Politics and the Law.

The Health Care System.

Economics of Health Care.

Read chapter 10, 11 & 12 of the class textbook and review the attached PowerPoint presentation.  Once done answer the following questions;

  1. Discuss how the structure of government impacts the policy development process.
  2.   Describe the legislative, judicial, and administrative (executive) processes involved in establishing federal, state, or local health policy.
  3. Describe the organization of the public healthcare subsystem at the federal, state, and local levels.
  4. Discuss the factors that influence the cost of health care.

As stated in the syllabus please present your assignment in an APA format word document, Arial 12 font attached to the forum in the discussion tab of the blackboard name “Week 3 discussion questions”.  A minimum of 2 evidence-based references are required (not counting the class textbook) no older than 5 years.    A minimum of 700 words without counting the first and last reference is required.  Please make sure you follow the instructions as given.

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then

APA format 500 words  

1.  What are your beliefs about the major concepts in nursing- person, environment, health, nursing?

2. Do you believe there is more than one right answer to situations?  How do you value the whole individual?  What barriers prevent us from responding to the contextual needs of our patients?

3.  Do you believe in health care for everyone?  Why or why not?

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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