The following objectives should be met by the end of this first module:
- Review the history of the health care system in the United States highlighting trends in morbidity and mortality, social welfare, federal initiatives, workforce and comparable health care systems.
- Apply HSO model of management to this chapter using environmental forces that are discussed.
- Understand the current structure of the US healthcare system.
- Define types of HSOs in the US by level of care provided, ownership, and "for profit" vs. "not-for-profit".
- Define education criteria for a health service administrator.
- Review and understand major state and federal regulatory guidelines for HSOs
- Describe sources and funds for healthcare and define DRGs and RBRVs.
- Define and state the significance of UR, PSROs, and PROs.
These notes are intended only to supplement your readings. The best way to ensure each module is absorbed is to complete all the readings prior to reviewing these lecture notes. I will try to highlight what I believe to be the most important topics from your module readings. If you have any questions or concerns or there is something you do not understand, please ask me. You can either post on the webboard the question you have (that way others can benefit from the response), or you can e-mail me if you want a more private response. Either way it is extremely important that you have a complete and thorough understanding of the material for the module. Good luck and have a great semester!
This chapter is included to expand the model that was introduced in module #1. This chapter explains several external and internal forces that impact upon our model. The three major forces in healthcare are financial, regulatory and provision of healthcare services. If you can understand the basis of these three forces and how they were developed and how they are changing, you can gain insight into any type of health care system, not just the United States.
Financing of health care is defined as the money that is provided to fund services needed by patients. Where is the money coming from and how does it get paid? Currently, the majority of funding for healthcare services in the US comes from insurance. This includes both federal insurance (Medicare and Medicaid) as well as privately owned insurance (Aetna, Prudential). Other funding comes from out of pocket by the patient themself. Regulation of healthcare involves the rules and laws that are passed that restrict, in some way, the provision of healthcare services. These may be tightly linked to funding and in this way an organization can be both a financier and regulator of healthcare (such as Medicare). For example, Medicare states that for an organization to receive federal money it must be credentialed by JCAHO. This is both regulation and financing. Finally, provision of health care involves "who" is providing the services. This means the healthcare workforce. Who is paying their salary, what is their incentive and who are they working for? All of these questions can help to further explain how provision of healthcare affects the system. In a country where socialized medicine is practiced (ex. Canada) the government performs all three roles, they are the financiers, the regulators and the providers of healthcare. That is not true in a market based healthcare system such as the United States.
The chapter starts out by defining the goals for a healthcare system and suggests keeping them in mind while learning about the rest of the healthcare system. You should know from organizational management, these goals then dictate any actions taken by an administrator.
- prolonging life and preventing premature death
- minimizing departures from physiological or functional norms by focusing attention on precursors of illness
- minimizing discomfort
- minimizing disability
- promoting high-level wellness or self-fulfillment
- promoting high-level satisfaction with the environment
- extending resistance to ill health and creating reserve capacity
- increasing opportunities for consumers to participate in health matters
The provision of services for healthcare is reviewed by defining health service workers. The US government is the only organization that employs more workers than healthcare. The workers areessential because healthcare is primarily a service industry. It cannot function without workers. Healthservice administrators, physicians, allied health care providers are all reviewed.
Regulation of healthcare is provided by both federal and state governments as defined by our constitution. Health care planning, utilization and inspections of facilities are all regularly reviewed for compliance. Professional associations are groups that represent professionals such as physicians, managers, nurses, etc. These organizations help to regulate the providers of healthcare themselves. They provide ethical guidelines for conduct and impose punishment when rules are broken. They also are the primary enforcers of standards for licensure and accreditation for healthcare professionals.
Lastly, financing of health care in the United States can come from three areas, federal funds, state funds, or personal funds. Expenditures for health care have been on the rise for the past three decades and recent changes in the financing system have been made to try to decrease these costs.
Our healthcare system has progressed through periods of regulation, competition to corporate restructuring. Managed care concepts have most recently directed the changes that the system has seen. Through a basic understanding of financing, regulation and provision we can better understand any changes and effects on the HSO as administrators.
That is it for notes for module #3! Let me know if you have any questions.