Health Care Delivery Systems Hx Essay

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HEALTH CARE DELIVERY
SYSTEMS:
HISTORICAL OVERVIEW
Bonnie Zauderer, PhD, RN edited by Peggy Landrum, PhD, RN,CS

Health Care in the US

1965: $41.5 billion
1985: $425 billion

Question #1: What is our health care cost today in the U.S.?

Before the 1980s
 Health care was a function of whatever physicians

determined necessary to diagnose and treat the patient  Hospitals were “Cash Cows”
 Insurance companies operated on a fee-for-service basis  Few limits were made on health care expenditures
 Employers, insurance companies (third-party payers), and government: there must be a less expensive way to deliver health care

 1974: National Health Planning and Resources

Development Act required every state to have a
Certificate of Need (CON)
– Influence on cost control minimal

 Professional Standards Review Organization

(PSRO): review quality, cost, and quantity of health care provided through Medicare

Medicare-qualified hospitals had to have

Utilization Review Committees
1983: Prospective Payment system established to eliminate cost based reimbursement Diagnosis Related Groups (DRG)
– Initially 468 DRG

Competition among providers
– Fixed rate reimbursement regardless of patient length of stay or use of hospital services
– Hospitals absorbed cost of uncovered expenses or closed
– More discharge planning and shorter LOS
– Health Care Financing Administration (HCFA) oversees cost containment for Medicare and
Medicaid

Managed Care Organizations
(MCOs)
– Provides comprehensive, preventive and treatment services to enrolled individuals
– Four categories of MCO

Types of MCOs
Health Maintenance Organization (HMO)
– Capitation
– Gatekeeper

Preferred Provider Organization (PPO)
Point-of-Service (POS)
Physician Hospital Organizations (PHO)

Factors Affecting Health Care
Increasing number of elderly
– Estimated that by 2020 50 million will be > 65
– Frail elderly (>85) fastest growing part of population – Numbers similar in Canada

Advances in technology
– Earlier recognition of diseases
– Newer treatments available

Factors Affecting Health Care
Economics
– Paying for health care greatest problem
– $1 billion daily for health care
– Medical care cost have increased 400% since
1965
– More people seeking care
– Population has increased and is continuing to grow Factors Affecting Health Care
Women’s Health
– More services in different settings
– Focus of care is prevention and not identification and treatment of disease

Uneven distribution of health services
– Uneven distribution
– Increased specialization = increased cost of care Factors Affecting Health Carev
Access to health care
– 37 million Americans have inadequate or no insurance – Many hospitals absorb cost

Homeless population
– 1985-1990 about 5.7 million homeless
– Need more acute services
– Problems often become chronic

Factors Affecting Health Care
Demographic changes
– More single parent and alternative type families – Cultural and ethnic diversity increasing— challenge is to meet needs of diverse populations Factors Affecting Health Care
Question #2:
What additional factors are affecting health care delivery in 2012?

Reforms of the 90s

1996 Kassebaum-Kennedy Act
– Placed restrictions on insurance companies including: – Portability of health insurance
– Limits on exclusions for pre-existing conditions
– Improved access to health care
– Little actual impact on health care

Reforms of the 90s
Balanced Budget Act of 1997
– Focused on Medicare reforms
– Medicare + Choice
– Expanded prospective payment system to outpatient, home health, and SNF
– Funded preventive measures

Reforms of the 90s
Children’s Health Insurance Program
– BBA of 1997 provided money to states to fund health care for at risk children
– 5 year funding
– What happened after the funding period ended? Types of Care
Health Promotion
– Assist individual to remain healthy, prevent injury and disease
– Prevent development of risk factors
– Requires active…