COMMUNITY NURSING WK 3
Week 3 lecture and discussion questions
Politics and The Law
The Health Care System
Economics of Health Care
Review the attached PowerPoint presentations. Once done answer the following questions.
Discuss the power of nursing to influence and change health policy.
Mention and discuss current health policy issues.
Describe and discuss the organization of the public health care system at the federal, state, and local levels.
Analyze the influence of socio-cultural, political, economic, ethical, and religious factors that influence the health and culturally diverse individuals, groups, and communities.
As stated in the syllabus present your assignment in an APA format word document, APA required font attached to the forum in the discussion tab of the blackboard titled “Week 3 discussion questions” and the SafeAssign exercise in the assignment tab of the blackboard which is a mandatory requirement.
A minimum of 2 evidence-based references (besides the class textbook) no older than 5 years must be used.
A minimum of 800 words is required and not exceeding 1,000 words (excluding the first and reference page). Please make sure to follow the instructions as given and use either spell-check or Grammarly before you post your assignment.
Economics of Health Care
Chapter 12
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
Factors Influencing Health Care Costs
Historical payment systems
Unnecessary use of services
Lack of preventive care
Lifestyle/health behaviors
Societal belief that disease would be eradicated
Technological advances
Aging of society
Utilization of drugs
Shift from nonprofit to for-profit health care
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Public Financing of Health Care: Medicare
Entitlement program to provide health care to the growing population of those 65 years of age or older
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
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Public Financing of Health Care: Medicare (Cont.)
Entitlement program to provide health care to the growing population of those 65 years of age or older
Part B
Purchased by monthly fee
Not compulsory
Helps pay for out-of-pocket costs for physician services, hospital outpatient care, durable medical equipment, and other services, including some home health care
Enrollees must pay deductibles and coinsurance
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Public Financing of Health Care: Medicare (Cont.)
Entitlement program to provide health care to the growing population of those 65 years of age or older
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
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Public Financing of Health Care: Medicare (Cont.)
Entitlement program to provide health care to the growing population of those 65 years of age or older
Part D
Initiated in 2006 to help defray costs of
prescription drugs
Optional; must enroll in an approved prescription drug plan
Monthly premium, deductibles, and co-payments
Must pay 100% of costs when costs reach “coverage gap” or “donut hole”
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Public Financing of Health Care: Medicaid
Title XIX of the Social Security Act—a public welfare assistance program
Provides universal health care coverage for the indigent and children
A joint state and federal venture
Eligibility for this program depends on the size and income of the family; federal government sets baseline eligibility requirements, but states can lower eligibility
Priority participation is given to children, pregnant women, and the disabled
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Public Financing of Health Care: Medicaid (Cont.)
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, lab and x-ray services, and EPSDT
Care by pediatric and family nurse practitioners is covered
Children under 18 also eligible for Children’s Health Insurance Program (CHIP)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Public Financing of Health Care: Governmental Grants
Directed toward funding large populations and different aggregates
Historically for health promotion and disease prevention measures
Administered by DHHS
“Block grants” provided to states to impact the health of the public as a whole
Health care providers and programs compete for funds through grant proposals and applications
Closely related to Healthy People 2020 objectives
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Philanthropic Financing of Health Care
Often research or disease oriented
Eligibility for services limited to the specific disease or population of interest
May include services rendered plus ancillary needs like transportation, parental housing, or wigs
Informational and research activities constitute the majority of services provided by these organizations
Examples include American Heart Association and the Shriners
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Health Insurance Plans
First established in 1930s
Types of plans
Indemnity, HMO, PPO, POS
Private insurance, cooperatives, cafeteria plans
Reimbursement mechanisms
Retrospective and prospective plans
Scope of services covered
Routine care, catastrophic, ambulatory
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Cost Containment
Capitated reimbursement
Prospective reimbursement for services
Access limitation
Primary care provider as gatekeeper
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
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Trends in Health Financing
New and innovative health care approaches
Cost sharing
Health alliances
Self-insurance
Flexible spending accounts
Health promotion and disease prevention
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Health Care Financing Reform
Lack of insurance is the major factor associated with lack of access to medical care.
The current dilemma is how to provide health care to all Americans that is acceptable and affordable.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Caring for the Uninsured
Should health care be one of those necessities available to all without cost?
Should health care be a right for all rather than a commodity to be available only to those who can afford it?
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Access to Health Care—Barriers
Insufficient financial support
Physical barriers
Structural inaccessibility, lack of appropriate equipment, or inability to communicate
Inequality in the distribution of services, transportation difficulty, conflict with work hours, and failure to provide services
Sociological barriers
Language difficulties and fear of reprisals
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Health Care Reform 2010
Individual mandate
Employer requirements
Expansion of Medicaid
Expansion of CHIP
Premium and cost-sharing subsidies to individuals
Changes to private insurance
Cost-containment provisions
Prevention and wellness
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Nurse’s Role in Economics
Researcher
Investigate efficient, cost-effective care, culturally sensitive treatment modalities, health education, disease prevention, and factors to change behaviors
Investigate, develop, and evaluate the effectiveness of health promotion and disease prevention
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Nurse’s Role in Economics (Cont.)
Educator
Health education is the foundation of community health nursing practice
Understand that knowledge empowers clients to actively participate in their health care
Demonstrate the effectiveness and value of education
Outcome measures for health education need to be established
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Nurse’s Role in Economics (Cont.)
Provider of care
Care must be appropriate, necessary, and cost effective.
Judicious application of the nursing process is imperative.
Serve as program service provider, health education provider, and heath program participant
Participate in grant proposal process, program design, and evaluation of these programs
Participate in statistical information–gathering process as basis for determining needs
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Nurse’s Role in Economics (Cont.)
Advocate
Become more involved in the economics of health care
Increase knowledge of health care funding and policy making
Use political power to influence health care funding
Advocate for increase in health promotion/disease prevention funding
Plan programs, seek funding, and evaluate program effectiveness through outcome measures
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Chapter 11
The Health Care System
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
U.S. Health Care System
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Figure 11-1
U.S. Health Care System (Cont.)
Private health care subsystem
Focus on the individual
Nonprofit and for-profit agencies
Models of services
Solo practice
Single specialty group practice
Multispecialty group practice
Integrated health maintenance model
Community health center
Voluntary or nonofficial agencies
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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U.S. Health Care System (Cont.)
Public health care system
Mandated by the U.S. Constitution
Focus on the population
“promote the general welfare of its citizens.”
Federal policies and practices influence local and state governments
Coordination of services under Department of Health and Human Services
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Public Health
Public health refers to the efforts organized by society to protect, promote, and restore the people’s health.
Concerned with a healthy population
Concerned with a healthy environment
Scope is broad
Encompasses activities that promote good health
Organized into multiple levels (federal, state, local)
Provides services for those unable to obtain health care without assistance
Establishes laws, rules, and regulations to protect the public
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Public Health System
Federal level subsystem
U.S. Department of Health and Human Services
Surgeon General and numerous other agencies
Targets general population, special populations, and international health
IOM Report, HHS in the 21st Century: Charting a New Course for a Healthier America (2008), recommended transformation of system
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Current HHS Strategic Plan
Transform health care
Advance scientific knowledge and innovation
Advance health, safety, and well-being of the American people
Increase efficiency, transparency, and accountability of HHS
Strengthen the nation’s health and human services infrastructure and workforce
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Public Health System (Cont.)
State level subsystem
State health departments
Responsible for the health of their citizens
Central authorities in the public health care system
Dependent on federal level for guidance and resources
Establish own state laws
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Public Health System (Cont.)
Local health department subsystem
Local health departments (LHD)
Responsible for direct delivery of public health services and protection of the health of citizens
Not all communities have LHDs
Responsible for:
Community health services
Environmental health services
Personal health services
Mental health services
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Health Care Providers
Provider organizations
Any organization that provides health care to the community
Health care professionals
The interprofessional health care team
Professionals and nonprofessionals
Nontraditional health care providers
Complementary and alternative therapies
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Quality Care
To Err Is Human: Building a Safer Health System (IOM, 1999) focused on safety within the health care delivery system
Crossing the Quality Chasm (IOM, 2001) focused on developing a new health care system for the twenty-first century, one that improves care
Leadership by Example (IOM, 2003) was a report requested by Congress that examined the federal government’s quality enhancement processes
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Quality Care (Cont.)
Who Will Keep the Public Healthy? (IOM, 2003) brought public health into the forefront by focusing on issues including globalization, rapid travel, scientific and technological advances, and demographic changes
In-depth exploration of educational needs for improved public health
Need for appropriately prepared public health professionals
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Quality Care (Cont.)
Who Will Keep the Public Healthy? (Cont.)
New content areas for public health professionals:
Informatics, genomics, communication, cultural competence, community-based anticipatory research, global health, policy and law, and public health ethics
Old content areas for public health professionals:
Epidemiology, biostatistics, environmental health, health services administration, and social and behavioral science
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Quality Care (Cont.)
Health Professions Education (IOM, 2003), the education of all health professionals is viewed as a bridge to quality care.
Provide patient-centered care
Work in interdisciplinary teams
Employ evidence-based practice
Apply quality improvement
Utilize informatics
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Quality Care (Cont.)
Priority Areas for National Action (IOM, 2003) identified priority areas that should be addressed to improve quality
Patient and family engagement
Population health
Safety
Care coordination
Palliative care
Overuse
Access
Health systems infrastructure capabilities
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Quality Care (Cont.)
Keeping Patients Safe: Transforming the Work Environment (IOM, 2004) addressed critical quality and safety issues with a focus on nursing care and nurses
Focused on nurses in acute care and the work environment for safer patient care
Also looked at nursing shortage, health care errors, patient safety risk factors, nurse’s role in quality improvement, and work environment threats to patient safety
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Quality Care (Cont.)
The Future of Nursing. Leading Change, Advancing Health (IOM, 2011) focuses on the nursing profession and how it might fit into the change process
Nurses should practice to the full extent of their education and training.
Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Quality Care (Cont.)
The Future of Nursing. Leading Change, Advancing Health (Cont.)
Nurses should be full partners with physicians and other health professionals in redesigning health care in the United States.
Effective workforce planning and policy making require better data collection and an improved information infrastructure.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Accreditation
Joint Commission
National Committee for Quality Assurance (NCQA)
Health Plan Effectiveness Data and Information Set (HEDIS)
American Healthcare Commission
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Agency for Healthcare Research and Quality (AHRQ)
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… the ultimate test of the public health subsystem is whether it effectively serves the people by their measurements, not those of the public health profession.
– Koop (1989)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Critical Issues in Health Care Delivery
Managed care
Information technology
Telehealth
Electronic medical records (EMRs)
Social media
Consumer advocacy and client rights
Client/consumer-centered health care
Coordination and access to care
Disparity in health care delivery
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Critical Issues in Health Care Delivery (Cont.)
Globalization and international health
World has no real boundaries
CDC active in responding to preparedness and international travel
WHO fosters collaborative global initiatives
ICN gives nursing perspective
Health care reform
The Clinton Health Reform Initiative
Patient Protection and Affordable Care Act of 2010
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Future of Public Health
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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What services?
Who has access?
Who pays?
How is it delivered?
What is the role of government?
Impact on Community Health Nursing
Principles of change that focus on quality, access, and cost…
The need for patient-centered care
The need for stronger primary care services
The need to deliver more care in the community
The need for seamless, coordinated care
The need for reconceptualized roles for health professionals
The need for interprofessional collaboration
– The Future of Nursing. Leading Change,
Advancing Health (IOM, 2011)
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