Chapter 1- Health
Care Systems
History of Health Care
Pertinent questions

When did most of the most significant
changes in health care occur?
 Why were the greatest advances made in this
time period?
 What are some possibilities for the future of
health care?
Health Care Systems
1.
2.
3.
4.
Many different types deliver
health care
Largest & fastest growing
industry
Employs over 10 million
workers in over 200 careers
$2,000,000,000 per day
industry
Hospitals – vary in size & type of
services
General hospitals – varied services
 Specialty hospitals – certain conditions or
ages (burns, pediatrics, cancer, heart, etc)
 Government hospitals – fed, state, local (VA,
military, state rehab or psychiatric)
 University or college medical centers –
provide services, RESEARCH, education

Classification – based on funding
sources
Private or proprietary – for profit (pt.
fees & organizational support)
 Religious – religious support, pt. fees
 Non-profit or voluntary – pt. fees,
donations
 Government – taxes, pt. fees

Long Term Care Facilities (LTC)

Provide care for elderly, physical or mental
disabilities, chronic or long term illnesses
 Pts are usually called residents
 Nursing homes or geriatric homes – provide
ADLs for those unable to care for themselves,
provide a safe environment, & promote social
interactions
Extended Care or Skilled Care
Facilities





Provide skilled nursing & rehab care
Prepare resident for return to home
environment
Subacute units – rehab for surgery, cancer tx,
dialysis
Independent or assisted living facilities –
individuals receive the help they need (meals,
transportation, housekeeping, etc)
Many are associated with LTC facilities,
enabling the individual to move from facility to
facility as need arises
Medical Offices
Privately owned offices to large
corporations
 Services: diagnosis, treatment,
examinations, basic lab tests, minor
surgery
 Some treat wide variety of illness/ages
& others specialize

Dental Offices
Private offices to dental clinics
 Can be found in major retail stores
 Can provide general or specialized
dental care

Clinics





Can refer to a group of medical/dental
professionals who share a facility & staff
Others specialized – surgery, emergency care
clinics, rehab clinics, diabetes or oncology
clinics
Can be affiliated with a hospital
Health department – pediatrics, sexually
transmitted diseases, immunizations, other
special services
Medical centers at universities – frequently
free or reduced cost care to provide learning
Optical Centers
May be individually owned or part of a
large chain
 Provide vision examinations, prescribe
eyeglasses or contacts, check for eye
diseases

Emergency Care Services
Provide special care for accidents or
sudden illness
 Examples – ambulance, rescue squads,
emergency care clinics, emergency
rooms in hospitals, helicopter or
airplane

Laboratories
Can be part of another facility or
separate health care service
 Medical labs – perform diagnostic tests
 Dental labs – prepare dentures and
other devices

Home Health Care
Provides care in patient’s home
 Examples – nursing, personal cares,
therapy, homemaking
 Offered by health departments,
hospitals, private agencies, government
agencies, nonprofit agencies, volunteer
groups

Hospice
Provides care for terminally ill persons
with a life expectancy of 6 months or
less
 Care provided in home or hospice
facility
 Allows death with dignity & comfort
 Provides psychological, social, spiritual,
& financial counseling for pt. & family

Mental Health Facilities
Deal with mental diseases and
disorders
 Examples – guidance/counseling
centers, psychiatric clinics/hospitals,
chemical abuse treatment centers for
alcohol or drug abuse, physical abuse
treatment centers

Genetic Counseling Centers

Can be independent or affiliated
 Works with couples or individuals who are
pregnant or considering pregnancy
 Performs prenatal screening, check for
genetic abnormalities & birth defects,
explains test results, identify medical options
when defect is present, help individuals cope
with psychological issues caused by genetic
disorder
 Used especially for older women, family
history of genetic disease, specific
race/nationality where genetic disease is
Rehabilitation Facilities
Care directed at helping pt. with mental
or physical disability obtain maximum
function
 Includes hospitals, clinics, private
centers
 Services – physical, occupational,
recreational, speech, & hearing tx

Health Maintenance
Organizations
Provide total health care directed
toward preventive care
 Services: examinations, basic medical
services, health education,
hospitalization, rehabilitation
 Mode of operation – large industry/corp,
private agencies, uses services of other
health care facilities

Industrial Health Care Centers or
Occupational Health Clinics
Located in large industries or
companies
 Provides health care for employees
 Services – basic exams, teach accident
prevention/safety, provide emergency
care

School Health Services
Found in schools & colleges
 Services – emergency care for
accidents & sudden illnesses,
speech/vision/hearing screenings,
promote health education, maintain safe
& sanitary school environment,
counseling

Government Agencies

Offered at international, federal, state, local
levels – most tax supported
 World Health Organization (WHO) –
international agency supported by United
Nations that provides statistics & information
about disease, publishes health information,
& investigates & deals with serious health
problems throughout the world
United States Department of
Health & Human Services
(USDHHS)
National Institute of Health (NIH) –
researching disease
 Centers for Disease Control & Prevention
(CDC) – researches causes, spread, &
control of diseases in populations
 Food & Drug Administration (FDA) –
regulates food & drug products sold to the
public

USDHHS (cont)

Agency for Health Care Policy & Research
(AHCPR) – established in 1990 to research
quality of health care delivery & identify
standards of treatment
 Occupational Safety & Health Administration
(OSHA) – establishes & enforces standards
protecting workers from job-related injuries &
illnesses
State & Local Health
Departments

Provides health services as directed by
USDHHS
 Provides specific needed services –
immunizations, inspections for environmental
health & sanitation, communicable disease
control, collection of statistics & health
records, health education, clinics for health
care & prevention
Volunteer or Nonprofit Agencies

Supported by donations, membership fees,
fundraisers, & grants
 Provides health services at national, state, or
local levels
 Examples – American Cancer Society,
American Heart Association, American
Diabetes Association, American Red Cross,
March of Dimes, etc.
 Many deal with one disease or group of
diseases to study, provide funding for
research, promote education, purchase
medical equipment, provide treatment
centers, & supply information
Health Insurance Plans





Cost of health care a major concern
Cost of health care is >12% of gross national
product
Health care costs are increasing faster than
other costs of living
Most people rely on health insurance plans to
pay for health care costs
Without insurance, cost of illness disastrous
Health Insurance Plans
Different plans offered by thousands of
agencies
 Pay a premium to purchase insurance
 If insured person has expenses covered
by the plan, the insurance company
pays for them
 Amount of payment and services vary
from plan to plan

Insurance terminology
Deductibles – amounts that must be paid by
the insured individual before policy begins to
pay
 Co-insurance – requires specific percentage
of expenses to be shared by individual &
company (80-20 80% paid by company, 20%
paid by individual)
 Co-payment – specific amount of money
patient pays for a particular service (example
- $20 per doctor’s appointment regardless of
total cost)

Insurance Plans
Many people have insurance from place
of employment
 Private policies can be purchased by
individuals

Health Maintenance
Organizations

Special type of insurance plan
 Monthly fee is paid for membership & price
remains same, regardless of number of visits
 Premium paid either by employer or individual
 Most pay for total health care – routine visits
& exams & preventive health care (not usually
covered by private insurance)
Health Maintenance
Organizations
Advantages – provides ready access to
health care, early detection & treatment
of disease, individual usually maintains
better health
 Disadvantages – individual can only use
HMO affiliated providers for health care.
If choose a provider outside of HMO,
individual pays for all costs

Preferred Provider Organizations
(PPO)
Usually provided by large company
 Company contracts with health care
agency
 Employee must use specific health care
agency
 Industry/company can provide health
care at lower rates

Medicare

Federal government health care plan
 Provides health care to those over 65 years
of age or persons with a disability who have
had social security benefits for at least 2
years
 Type A coverage – hospital services & LTC
facility after hospitalization
 Type B coverage – Dr. services, outpatient
therapy, other health care. Individual pays
premium for this coverage. 80-20 coinsurance – Medicare pays 80%, individual or
insurance pays 20%
Medicaid (MediCal)

Medical assistance program offered by states
(vary from state to state)
 Covers individuals with low incomes, children
who qualify for public assistance, the
physically disabled or blind
 State Children’s Health Insurance Program
(SCHIP) – established 1997 to provide health
care to uninsured children of working families
who earn too much to qualify for Medicaid
Worker’s Compensation
Provides treatment for workers injured
on the job
 Administered by the state
 Payments made by employers & state
 Provides payment for health care & lost
wages

United States Government Plans





Provides health care for all military personnel
TRICARE
Cares for all active duty members & families
Cares for survivors of military personnel &
retirees & their families
Veteran’s Administration provides for military
veterans with service connected disability
Managed Care





Developed because of rising health care
costs & need to spend money efficiently
All health care must have a purpose
Second opinion or verification of need often
required
Includes preventive care, physical exams,
well-baby care, immunizations, wellness
education (good nutrition, exercise, weight
control, healthy living)
Usually provided by HMOs & PPOs by setting
up network of providers – restricted usage
Organizational Structure
Often called line of authority or chain of
command
 Indicates area of responsibility
 Leads to efficient operation of facility

Hospital Organizational Chart
Shows organization by departments
 Notes various divisions of departments
 Each department can have an individual
organization

Medical Office Organizational
Chart
Simpler organizational chart
 Even with fewer people, lines of
authority are clearly shown & easy to
follow

Summary





In both cases, chain of command is clearly
indicated
Health care workers must identify &
understand their position in the organizational
structure
Allows workers to know the line of authority &
understand who is their immediate supervisor
Questions/concerns/problems – go to
immediate supervisor
If supervisor is unable to solve the problem,
go to the next level in the chain.
Trends in Health Care
Many events lead to changes in health
care (example AIDS)
 Changes occur almost daily
 1st trend is cost containment

Methods Used to Contain Costs

Diagnostic related groups – DRGs
– Attempt by Congress to control costs
– Payment based on diagnosis
– Certain amount paid for each
disease/condition
– Agencies that provide care for less keep
the money
– Agencies accept loss if care costs exceed
payment allowed
Combination of Services
Agencies combine services to avoid
duplication
 Share clinics, labs, etc
 HMO & PPO examples
 Provides care to larger number of
people at a decrease in cost per person

Outpatient Services
Patients receive care without being
admitted to hospitals
 Reducing length of stay or decreasing
need for hospitalization lowers costs
 Often use less expensive home care or
skilled nursing care
 Examples – outpatient surgery, xrays,
diagnostic tests

Mass or Bulk Purchasing
Buying equipment & supplies in larger
quantities at reduced prices
 Often combines department or agency
orders
 Computerized inventories can be used
to determine when supplies are needed
& to prevent overstocking & waste

Early Intervention & Preventive
Services

Providing care before acute or chronic
disease occurs
 Prevention is ALWAYS more cost effective
 Methods – immunization, patient education,
regular physical exams, easy access to
health care, incentives for prevention
 Studies show people with limited access to
health care use emergency departments
Energy Conservation
Monitoring use of energy to control
costs & conserve resources
 Electricity, water, gas
 Energy efficient buildings
 Recycling

Agency for Health Care Policy &
Research (AHCPR)





Federal agency developed in 1990
Purpose – to research quality of health care
delivery & identify standards of treatment that
should be provided
Quality of health care should not be lowered
simply to contain costs
Need to provide quality care while be
attentive to avoiding waste & controlling costs
Consumers need to be responsible as well
Home Health Care
Rapidly growing field due to insurance
regulating hospital stays
 Less expensive to perform
 All aspects involved – nursing, physical
& occupational therapy, respiratory
therapy, social services, nutritional
services, homemaking services
 What are advantages to home care?

Geriatric Care
Care of the elderly
 Rapid growth due to longer life spans &
“baby boomers”
 Lead to growth of facilities – adult day
care, retirement communities, assisted
& independent living facilities, LTC
facilities

Geriatric Care

Omnibus Budget Reconciliation Act (OBRA)
of 1987
– Federal law creating regs regarding LTC and
home health
– Requires state to establish training & competency
programs for assistants
– Requires nursing assistants to:
• Complete mandatory state-approved training
• Pass written & competency exams
• Obtain certificate or registration
Geriatric Care

Other OBRA requirements
– Continuing education
– Periodic performance evaluations
– Retraining/retesting if CNA does not work
in a facility for more than 2 years
States must maintain registry
 Requires compliance with patients’
rights to ensure certain standards of
care

Telemedicine
Uses video, audio, & computer systems
to provide health care services
 Allows interaction even though workers
are in different locations

– EMTs at scene of accident
– Surgeons using remote control arms
– Watching procedures by video

May allow people to receive tx in homes
Wellness

State of being in optimum health with
balanced relationship between physical,
mental, & social health
 Recognizes importance of
–
–
–
–

Good nutrition
Exercise
Weight control
Healthy living habits
What are examples of facilities stressing this?
5 Ways to Promote Wellness

Physical wellness
– Well-balanced diet
– Regular exercise
– Routine physical exams/immunizations
– Regular dental/vision care
– Avoidance of alcohol, tobacco, caffeine,
drugs, environmental contaminants, & risky
sexual behaviors
5 Ways to Promote Wellness

Emotional Wellness
– Understanding feelings & expressing them
appropriately
– Accepting one’s limitations
– Adjusting to change
– Coping with stress
– Enjoying life
– Remaining optimistic
5 Ways to Promote Wellness

Social Wellness
– Showing concern, fairness, affection,
tolerance, & respect for others
– Communicating & interacting well
– Sharing thoughts & ideas
– Practicing honesty & loyalty
5 Ways to Promote Wellness

Mental & Intellectual Wellness
– Being creative, logical, curious, & openminded
– Using common sense
– Obtaining continual learning
– Questions/evaluating information &
situations
– Learning from life experiences
– Using flexibility & creativity to problem solve
5 Ways to Promote Wellness

Spiritual Wellness
– Using values, ethics & morals to find
meaning, direction, & purpose in life
Alternative & Complementary
Methods of Health Care

Most health care in the U.S. is
biomedical or “Western” system
– Based on evaluating physical signs &
symptoms, determining cause of disease,
& treatment

Major trend towards other methods
– Alternative therapy – in place of biomedical
– Complementary – Used with biomedical
Holistic Health Care
Part of alternative/complementary tx
 Consider the whole person &
recognizes that the health of each part
has an effect on total health status
 Life force or energy helps with healing
 Many therapies based on culture
 Skilled practitioners, rituals, specialized
practices part of therapy

Examples of Alternative or
Complementary Practitioners
Ayurvedic practitioners – Indian
philosophy to maintain harmony by diet,
exercise, yoga, & living practices
 Chinese medicine – Life energy flows
through the person through pathways
that link the organs together: use
acupressure & accupuncture, tai chi,
herbs to maintain energy flow

Examples continued
Chiropractors – brain sends vital energy
through nerves in spinal cord,
misalignment causes pain: use spinal
manipulation, massage, & exercise
 Homeopaths – body has ability to heal
itself through the immune system: use
drugs from plants, animals, & minerals
to cause symptoms & activate immunity

Examples cont.
Hypnotists – help people achieve a
trance-like state to become receptive to
verbal suggestions to change behaviors
 Naturopaths – use only natural
therapies like fasting, special diets,
lifestyle changes & avoid surgery or
medicine

Alternative/Complementary
Medicine

Most therapies are holistic & noninvasive
 Most are less expensive than traditional
treatments
 Office of Alternative Medicine (OAM) –
established by NIH to research therapies &
determine standards of quality care.
Practioners may required education or
licenses before practicing. Also labels
therapy as experimental.
Remember
Patients have the right to choose their
own type of care
 Be non-judgmental
 Important for health care providers to be
aware of alternative treatments

National Health Care Plan
High costs of health care + large
number of uninsured people = need for
this plan
 No current plan, many have been
proposed
 Problems – cost of creating, who pays
more, lack of free choice, new
regulations need to be created

Past & Current Trends







Polio vaccine
Antibiotic development
Cancer & AIDS drugs
Computers
Test tube babies
Cloning
Health care will continue to change – be
aware!