Discussion Health Promotion: Prevention Of Disease W2

Discussion:

Using the information provided in class and resources, select one from the below topics and briefly make your discussion:

1. Differentiate between private and public sector functions and responsibilities in the delivery of health care.

2. Describe the mechanisms by which health care in the United States is financed in both the private sector and the public sectors.

3. Analyze the influence of health legislation on the health care delivery system.

Instructions:

Post your discussion to the Moodle Discussion Forum. Word limit 500 words. Reply to at least two other student posts with a reflection of their response.

Please make sure to provide citations and references (in APA format) for your work

Health Policy and the Delivery System

The Patient Protection and Affordable Care Act (PPACA)

� New health care federal reform law signed in 2010 � Largest change in the financing of the American health

care system since Medicare and Medicaid (1965) � Focus on vulnerable populations: affordability,

accessibility, and financing of health care � Designed to reduce number of uninsured persons via

expanding Medicaid and establish subsidies � US Supreme Court upheld the ACA in June 2012 � Likely will change secondary to Trump presidency

Key Features of PPACA

� PPACA lacks bipartisan support � Change in political landscape may result in

repeal or significant changes � No exclusion for preexisting conditions � Health insurance is mandated for everyone � Marketplace exchange for insurance plans � All policies must cover essential benefits � Medicaid expanded; subsidies available

Measuring the Nation’s Health

� Health, United States report (annual) Ø Informs policymakers of trends in nation’s health

� Healthy People 2020 Ø 10-year agenda for improving nation’s health Ø Goal is to increase quality and years of healthy life,

and eliminate health disparities � Central Intelligence Agency (CIA) statistics

Ø Morbidity data Ø Compares United States with other countries

US Health Trends

� Successes in infection, other diseases � Concerns: sedentary lifestyle, obesity, chronic

illness � Health disparities persistent

Ø Contribute to unfavorable US health indicators Ø Compromise progress in world health

� Vulnerable populations due to age, education, language, location

� Rise in suicide and drug poisoning deaths esp involving opioid analgesics

Historical Role of Women

� Nurses have long tradition of health promotion � Nursing pioneers

Ø Florence Nightingale (Crimean War 1884)—crusaded for nutritious food, cleanliness, sanitation

Ø Lillian Wald (Henry St Settlement—NYC 1883) founded NYC visiting nurses association to provide health services for indigents in tenements

� Through the ensuing decades nurses developed unique role agents for health promotion

� US Health Care system undergoing changes Ø Sparked by health care reform politics Ø Large organizations involved in forming health policy

� Health and medicine division Ø Previously known as Institute of Medicine (IOM) Ø Research from a systems approach Ø Advisement on safe delivery of health care Ø Health care system (not practitioners) is basic cause

of medical errors

A Safer System

� Overriding objective is for all people (global) to attain highest possible health

� Current agenda—six goals Promoting development Enhancing partnerships Fostering health security Improving performance Strengthening health systems Harnessing research info

� Budget issues limit achievement of goals � Huge health disparities in developing nations

Global Health World Health Organization

� Earliest views were holistic, emerging from integrated worldview

� Hygiene incorporated into most religions � Primitive peoples had mystical view of sickness

and cure—tied to religion � During middle-ages widespread epidemic

diseases leading cause of death ( leprosy, plague, smallpox, TB)

Historical Influences Health Care

� Adequate food supply prolonged life span Ø Transportation enhanced food distribution Ø Technological advances improved food production

� Industrial advances prevented diseases Ø Flush toilet, sewer systems Ø Decrease in typhoid, paratyphoid, gastroenteritis

Historical Industrial Influences

� Elizabethan poor laws (1601) England Ø Relief for infants, sick, elderly, workhouse laborers

� New Law 1834—harsher philosophy Ø Pauperism in able-bodied workers viewed as moral

failing Ø Suspicious and punitive view of indigence

� Protestant work ethic (rewards work efforts) Ø Philosophy brought to United States by Puritans Ø Influences modern health care—fee-for-service

Historical Socioeconomic Influences

� Edwin Chadwick—father of public health � Disease viewed as impediment to ability to self-

support (Chadwick’s view) � Public health services and welfare combined

creating a more benevolent view of indigence � Puritan ethic in the United States offered a

harsher view toward indigence and health care � Health and welfare departments continue to

have contradictory approach to poor

Public Health Influences

� Prior to 20th century infectious diseases (ID) major cause of death

� Scientific advances → Improved health Ø Louis Pasteur—germ theory Ø Joseph Lister—antisepsis

� Innovations: safeguard water, food, and milk supply; sewage systems; urban housing regs

� Antibiotics (1936-1954) decrease in ID � ID death persists in vulnerable populations

Scientific Influences

Major milestones with effects on health care � New Deal (Great Depression) � Social Security Act 1935

Ø Grants-in-aid for state and local public health Ø Assistance programs: blind, elderly, disabled

� Medicare and Medicaid (1965) � Patient Protection and Affordable Care Act

(2010)

Political and Economic Influences

Preventative vs Curative Medicine

� Early prevention directed toward individuals Ø Originated in medical practice vs public health Ø Focus was on poor—state welfare programs

� Public health services eventually emerged Ø Focus on societal prevention vs individual cure Ø Immunizations, screenings, education Ø Education and career paths for pubic health vs medical

practitioners remained separate � 1960s emphasis shifted from individual to societal public

health goals � Evolution toward greater government in health care

Organization of Delivery System

� Huge system: public and private components � Multifaceted and complex interrelationships

Ø Providers and consumers Ø Varied settings: private and public services

� Public sector: nonprofit agencies, government agencies, organized at local, state, and national levels (US Department of Health and Human Services)

� Private sector: for profit services

Private Sector Independent Practice

� Independent practice—free-market system Ø Fee-for-service; hallmark is choice of provider Ø Managed care health organizations evolved Ø Prevention has gained importance

� Nurse-managed centers Ø Advanced Practice Nurse serve as primary care

providers Ø Multidisciplinary collaborative approach Ø Focus: vulnerable populations

Private Sector Managed Care

� Managed health care/health maintenance organizations (HMOs)—emerged 1990s Ø Groups of providers, contract with HMOs Ø Comprehensive care for prepaid fee Ø Motivation and goal is to control costs

� Managed care: key elements Ø Control costs, regulate health care utilization Ø PCP gatekeeper to system; coordinate care Ø Payment based on network status: in-network vs out

Private Sector Health Maintenance Organizations

� Capitation method of payment Ø Provider receives fixed payment per enrollee.

Provider provides all necessary care to enrollee � PCP is gatekeeper

Ø Specialist require referral Ø Members (patients) may have copays Ø Must use network providers

� Medicare Advantage plans are HMO alterative to traditional Medicare

Private Sector IPAs and ACOs

� Independent practice associations (IPAs) Ø Physician organizations Ø Care for HMO members in private office Ø Several models available

� Accountable Care Organization (ACOs) Ø Key component in Affordable Care Act Ø Not yet in place—Medicare reform Ø Structure will be similar to HMOs Ø Focus is cost-containment

Private Sector Concierge and Hospitalists

� Concierge medical practices Ø Membership fee for enhanced health care Ø Fewer patients—more time per patient Ø Focus: personalized, holistic care for higher income

individuals • Typical household income—$125,000-$250,000 • Typical patient—age 50 and older

� Hospitalist movement Ø Physicians or APNs who provide comprehensive

hospital care—improved quality and safety of care

Private Sector POS and HDHPs

� Point-of-service plans (POS) Ø Additional fee for providers outside of network Ø Increases consumer choice

� High Deductible Health Insurance Plans Ø High annual out-of-pocket deduction Ø Suitable for healthy persons—low monthly premium Ø Health Savings Account (HSAs)

• Employer contributions plus pretax deposits allowed • Withdrawals for health-related expenses • In-network providers offer enhanced savings

Private Sector PPOs

� Preferred Provider Organization—PPO � Key elements

Ø Contracted providers who will deliver member services at prenegotiated rate (discounted)

Ø Extra cost if non-PPO providers used Ø Copays by members required at time of visit Ø Preauthorization required for hospitalization or costly

tests and procedures Ø 52% of employer-sponsored plans are PPOs

Public Sector Power and Influence

� Source of power—shared federal/state Ø Federal: tax/spend general welfare Ø State: health authority based on 10th Amendment

� Influence of political philosophy Ø Each new administration since 1980s has introduced

new philosophy, bills, or components of health care Ø Most recent legislation: HIPAA (1996) Medicare

Prescription Drug Act (2003) Affordable Care Act (2010), Children’s Health Insurance Program (2015)

� National health care debate

Public Sector Current/Future Policy

� Current political issues re health care Ø Lack of political consensus—partisan discord Ø Major factors: cost, access, quality Ø Discordant partisan views concerning ACA

� Nurse’s role in health care reform Ø ANA: advocate for single-payer system Ø Focus on primary care, prevention Ø Push for nurses to function to full extent of education and

training—remove barriers Ø Nurses comprise largest segment of health care

workforce—3 million members

Official Health Care Agencies

Type of Agency

Key Characteristics

Local � Local health department � Direct services to public

State � State health department � Policy, planning, program coordination

Federal � Run by executive and legislative branches— determine health policy

� USHHS—administers policy

Official Health Care Agencies (Cont.)

Type of Agency/ Personnel

Key Characteristics

Chief Nursing Officer

� Serves in US Public Health Service � Works with US Surgeon General on nursing and public health policy

Federal Emergency Management Agency (FEMA)

� Part of Department of Homeland Security � Disaster-related services � Assists individuals, communities, states

Official Health Care Agencies (Cont.)

Type of Agency/ Personnel

Key Characteristics

Military Health System

� Comprehensive medical care for active duty personnel, dependents, retirees � Responds to natural disasters and humanitarian crisis throughout the world � Veteran’s Administration: independent agency under President to provide for veteran care

Wounded warrior care

� Extensive care and rehabilitation to return severely injured soldiers to active duty or transition to VA health system

Health Care Legislation and Agencies

Legislation/ Agencies

Key Information

Americans with Disabilities

� Prohibit job discrimination and require services to people with disabilities

Patient Self- Determination Act

� Advanced directives for health care

Federal Health Information Privacy

� Safeguards security/confidentiality of health information

International- WHO

� Worldwide guidance in promoting world health through standards, programming, and collaboration

Voluntary (not-for- profit) Agencies

� Influence policy/legislation � Philanthropic (nongovernmental)

American Red Cross

� Volunteer-led humanitarian organization � Congressional charter—officially sanctioned but

no direct government supervision � 700 local chapters, 500,000 volunteers, 35,000

employees � Responds to both small local disasters (house

fire) and large natural disasters � Blood products, health education,

communication for servicemen/families

Financing Health Care

� Costs Ø Increasing due to multiple factors Ø Less time in system for health promotion

� Sources Ø Federal government (Medicare, Medicaid) Ø State funded programs—Medicaid, CHIP Ø Third-party payment (insurance) Ø Employer provided health plan benefits Ø Independent sources Ø Out-of-pocket: deductibles, copays, health savings accounts Ø Affordable care act subsidies

Mechanism for Financing

� Independent practice with fee-for-service—physicians, APNs, health care professionals

� Salaried providers—nurses, APNs, physicians Ø Overtime is uncompensated Ø Often leads to burnout from overwork

� Hourly compensation Ø Most hospital and outpatient staff Ø Workers eligible for overtime

� Capitation—flat fee regardless of services used Ø Encourages preventive care to keep people healthy Ø Some individuals make unnecessary visits Ø HMO sponsors and bears risk of illness

Cost Containment � Cost-containment initiatives

Ø Prospective payment system, limits on provider payments, Medicare Advantage (MA) plans

� Care management Ø Determines and coordinates care Ø Across continuum of health care services Ø Reduce waste, improve quality, control costs

� Managed care issues Ø Quality of care vs cost control Ø PCP as gatekeeper

Managed Care

� Care management: professional oversees care Ø Coordination of care Ø Insuring quality care Ø Cost containment

� Managed care issues Ø Renewed importance with Affordable Care Act Ø Cost containment Ø Provide high-quality optimum care

Health Insurance

� Private insurance Ø Traditional insurance companies (BC/BS) Ø PPOs—“brokers” between insurers/providers Ø HMOs—prepayment plans Ø POS—combination of HMOs and PPOs Ø Self-insurance/self-funded

� Public insurance/assistance Ø Medicare Ø Medicaid

Medicare

� Federal program � Paid through taxes � Finances medical care for:

Ø People over 65 Ø Disabled Ø People with end-stage renal disease Ø Hospice

Medicare (Cont.)

� Part A Ø Inpatient care in hospitals, skilled nursing facilities, home health

care, hospice � Part B

Ø Supplementary voluntary coverage Ø Pays doctor’s visits

� Part D Ø Pharmaceutical costs—multiple plans available

� Challenges Ø Growth in elderly population Ø Depletion of Medicare resources (trust fund) Ø Uncovered services (glasses, dental, hearing aids)

Medicaid

� Assistance program managed jointly by federal and state funds

� State-determined eligibility � Costs up to 50% of state budgets—open-ended

program � Benefits vary by state � Available to:

Ø Certain low-income individuals Ø No age requirements Ø Families with children: 5-year lifetime limit

The Uninsured

� Of all developed countries, the United States has the highest proportion of population with no health insurance

� 2008: 46 million uninsured younger than age 65 � Most uninsured individuals live in families in which there is at least

one full-time worker � Groups at most risk

Ø Persons of Mexican origin Ø Young adults Ø Working uninsured Ø Illegal aliens

� ACA expected to reduce uninsured numbers

Affordable Care Act and HIPPA

� The Affordable Care Act is expected to reduce the number of uninsured people by 60% Ø Expansion of Medicaid Ø Subsidies to pay health insurance premiums Ø Federal mandate requiring citizens to enroll in an

insurance plan—penalties for noncompliance Ø Provision allowing children to remain on employer family

insurance to age of 26 � Health Insurance Portability and Accountability Act

(HIPAA) Ø Provisions for maintaining coverage if lose/leave job

Unauthorized Immigrants

� 11.3 million illegal aliens in United States (2014) Ø 50% from Mexico Ø Some illegal entry; others overstayed visa Ø Federal law mandates anyone entering ER must be

treated regardless of ability to pay � Illegal aliens are vulnerable population

Ø Indigent but not eligible for Medicare or Medicaid Ø Many do not seek care for fear of deportation

� Immigration reform highly contentious issue

Health Care in Other Countries

� Canadian health care system Ø Universal coverage; social insurance plan Ø Private plans available for unpaid services Ø Issues: two-tiered system, shortage of providers, delays in service

� German health care system Ø Nearly universal access (87%), but private insurance (10%) pays

providers better Ø Issues: two-tiered system, weakening public system, increased cost

� UK health care system Ø National health insurance—spends least on health care per capita

Nurse’s Role in Health Policy

� Advocate Ø Individual Ø Justice in health care system

� Participating in policy decision-making Ø Voting Ø Communicating with legislators Ø Running for political office Ø Lobbying though professional organizations

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