Chapter 9
Health Care Systems and
Policy
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Learning Objectives
• Describe factors affecting the cost and
delivery of health care.
• Explain why health promotion is a
major component of the rhetoric about
health care reform at the national level.
• Differentiate between traditional
systems of health care and managed
forms of health care.
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Learning Objectives
• Describe eligibility requirements for and
services provided to recipients of
Medicare and Medicaid.
• Identify consumer trends affecting
health care.
• State the value of using medical
nutrition therapy protocols to document
client outcomes in various health care
settings.
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Introduction
• In 2000, Americans spent more
than $1.2 trillion for health care
which represents over 13% of the
gross national product.
• This amount exceeds the average
amount spent by any other
industrialized country.
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Introduction
• Public policy is attempting to direct our
medical system toward health
promotion although Medicaid and
Medicare and other major third-party
payers offer limited reimbursement for
preventive procedures.
• Many studies show that early detection
and intervention, immunization, and
behavior change could significantly
reduce many of the leading causes of
death and disability.
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An Overview of the Health
Care Industry
• Two general categories of health
insurance in the United States:
– Private
• Traditional fee-for-service
• Group contract
– Public
• Medicare
• Medicaid
• State Children’s Health Insurance
Program
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Private Insurance
• Approximately 70.2% of
Americans have private insurance.
• Private insurance can be in the
form of traditional fee-for-service
insurance or group contract
insurance.
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Private Insurance
• Traditional Fee-for-Service Plans
– Include a billing system in which the
provider charges a fee for each service
rendered.
– Critics of this plan claim that they
encourage physicians to provide more
services than necessary.
– Proponents prefer the greater flexibility and
unrestricted access to physicians, tests,
hospitals, and treatments.
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Private Insurance
• Group Contract Insurance
– Managed-care systems, represented by
health maintenance organizations (HMOs)
and preferred provider organizations
(PPOs), are prepaid group practice plans
that offer health care services through
groups of medical practitioners.
– The goal of managed care is improved
quality of care with decreased cost.
– 91% of employees with health insurance
were enrolled in managed-care plans in
1999.
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Private Insurance – Group
Contract Insurance
• HMOs provide comprehensive services
across the continuum of care and they
make money by keeping people healthy.
• Prepaid group health plans emphasize
health promotion since they provide
health care services at a preset cost.
• By keeping people healthy, HMOs avoid
lengthy hospitalizations and costly
services.
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Private Insurance – Group
Contract Insurance
• General HMO models:
– Staff model
– Group model
– Network model
– Independent practice association
(IPA)
– Point-of-service (POS) plan
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Private Insurance – Group
Contract Insurance
• In some HMOs, provider receives a
capitation payment
– Capitation payment – A
predetermined fee paid per enrollee
per month to the provider
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Public Insurance
• Medicare and Medicaid administered by the Centers for
Medicare and Medicaid Services
(CMS)
• State Children’s Health Insurance
Program
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The Medicare Program
• Medicare is the largest health care
insurer in the U.S.
• It is designed to assist:
– People 65 and older
– People of any age with end-stage renal
disease
– People eligible for Social Security disability
payment programs for more than 2 years
– Qualified railroad retirement beneficiaries
and merchant seamen
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The Medicare Program
• Medicare consists of two separate
parts:
– Hospital insurance (Part A)
– Medical insurance (Part B)
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The Medicare Program
• Medicare Part A
– Provides hospital insurance benefits
that include up to 90 days of
inpatient care annually with a 20
percent coinsurance fee.
– Hospital inpatient charges are
reimbursed according to prospective
payment system known as diagnosis
related groups (DRGs).
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The Medicare Program
• Medicare Part B
– An optional insurance program financed
through premiums paid by enrollees and
contributions from federal funds.
– Enrolled Medicare Medical Nutrition Therapy
(MNT) providers are able to bill Medicare for
MNT services provided to beneficiaries with
type 1, type 2, and gestational diabetes,
nondialysis kidney disease, and post-kidney
transplants.
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The Medicare Program
• Coverage Gaps
• Medicare Modernization Act
• Medicare Advantage Plan
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The Medicaid Program
• Medicaid is a joint state and federal
program that provides assistance with
medical care for:
– Eligible, low-income persons
– Certain low-income pregnant women and
children
– The aged, blind, and people with disabilities
– Members of families with dependent
children in which one parent is absent,
incapacitated, or unemployed
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The Medicaid Program
• The individual states define
eligibility, benefits, and payment
schedules.
• Typically, one must meet three
criteria, including income,
categorical, and resource.
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The Medicaid Program
• Medicaid covers a variety of services
and settings, including inpatient and
outpatient hospital services, physicians’
services, skilled nursing home and
home health services, and laboratory
and x-ray tests.
• To date, 36 state Medicaid programs
cover certain forms of nutrition services
provided by dietitians.
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The State Children’s Health
Insurance Program
• The State Children’s Health Insurance
Program (SCHIP) is the largest single
expansion of health insurance coverage
for children in more than 30 years.
• States have flexibility in targeting
eligible uninsured children.
• Many of the children served come from
working families with incomes too high
to qualify for Medicaid but too low to
afford private health insurance.
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SCHIP Enrollment,
1999-2003
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The Uninsured
• The uninsured include the working
poor and those who work for small
businesses.
• The employed uninsured number
15 million.
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The Uninsured
• The non-working uninsured
number 9 million and include:
– The homeless
– Some deinstitutionalized mentally ill
patients
– Low-income people who do not
qualify for Medicaid
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% of U.S. Persons without
Health Care Coverage, 2003
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Demographic Trends and
Health Care
• By the year 2030, the baby boom
will become a senior boom with 21
percent of the population over 65
years of age.
• Racial and geographical factors in
the population are also important
to the shape of the future.
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The Need for Health Care
Reform
• Health care reform refers to the
efforts undertaken to ensure that
everyone in the U.S. has access to
quality health care at an affordable
price.
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The Need for Health Care
Reform
• Some of the challenges of health
care reform include:
– Making health care accessible to
everyone.
– Containing costs.
– Providing nursing home care to those
who need it.
– Ensuring that Medicare and Medicaid
can serve all who are eligible.
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The Need for Health Care
Reform
• Cost, access, and quality are
interrelated and manipulating one has
an astounding impact on the others.
• Health care policy makers are studying
alternative models of delivery and
financing in hopes of applying other
nations’ successes to the U.S.
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The High Cost of Health Care
• Health care inflation is well
established and the level of health
care activity is expected to grow
as a result of various factors
including:
– An aging population
– Increased demand
– Continuing advances in medicine
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National Health Expenditures
(Billions of Dollars)
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The High Cost of Health Care
• Major contributors to health care
expenditures in the U.S. are:
– The administrative cost of the
insurance process itself
– Professional liability costs
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The Nation’s Health Dollar,
2002
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The High Cost of Health Care
• Efforts at Cost Containment
– Efforts to curb soaring health care
costs cover a broad spectrum...
• from slowing hospital construction
• to reducing length of hospital stays, and
• increasing copayments and deductibles
for insured employees and Medicare
recipients.
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The High Cost of Health Care
- Cost Containment
• One example of cost containment
is the prospective payment system
(PPS) that the federal government
implemented.
– The purpose of the PPS was to
change the behavior of health care
providers by changing incentives
under which care is provided and
reimbursed.
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The High Cost of Health Care
- Cost Containment
• PPS (continued)
– Prospective payment means knowing the
amount of payment in advance.
– PPS uses diagnosis related groups
(DRGs) as a basis for reimbursement.
– Patients are classified according to the
principal diagnosis, secondary diagnosis,
sex, age, and surgical procedures.
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The High Cost of Health Care
- Cost Containment
• PPS (continued)
– There are 23 categories and a total of
490 DRGs.
– One consequence of PPS has been an
increased focus on outpatient
services.
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The High Cost of Health Care
• Equity and Access as Issues in
Health Care
– Public opinion polls in the U.S. reveal
that most people believe all citizens
are entitled to access to health care...
– but debate continues about the
acceptable level of health care and
what benefits should be included.
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The High Cost of Health Care
– Equity and Access
• Racial and Ethnic Disparities in
Health
– A recent report released by DHHS
shows significant improvements in
the health of racial and ethnic
minorities but also indicates that
important disparities in health persist.
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Health Care Reform in the
United States
• Almost all industrialized countries
except the U.S. have national health
care programs.
• In these systems, coverage is generally
universal and uniform and costs are
paid entirely from tax revenues or by
some combination of individual and
employer premiums and government
subsidization.
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Health Care Reform in the
United States
• Health care reform in the U.S.
raises a formidable list of issues
including:
– Overall cost containment
– Universal access
– Emphasis on prevention
– Reduction in administrative
superstructure and costs
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Health Care Reform in the
United States
• While the government remains
undecided on what kind of health
care system is needed or how to
pay for it, health care reform is
evolving at an accelerating rate
without legislation.
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Nutrition as a Component of
Health Care Reform
• Many believe that nutrition
services are the cornerstone of
cost-effective prevention and are
essential to halting the spiraling
cost of health care.
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Nutrition as a Component of
Health Care Reform
• The American Dietetic Association
(ADA) has urged that nutrition
services be included in any health
care reform legislation.
• Registered dietitians also need to
be recognized as the nutrition
experts of the health care team.
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Nutrition as a Component of
Health Care Reform
• Cost-Effectiveness of Nutrition
Services
– ADA encourages all of its practitioners
to document the cost-effectiveness
of nutrition services.
– Cost-effectiveness studies compare
the costs of providing health care
against a desirable change in patient
health outcomes.
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Nutrition as a Component of
Health Care Reform
• Cost-Effectiveness (continued)
– Effective nutrition therapy can produce
economic benefits as a result of altered food
habits and risk factors.
– Practice guidelines or protocols that clearly
specify appropriate care and acceptable
limits of care for each disease state or
condition are important to enhance the
quality, efficiency, and effectiveness of the
health care system.
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Nutrition as a Component of
Health Care Reform
• Care delivered according to a protocol
has been linked with positive outcomes
for the client.
• Examples of outcomes include:
–
–
–
–
Measure of control (serum lipid profiles)
Quality of life
Dietary intake
Patient satisfaction
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Measurable Outcomes of
Nutrition Intervention
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Nutrition as a Component of
Health Care Reform
• Developing standardized protocols
of care for nutrition intervention is
considered a must for achieving
payment for nutrition services and
expanding current levels of thirdparty reimbursement.
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Medical Nutrition Therapy
and Medicare Reform
• The ADA believes that
reimbursement for nutrition
services through Medicare and
Medicaid is inadequate.
• ADA supports the inclusion of
medical nutrition therapy as a
covered benefit in all types of
health care delivery.
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Medical Nutrition Therapy
Providing Return on Investment
• Oxford Health Plan
– Saved $10 for every $1 spent on nutrition
counseling for at-risk elderly patients
• The Lewin Group
– 8.6% reduction in hospital utilization for
patients with CVD
– 16.9% reduction in physician visits for
patients with CVD
– 9.5% reduction in hospital utilization for
diabetes patients
– 23.5% reduction in physician visits for
diabetes patients
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Medical Nutrition Therapy
Providing Return on Investment
• University of California Irvine
– Lipid drug eligibility was obviated in 34 of
67 subjects
– Estimated annual cost savings from the
avoidance of lipid medication was $60,652
• Pfizer Corporation
– Projected $728,772 annual savings from
reduced cardiac claims
• U.S. Department of Defense
– Saved $3.1 million the first year for CVD
patients
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Evaluating Nutrition Risk in
Older Adults
• NSI DETERMINE Checklist - a
nutrition screening tool to help
identify warning signs of potential
nutrition problems.
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Evaluating Nutrition Risk in
Older Adults
• “Determine Your Nutritional Health”
Checklist
– I have an illness or condition that made me
change the kind or amount of food I eat.
– I eat fewer than two meals each day.
– I eat few fruits or vegetables or milk
products.
– I have three or more alcoholic drinks almost
every day.
– I have tooth or mouth problems that make
it hard for me to eat.
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Evaluating Nutrition Risk in
Older Adults
• “Determine Your Nutritional Health”
Checklist (continued)
– I don’t always have enough money to buy
the food I need.
– I eat alone most of the time.
– I take three or more different prescribed or
over-the-counter medicines a day.
– Without wanting to do so, I have lost or
gained 10 pounds in the last 6 months.
– I am not always physically able to shop,
cook, and/or feed myself.
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Evaluating Nutrition Risk in
Older Adults
• Campaign Long-Term Nutrition
Risk Reduction
– Demonstrates how nutrition screening
and case management can help lower
nutrition risk among frail, homebound
older adults.
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Evaluating Nutrition Risk in
Older Adults
• Goals and Objectives
– Improve the nutritional status of frail,
homebound older adults receiving home
services under the Medicaid Waiver Program
by:
• Nutritionally screening clients
• Providing home-based medical nutrition therapy
where indicated
• Using a coordinated case management approach
to determine need for further services
• Evaluating the effectiveness of home-based
medical nutrition therapy
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Evaluating Nutrition Risk in
Older Adults
• Methodology
– Older adults contacted to complete
"Nutrition Screening Checklist"
– Clients identified as “at risk” referred for for
an initial home visit and in-depth nutritional
assessment
– MNT care plan devised and carried out
– In-depth nutritional assessment repeated at
discharge
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Evaluating Nutrition Risk in
Older Adults
• Results
– Semiannual samplings of 20% of all
discharged patients
– 89% of clients surveyed lowered their
nutrition risk scores after receiving
home-based medical nutrition
therapy.
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On the Horizon: Changes in
Health Care and Its Delivery
• The future offers much that is
positive for the profession of
dietetics.
• Yet to be achieved are the
effective provision and allocation of
resources, such as nutrition
services as part of preventive care.
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On the Horizon: Changes in
Health Care and Its Delivery
• A coordinated strategy for health care,
political will, and active collaboration of
both health care professionals and
consumers of health care services will
be required to achieve this goal.
• Health care reform for the U.S. is
certain, but the exact nature of the
reform will continue to evolve.
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Ethics and the Nutrition
Professional
• What Is Ethics?
– A philosophical discipline that attempts to
determine what is morally good and bad,
right and wrong
• Codes of Ethics
– The ADA published its first code of ethics in
1942
– Most recent code became effective in 1999
– ADA code applies to all ADA members and
credentialed practitioners
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Ethics and the Nutrition
Professional
• Guiding Principles
– Autonomy - respecting the individual’s
rights of self-determination, independence,
and privacy
– Beneficence - protecting clients from harm
and maximizing possible benefits
– Non-maleficence - the obligation not to
inflict harm intentionally
– Justice - striving for fairness in one’s
actions and equality in the allocation of
resources
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Ethics and the Nutrition
Professional
• Health Promotion and Ethics
• Ethical Decision Making
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