finances health care through taxes o Care provided by private providers • National Health System o Financing a tax supported NHI o Government manages the infrastructure for delivery o Government operates medical institutions … Providers are government employees or organized § Socialized Health Insurance o Financed through government-mandated contributions by employers and employees o Health delivered by private providers o Insurance and payment closely integrated o Government exercises overall control Cost control in National Healthcare programs • Global budgets o Determine the national health care expenditures • Health care resources are allocated in the budgetary: o Availability and dissemination of service and technology o Reimbursement levels National Healthcare programs • Theoretically, no one is uninsured • Universal access: o Is managed by the government o Provides a defined set of health care services to all citizens National Health Insurance (NHI) • Government finances health care through taxes, but rendered by private providers • National health care program (i.e., Canada) Requires government consolidation of financial, insurance and payment • Government manages the infrastructure o Medical institutions are operated by government o Workers are government workers or organized (i.e. physicians, nurses…) • Tax-supported • Great Britain Socialized Health Insurance • Germany, Israel, and Japan: • Financed through government-mandated contributions by employers and employees • Health care delivered by private providers • Financed through government-mandated contributions by employers and employees • Health care delivered by private providers • Private, not-for-profit insurance companies • Called sickness funds • Collect and pay physicians and hospitals • Insurance and payment are closely integrated • Financing integrated with insurance and payment • Government has overall control Implications for Health Services Managers: They must understand changes/shifts in the system, take advantage of new marketopportunities and minimize threats. Also, evaluate the need for training and understand the impact of new regulations. In addition to this, they must: • Position the organization (know where they fit in the macro environment) • Handle Threats & Opportunities (be proactive with changes in reimbursement, insurance, delivery) • Evaluate Implications (Look at policy changes) • Plan (strategic thinking: services to be added or discontinued) • Capture New Markets (now emerging trends before market is overcrowded) • Comply with Regulations and follow your mission ACA Their goal is to increase access to health care and make it more affordable • All US citizens and legal residents are required to have health insurance or pay a fine. • Avenues for covering the uninsured: Medicaid expansion and government-run exchanges. • Insurance companies are required to include coverage for a variety of health care Services.
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