Discussion Health Promotion: Prevention of Disease W2

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Chapter 3

Health Policy and the Delivery System

The Patient Protection and Affordable Care Act (PPACA)

� New health care federal reform law signed in 2010 � Largest change in the financing of the American health

care system since Medicare and Medicaid (1965) � Focus on vulnerable populations: affordability,

accessibility, and financing of health care � Designed to reduce number of uninsured persons via

expanding Medicaid and establish subsidies � US Supreme Court upheld the ACA in June 2012 � Likely will change secondary to Trump presidency

Key Features of PPACA

� PPACA lacks bipartisan support � Change in political landscape may result in

repeal or significant changes � No exclusion for preexisting conditions � Health insurance is mandated for everyone � Marketplace exchange for insurance plans � All policies must cover essential benefits � Medicaid expanded; subsidies available

Measuring the Nation’s Health

� Health, United States report (annual) Ø Informs policymakers of trends in nation’s health

� Healthy People 2020 Ø 10-year agenda for improving nation’s health Ø Goal is to increase quality and years of healthy life,

and eliminate health disparities � Central Intelligence Agency (CIA) statistics

Ø Morbidity data Ø Compares United States with other countries

US Health Trends

� Successes in infection, other diseases � Concerns: sedentary lifestyle, obesity, chronic

illness � Health disparities persistent

Ø Contribute to unfavorable US health indicators Ø Compromise progress in world health

� Vulnerable populations due to age, education, language, location

� Rise in suicide and drug poisoning deaths esp involving opioid analgesics

Historical Role of Women

� Nurses have long tradition of health promotion � Nursing pioneers

Ø Florence Nightingale (Crimean War 1884)—crusaded for nutritious food, cleanliness, sanitation

Ø Lillian Wald (Henry St Settlement—NYC 1883) founded NYC visiting nurses association to provide health services for indigents in tenements

� Through the ensuing decades nurses developed unique role agents for health promotion

� US Health Care system undergoing changes Ø Sparked by health care reform politics Ø Large organizations involved in forming health policy

� Health and medicine division Ø Previously known as Institute of Medicine (IOM) Ø Research from a systems approach Ø Advisement on safe delivery of health care Ø Health care system (not practitioners) is basic cause

of medical errors

A Safer System

� Overriding objective is for all people (global) to attain highest possible health

� Current agenda—six goals Promoting development Enhancing partnerships Fostering health security Improving performance Strengthening health systems Harnessing research info

� Budget issues limit achievement of goals � Huge health disparities in developing nations

Global Health World Health Organization

� Earliest views were holistic, emerging from integrated worldview

� Hygiene incorporated into most religions � Primitive peoples had mystical view of sickness

and cure—tied to religion � During middle-ages widespread epidemic

diseases leading cause of death ( leprosy, plague, smallpox, TB)

Historical Influences Health Care

� Adequate food supply prolonged life span Ø Transportation enhanced food distribution Ø Technological advances improved food production

� Industrial advances prevented diseases Ø Flush toilet, sewer systems Ø Decrease in typhoid, paratyphoid, gastroenteritis

Historical Industrial Influences

� Elizabethan poor laws (1601) England Ø Relief for infants, sick, elderly, workhouse laborers

� New Law 1834—harsher philosophy Ø Pauperism in able-bodied workers viewed as moral

failing Ø Suspicious and punitive view of indigence

� Protestant work ethic (rewards work efforts) Ø Philosophy brought to United States by Puritans Ø Influences modern health care—fee-for-service

Historical Socioeconomic Influences

� Edwin Chadwick—father of public health � Disease viewed as impediment to ability to self-

support (Chadwick’s view) � Public health services and welfare combined

creating a more benevolent view of indigence � Puritan ethic in the United States offered a

harsher view toward indigence and health care � Health and welfare departments continue to

have contradictory approach to poor

Public Health Influences

� Prior to 20th century infectious diseases (ID) major cause of death

� Scientific advances → Improved health Ø Louis Pasteur—germ theory Ø Joseph Lister—antisepsis

� Innovations: safeguard water, food, and milk supply; sewage systems; urban housing regs

� Antibiotics (1936-1954) decrease in ID � ID death persists in vulnerable populations

Scientific Influences

Major milestones with effects on health care � New Deal (Great Depression) � Social Security Act 1935

Ø Grants-in-aid for state and local public health Ø Assistance programs: blind, elderly, disabled

� Medicare and Medicaid (1965) � Patient Protection and Affordable Care Act

(2010)

Political and Economic Influences

Preventative vs Curative Medicine

� Early prevention directed toward individuals Ø Originated in medical practice vs public health Ø Focus was on poor—state welfare programs

� Public health services eventually emerged Ø Focus on societal prevention vs individual cure Ø Immunizations, screenings, education Ø Education and career paths for pubic health vs medical

practitioners remained separate � 1960s emphasis shifted from individual to societal public

health goals � Evolution toward greater government in health care

Organization of Delivery System

� Huge system: public and private components � Multifaceted and complex interrelationships

Ø Providers and consumers Ø Varied settings: private and public services

� Public sector: nonprofit agencies, government agencies, organized at local, state, and national levels (US Department of Health and Human Services)

� Private sector: for profit services

Private Sector Independent Practice

� Independent practice—free-market system Ø Fee-for-service; hallmark is choice of provider Ø Managed care health organizations evolved Ø Prevention has gained importance

� Nurse-managed centers Ø Advanced Practice Nurse serve as primary care

providers Ø Multidisciplinary collaborative approach Ø Focus: vulnerable populations

Private Sector Managed Care

� Managed health care/health maintenance organizations (HMOs)—emerged 1990s Ø Groups of providers, contract with HMOs Ø Comprehensive care for prepaid fee Ø Motivation and goal is to control costs

� Managed care: key elements Ø Control costs, regulate health care utilization Ø PCP gatekeeper to system; coordinate care Ø Payment based on network status: in-network vs out

Private Sector Health Maintenance Organizations

� Capitation method of payment Ø Provider receives fixed payment per enrollee.

Provider provides all necessary care to enrollee � PCP is gatekeeper

Ø Specialist require referral Ø Members (patients) may have copays Ø Must use network providers

� Medicare Advantage plans are HMO alterative to traditional Medicare

Private Sector IPAs and ACOs

� Independent practice associations (IPAs) Ø Physician organizations Ø Care for HMO members in private office Ø Several models available

� Accountable Care Organization (ACOs) Ø Key component in Affordable Care Act Ø Not yet in place—Medicare reform Ø Structure will be similar to HMOs Ø Focus is cost-containment

Private Sector Concierge and Hospitalists

� Concierge medical practices Ø Membership fee for enhanced health care Ø Fewer patients—more time per patient Ø Focus: personalized, holistic care for higher income

individuals • Typical household income—$125,000-$250,000 • Typical patient—age 50 and older

� Hospitalist movement Ø Physicians or APNs who provide comprehensive

hospital care—improved quality and safety of care

Private Sector POS and HDHPs

� Point-of-service plans (POS) Ø Additional fee for providers outside of network Ø Increases consumer choice

� High Deductible Health Insurance Plans Ø High annual out-of-pocket deduction Ø Suitable for healthy persons—low monthly premium Ø Health Savings Account (HSAs)

• Employer contributions plus pretax deposits allowed • Withdrawals for health-related expenses • In-network providers offer enhanced savings

Private Sector PPOs

� Preferred Provider Organization—PPO � Key elements

Ø Contracted providers who will deliver member services at prenegotiated rate (discounted)

Ø Extra cost if non-PPO providers used Ø Copays by members required at time of visit Ø Preauthorization required for hospitalization or costly

tests and procedures Ø 52% of employer-sponsored plans are PPOs

Public Sector Power and Influence

� Source of power—shared federal/state Ø Federal: tax/spend general welfare Ø State: health authority based on 10th Amendment

� Influence of political philosophy Ø Each new administration since 1980s has introduced

new philosophy, bills, or components of health care Ø Most recent legislation: HIPAA (1996) Medicare

Prescription Drug Act (2003) Affordable Care Act (2010), Children’s Health Insurance Program (2015)

� National health care debate

Public Sector Current/Future Policy

� Current political issues re health care Ø Lack of political consensus—partisan discord Ø Major factors: cost, access, quality Ø Discordant partisan views concerning ACA

� Nurse’s role in health care reform Ø ANA: advocate for single-payer system Ø Focus on primary care, prevention Ø Push for nurses to function to full extent of education and

training—remove barriers Ø Nurses comprise largest segment of health care

workforce—3 million members

Official Health Care Agencies

Type of Agency

Key Characteristics

Local � Local health department � Direct services to public

State � State health department � Policy, planning, program coordination

Federal � Run by executive and legislative branches— determine health policy

� USHHS—administers policy

Official Health Care Agencies (Cont.)

Type of Agency/ Personnel

Key Characteristics

Chief Nursing Officer

� Serves in US Public Health Service � Works with US Surgeon General on nursing and public health policy

Federal Emergency Management Agency (FEMA)

� Part of Department of Homeland Security � Disaster-related services � Assists individuals, communities, states

Official Health Care Agencies (Cont.)

Type of Agency/ Personnel

Key Characteristics

Military Health System

� Comprehensive medical care for active duty personnel, dependents, retirees � Responds to natural disasters and humanitarian crisis throughout the world � Veteran’s Administration: independent agency under President to provide for veteran care

Wounded warrior care

� Extensive care and rehabilitation to return severely injured soldiers to active duty or transition to VA health system

Health Care Legislation and Agencies

Legislation/ Agencies

Key Information

Americans with Disabilities

� Prohibit job discrimination and require services to people with disabilities

Patient Self- Determination Act

� Advanced directives for health care

Federal Health Information Privacy

� Safeguards security/confidentiality of health information

International- WHO

� Worldwide guidance in promoting world health through standards, programming, and collaboration

Voluntary (not-for- profit) Agencies

� Influence policy/legislation � Philanthropic (nongovernmental)

American Red Cross

� Volunteer-led humanitarian organization � Congressional charter—officially sanctioned but

no direct government supervision � 700 local chapters, 500,000 volunteers, 35,000

employees � Responds to both small local disasters (house

fire) and large natural disasters � Blood products, health education,

communication for servicemen/families

Financing Health Care

� Costs Ø Increasing due to multiple factors Ø Less time in system for health promotion

� Sources Ø Federal government (Medicare, Medicaid) Ø State funded programs—Medicaid, CHIP Ø Third-party payment (insurance) Ø Employer provided health plan benefits Ø Independent sources Ø Out-of-pocket: deductibles, copays, health savings accounts Ø Affordable care act subsidies

Mechanism for Financing

� Independent practice with fee-for-service—physicians, APNs, health care professionals

� Salaried providers—nurses, APNs, physicians Ø Overtime is uncompensated Ø Often leads to burnout from overwork

� Hourly compensation Ø Most hospital and outpatient staff Ø Workers eligible for overtime

� Capitation—flat fee regardless of services used Ø Encourages preventive care to keep people healthy Ø Some individuals make unnecessary visits Ø HMO sponsors and bears risk of illness

Cost Containment � Cost-containment initiatives

Ø Prospective payment system, limits on provider payments, Medicare Advantage (MA) plans

� Care management Ø Determines and coordinates care Ø Across continuum of health care services Ø Reduce waste, improve quality, control costs

� Managed care issues Ø Quality of care vs cost control Ø PCP as gatekeeper

Managed Care

� Care management: professional oversees care Ø Coordination of care Ø Insuring quality care Ø Cost containment

� Managed care issues Ø Renewed importance with Affordable Care Act Ø Cost containment Ø Provide high-quality optimum care

Health Insurance

� Private insurance Ø Traditional insurance companies (BC/BS) Ø PPOs—“brokers” between insurers/providers Ø HMOs—prepayment plans Ø POS—combination of HMOs and PPOs Ø Self-insurance/self-funded

� Public insurance/assistance Ø Medicare Ø Medicaid

Medicare

� Federal program � Paid through taxes � Finances medical care for:

Ø People over 65 Ø Disabled Ø People with end-stage renal disease Ø Hospice

Medicare (Cont.)

� Part A Ø Inpatient care in hospitals, skilled nursing facilities, home health

care, hospice � Part B

Ø Supplementary voluntary coverage Ø Pays doctor’s visits

� Part D Ø Pharmaceutical costs—multiple plans available

� Challenges Ø Growth in elderly population Ø Depletion of Medicare resources (trust fund) Ø Uncovered services (glasses, dental, hearing aids)

Medicaid

� Assistance program managed jointly by federal and state funds

� State-determined eligibility � Costs up to 50% of state budgets—open-ended

program � Benefits vary by state � Available to:

Ø Certain low-income individuals Ø No age requirements Ø Families with children: 5-year lifetime limit

The Uninsured

� Of all developed countries, the United States has the highest proportion of population with no health insurance

� 2008: 46 million uninsured younger than age 65 � Most uninsured individuals live in families in which there is at least

one full-time worker � Groups at most risk

Ø Persons of Mexican origin Ø Young adults Ø Working uninsured Ø Illegal aliens

� ACA expected to reduce uninsured numbers

Affordable Care Act and HIPPA

� The Affordable Care Act is expected to reduce the number of uninsured people by 60% Ø Expansion of Medicaid Ø Subsidies to pay health insurance premiums Ø Federal mandate requiring citizens to enroll in an

insurance plan—penalties for noncompliance Ø Provision allowing children to remain on employer family

insurance to age of 26 � Health Insurance Portability and Accountability Act

(HIPAA) Ø Provisions for maintaining coverage if lose/leave job

Unauthorized Immigrants

� 11.3 million illegal aliens in United States (2014) Ø 50% from Mexico Ø Some illegal entry; others overstayed visa Ø Federal law mandates anyone entering ER must be

treated regardless of ability to pay � Illegal aliens are vulnerable population

Ø Indigent but not eligible for Medicare or Medicaid Ø Many do not seek care for fear of deportation

� Immigration reform highly contentious issue

Health Care in Other Countries

� Canadian health care system Ø Universal coverage; social insurance plan Ø Private plans available for unpaid services Ø Issues: two-tiered system, shortage of providers, delays in service

� German health care system Ø Nearly universal access (87%), but private insurance (10%) pays

providers better Ø Issues: two-tiered system, weakening public system, increased cost

� UK health care system Ø National health insurance—spends least on health care per capita

Nurse’s Role in Health Policy

� Advocate Ø Individual Ø Justice in health care system

� Participating in policy decision-making Ø Voting Ø Communicating with legislators Ø Running for political office Ø Lobbying though professional organizations