The Health Care System

Need prove in turnitin

Politics and The Law

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Economics of Health Care

Read chapter 10, 11 & 12 of the class textbook and 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.

Please present your assignment Word document, 12 Arial font attached to the forum in the discussion tab of the blackboard titled “Week 3 discussion questions”, in the Turnitin in the assignment tab of the blackboard and in the exercise forum in the assignment the tab of the blackboard as well (new requirement from the Distance Learning Department).

To access the exercise forum, click in the assignment on the left side of the blackboard, then on the assignment and then click exercise to post your assignment.

A minimum of 2 references (excluding the class textbook) no older than 5 years must be used. If you use the textbook as a reference will not be counted. Every reference that you present in your assignment must be quoted in the assignment.

in the discussion tab of the blackboard, Turnitin and exercise tab.

Please make sure you use spell check before you post your assignment and replies. I have found many grammar/spellings errors in the assignments which are not acceptable for a student close to complete his/her BSN.

A minimum of 700 words are required (not counting first and reference page) and please use the example of the first page that I emailed at the beginning of the course.

Economics of Health Care

Chapter 12

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

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

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

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

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”

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

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)

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

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

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

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

Trends in Health Financing

New and innovative health care approaches

Cost sharing

Health alliances

Self-insurance

Flexible spending accounts

Health promotion and disease prevention

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.

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?

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

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

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

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

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

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

Chapter 10

Policy, Politics, Legislation, and Community Health Nursing

Nurses Who Made a Difference…

Florence Nightingale

Sojourner Truth

Clara Barton

Lavinia Dock

Lillian Wald

Mary Breckenridge

Susie Walking Bear Yellowtail

Florence Wald

Ruth Watson Lubic

Nurses’ Historical and Current Activity in Health Care Policy

Florence Nightingale

First nurse to exert political pressure on a government

Transformed military health

Knew the value of data in influencing policy

Collected and analyzed data about health services and outcomes, which now is a critical element of public health

Photo credit:

http://commons.wikimedia.org/wiki/Florence_Nightingale

Nurses’ Historical and Current Activity in Health Care Policy (Cont.)

Sojourner Truth

Advocate for abolishing slavery

Supported women’s rights

Helped transform racist and sexist policies that limited health and well-being of blacks and women

Fought for human rights

Lobbied for funds to educate nurses and physicians

Photo credit:

http://commons.wikimedia.org/wiki/File:Carte_de_visite.jpg

Nurses’ Historical and Current Activity in Health Care Policy (Cont.)

Clara Barton

Organized relief efforts during U.S. Civil War

Persuaded Congress to ratify the Treaty of Geneva, which allowed the Red Cross to perform humanitarian efforts in times of peace

Photo credit:

http://commons.wikimedia.org/wiki/File:WcbbustCBarton.jpg

Nurses’ Historical and Current Activity in Health Care Policy (Cont.)

Lavinia Dock

Prolific writer and political activist

Campaigned to allow nurses to control the nursing profession

Advocated for women’s right to vote

Worked closely with Isabel Hampton Robb and Mary Adelaide Nutting to found forerunner to NLN

Photo credit: http://commons.wikimedia.org/wiki/File:Lavinia_Lloyd_Dock.jpg

Nurses’ Historical and Current Activity in Health Care Policy (Cont.)

Lillian Wald

Recognized connection between health and social conditions

Advocate for development of the Children’s Bureau in 1912

Frequently appeared at White House in development of national and international policy

Photo credit: http://commons.wikimedia.org/wiki/File:Lillian_Wald_-_William_Valentine_Schevill.jpg

Nurses’ Historical and Current Activity in Health Care Policy (Cont.)

Mary Breckenridge

Developed nursing in rural Kentucky

Established Frontier Nursing Service

Photo credit:

http://commons.wikimedia.org/wiki/File:WENDOVER.jpg

Nurses’ Historical and Current Activity in Health Care Policy (Cont.)

Florence Wald

Nursing leader in establishing hospice care in the United States

Modeled hospice after similar services offered in United Kingdom

Photo credit:

http://commons.wikimedia.org/wiki/File:Hospice_Media_Logo.png

Nurses’ Historical and Current Activity in Health Care Policy (Cont.)

Susie Walking Bear Yellowtail

Walked from reservation to reservation to improve health services for Native Americans

Established Native American Nurses Association

Photo credit:

http://commons.wikimedia.org/wiki/File:Ketchican_totem_pole_2.jpg

Nurses’ Historical and Current Activity in Health Care Policy (Cont.)

Ruth Watson Lubic

Nurse-midwife who crusaded for freestanding birth centers in the United States

Leader in community-based birth center movement

Photo credit:

http://commons.wikimedia.org/wiki/File:Silverton_Hospital_birth_center_-_Silverton,_Oregon.JPG

Definitions to Know

Social justice

Laws

Public health law

Statutes

Organizations

Professional associations

Policy

Public policy

Health policy

Nursing policy

Institutional policies

Organizational policies

Social policy

Definitions

Policy denotes a course of action to be followed by a government, business, or institution to obtain a desired effect.

Public policy denotes precepts and standards formed by governmental bodies (legislative, executive, or judicial) that are of fundamental concern to the state and the whole of the general public.

Definitions (Cont.)

Health policy is a statement of a decision regarding a goal in health care and a plan for achieving that goal.

Nursing policy specifies nursing leadership that influences and shapes health policy and nursing practice.

Institutional policies are rules that govern worksites and identify the institution’s goals, operation, and treatment of employees.

Definitions (Cont.)

Organizational policies are rules that govern organizations and their positions on issues with which the organization is concerned (Mason et al., 2007).

Social policy is policy associated with individuals and communities. In very general terms, social policy can be defined as the branch of public policy that advances social welfare and enhances participation in society.

Definitions (Cont.)

Laws are rules of conduct or procedure; they result from a combination of legislation, judicial decisions, constitutional decisions, and administrative actions.

Public health law focuses on legal issues in public health practice and on the public health effects of legal practice. Public health law typically has three major areas of practice: police power, disease and injury prevention, and the law of populations.

Statutes are any laws passed by a legislative body at the federal, state, or local level.

Definitions (Cont.)

Organizations are associations that set and enforce standards in a particular area; a group of individuals who voluntarily enter into an agreement to accomplish a purpose.

A professional association is a nonprofit organization seeking to further a particular profession, the interests of individuals engaged in that profession, and the public interest.

Policy is based on values, and the first step in forming policy is identification of the issue. Therefore, it would seem rational to define “health” as the starting point for any policy annexed to health care issues.

Many Healthy People 2020 objectives directly or indirectly involve health policy.

– Nies and McEwen, 2015

Shifts in Philosophy at the CDC

From Centers for Disease Control and Prevention: State of the CDC: fiscal year 2008, The Author.

From…	To…
Disease orientation	Health protection focus
Designing and implementing sponsored programs	Informing and guiding health system actors
Allocating agency resources	Leveraging resources to steer larger health system
Emphasis on clinical prevention	Focus on prevention and health protection
Transaction-based relationships	Partnerships and strategic alliances
Program requirements	Incentives for participation/cooperation
Collecting and analyzing health data	Creating integrated health information systems
Issuing advisories and guidelines	Building decision-support system

Healthy People 2020

Vision

A society in which all people live long, healthy lives.

Overarching Goals

Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.

Achieve health equity, eliminate disparities, and improve the health of all groups.

Create social and physical environments that promote good health for all.

Promote quality of life, healthy development, and healthy behaviors across all life stages.

Nies: Power Points, Evolve Resources for Nies/McEwen: Community Health Nursing, 4th ed.

Overview of Health Policy

Public Health Policies

Decisions made at all levels of government (local, state, or federal)

Influence health care through monitoring, production, provision, and financing of health care services

Everyone is affected, from providers to consumers

Influence all health care organizations

Overview of Health Policy (Cont.)

Public Health System

Authority for public health vested with states

Responsibility delineated by constitution

Compliance with federal program standards is voluntary but impacted by revenue

Policies influenced by social and political theories

Economics is one factor in decision making

Decisions are slow and deliberate and more reactive

Needs determined by voting shifts, electoral realignment, and term limits

Overview of Health Policy (Cont.)

Private Health Sector

Includes employers, professional organizations, nonprofit health care organizations, and for-profit corporations that deliver, insure, or fund health care services outside of government control

Policies evolve differently—influenced by economics and business management

Economics is central factor in decision making

Decisions are swift and proactive

Needs determined by consumerism, market trends, and economics

How a Bill Becomes a Law

Figure 10-1. From publicdomainclip-art.blogspot.com/2007_09_01_archive.html. Retrieved October 19, 2009.

Impact of Federal Legislation on Health Care

Prevention of illness by influencing the environment

Provision of funding to support programs that influence health care

Increased the involvement of state and local governments in health care

Promoted similarities of services in all states

Funding resulted in increased regulations

Standardized U.S. public health policy

Critical Federal Legislation Related to Health Care

Pure Food and Drug Act of 1906

Manufacturing, labeling, and sale of food

Children’s Bureau Act of 1912

Regulated unhealthy child labor practices

Shepherd-Towner Act in 1921 extended to infants

Social Security Act of 1935; 1965; 1972

Benefits for mothers, children, elderly, disabled

Critical Federal Legislation Related to Health Care (Cont.)

Medicare (Title XVIII) in 1965

Health care services for people over 65, with permanent disabilities, and those with end-stage renal disease

Medicaid (Title XIX) in 1965

Combined federal and state program

Access to care for poor and medically needy

Critical Federal Legislation Related to Health Care (Cont.)

Public Health Act of 1944

Consolidated all existing public health legislation into one law

Health services for migratory workers

Family planning services

Health research facilities

National Institute of Health (NIH)

Nurse training acts

Traineeships for graduate students in public health

Home health services for Alzheimer’s disease patients

Prevention and primary care services

Rural health clinics

Communicable disease control

Critical Federal Legislation Related to Health Care (Cont.)

McCarren-Ferguson Act of 1945

Gave states right to regulate insurance plans

Hill-Burton Act of 1946

Federal assistance in construction of hospitals with stipulations about service for the uninsured

Health Amendments Act of 1956; Title II

Funds for RN education in administration, supervision, and teaching

1964 Nurses Training Act: funds for loans and scholarships and to develop more nursing schools

Critical Federal Legislation Related to Health Care (Cont.)

Occupational Safety and Health Act of 1970

Focused on health needs and risks in workplace and environment

Health Maintenance Organization Act of 1973

Employers must offer federally qualified HMOs as health care option to employees

States had oversight on HMOs

Critical Federal Legislation Related to Health Care (Cont.)

National Health Planning and Resources Act of 1974

Assigned responsibility for health planning to states and local health system agencies

Required health care facilities to obtain prior approval for expansion in form of Certificate of Need (CON)

Critical Federal Legislation Related to Health Care (Cont.)

Omnibus Budget and Reconciliation Acts

1981, 1987, 1989, and 1990

Enacted to reduce huge federal deficit

Impacted funding for nursing homes, home health agencies, and hospitals

Established new guidelines and regulations including a move from process to outcome evaluation, use of restraints, and prescription drugs for Medicaid recipients

Critical Federal Legislation Related to Health Care (Cont.)

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

Amendment to SSA of 1935

Established PPS for Medicare, the DRG system

COBRA of 1985

Requires all EDs that participate in Medicare to provide care for all, regardless of ability to pay

Ensures continuation of insurance after loss of job

Example of how federal government can affect state health care practices

Critical Federal Legislation Related to Health Care (Cont.)

Family Support Act of 1988

Expanded coverage for poor women and children

Expanded Aid to Families with Dependent Children (AFDC)

Health Objectives Planning Act of 1990

Response to the first Healthy People report (1979)

United States began to identify and monitor national health goals; Healthy People 2000, 2010, and 2020

Critical Federal Legislation Related to Health Care (Cont.)

Health Insurance Portability and Accountability Act (HIPAA) of 1996

Ensured portability of insurance coverage

Offered protection for patient privacy and confidentiality

Welfare Reform Act of 1996

Restricted eligibility for AFDC, Medicaid, etc.

TANF helped move recipients into work; welfare offered temporary assistance

Many underserved lost Medicaid coverage

Critical Federal Legislation Related to Health Care (Cont.)

The State Child Health Improvement Act (SCHIP) of 1997; 2009

Provides insurance for children and families who cannot afford health insurance

Medicare Modernization Act of 2003

Most significant law in 40 years for senior health care

Provides seniors and disabled with some Rx drug benefit coverage, more choice, and better benefits

Critical Federal Legislation Related to Health Care (Cont.)

Nurse Reinvestment Act of 2003

Funding provided to increase enrollments and number of practicing nurses

Mental Health Parity and Addictions Equity Act of 2008

Financial requirements (deductibles, co-payments) and treatment limitations (number of visits; days of coverage) that apply to mental health benefits must be no more restrictive than the predominant financial requirements or treatment limitations that apply to substantially all medical/surgical benefits

Critical Federal Legislation Related to Health Care (Cont.)

Patient Protection and Affordable Care Act of 2010

All U.S. citizens and legal residents to have qualifying health coverage

Changes eligibility requirements for Medicaid and expands CHIPS

Subsidizes premiums for lower and middle income families

Requires coverage of dependent adult children up to age 26

Critical Federal Legislation Related to Health Care (Cont.)

Patient Protection and Affordable Care Act of 2010 (Cont.)

Significant insurance reforms

Established high-risk pools

Covers preexisting conditions

No lifetime limits on coverage

Cannot drop policyholders when they get sick

Must provide preventive care and screenings without customer cost-sharing

Fosters nonprofit, member-run exchanges

Implemented over several years

Critical Federal Legislation Related to Health Care (Cont.)

Patient Protection and Affordable Care Act of 2010 (Cont.)

Funded through new fees and taxes.

Taxes on indoor tanning

Medicare taxes for higher income brackets

Fees for pharmaceutical companies and medical devices

Penalties for those who do not obtain health insurance

Cost-cutting measures

Cuts to Medicare Advantage programs

Reductions in Medicare spending

Reduce administrative costs, streamline care, reduce fraud and abuse

The health reform legislation in 2010 was strongly influenced by the rising number of uninsured and underinsured.

The United States is only major developed country to not have universal health coverage.

State Legislative Role

Focus on financing and delivery of services and oversight of insurance to address the mission of public health throughout the state

Assess health needs

Ensure adequate statutory base for health activities

Establish statewide health objectives

Ensure appropriate organized statewide effort to develop and maintain essential services

Guarantee minimum set of essential health services

Support local service capacity

Effective Use of Nurses: A Policy Issue

Title VII funding (HRSA) provides the largest source of federal funding for nursing education

Favors education for practice in rural and medically underserved communities

Nursing shortage is a crisis

Economic impact on positions

Focus on hiring BSN graduates (not ADN)

Shortage of nursing faculty

Nurse Education, Expansion, and Development Act of 2009 amended above to increase funds for nursing schools

Nurses’ Roles in Political Activities

The Power of One and Many

…as Change Agents

…with Coalitions

…as Lobbyists

…on Political Action Committees (PACs)

…in Campaigning

…in Voting Strength

…in Public Office

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