Required reading: Catalano, chapter 16
Politics is the way in which people in any society try to influence decision making and the allocation of resources. Because resources (money, time, personnel) are limited, it is necessary to make choice regarding their use.
Politics is a part of every organization and a part of government at every level.
In a democratic society, all citizens can choose to be involved at some level in this decision-making process.
"Politics":
GOVERNMENT – a broad term that refers to almost any type of hierarchical structure to organize and direct an organization.
Therefore, any health care facility can be considered a type of government that has its own politics.
….where nurses should have a considerable amount of influence.
Historically, nurses have avoided politics. But as individual citizens and as a professional group, nurses need to recognize that their personal and professional lives are affected by politics. (eg: managed care, cost containment, major daily health care changes).
As a large group of voters, nurses have the power, influence, and skill to be active in politics.
Nurses’ professional survival depends on political involvement.
Henry Adams said "Knowledge of human nature is the beginning and the end of a political education."
Nurses, who are among the most astute observers, are ideally
suited to the art and science of politics.
Why Should Nurses Be Involved?
On a personal level, politics influences:
Hannah Ropes was able to fight incompetence and obtain decent care for wounded Civil War soldiers because she understood who the influential people in Washington were.
Today, with many interests competing to be heard in the decision-making circles of our nation, the person who understands power and politics is the one most likely to obtain the resources needed to accomplish desired ends.
Health care is costly, and public dollars can be and are spent in many ways to provide health care. Legislative and administrative decisions of governmental agencies determine what part of the federal and state budget is allocated to health care, how much is used for preventive health programs, how much for research, how much for care & treatment, how much for education, and what diseases are targeted for investigation.
Decisions are also made in health care agencies. What positions will be funded, what equipment purchased, what programs should be adopted and which of the current programs should be dropped.
Knowing where decision making occurs, who makes the decisions, and being familiar with how you can influence that process is important.
POLITICS INFLUENCES NURSES’ PROFESSIONAL STATUS THROUGH LICENSURE AND CERTIFICATION
Nurses’ practice is controlled by the Nurse Practice Act of each state.
The NPA legally defines nursing and the scope of nursing practice is outlined in that document.
Nurses experience effects of government regulation directly:
A set of activities, methods, tactics, and behaviors that affect or have the potential to affect governmental and legislative processes and outcomes.
(eg: grass roots efforts to change policy, activities of lobbyists to change elected officials’ opinions or votes, give & take of political compromise within legislative bodies, power of veto by president)
Government is influenced by the forces that drive politics and the three concepts that constitute it
Refers to membership in a political party (Republicans, Democrats, Independent)
Self-Interest
Most important factor in politics
Dictates the kind of issue legislators become involved in and present to their constituents as the key issues. (eg: Catholic majority population – Congress- man is pro-life)
In electoral politics, principle of self-interest means that an elected official will not make legislative or political decisions that could lead to professional damage or cost an election.
Ideology
Exception to self-interest rule:
Elected official was so ideologically committed to an issue that he/she defied conventional wisdom and made decisions that went against self-interest
Ideology is a broad concept that embodies beliefs and principles of an individual or group (eg: conservatives, liberals, radicals)
Conservatives:
support less government regulation and involvement in
everyday life, fewer taxes, and smaller social programs
(LESS government = BETTER government)
Applied to current range of issues, tend to be pro-life,
anti-gun control, favor individual rights to choose type of education for
children
Liberals:
Believe government has a moral responsibility to do good
for society
Believe government intervention is necessary for the
greater good of citizens
Translates into:
larger government structures
increased taxes to fund social programs
larger government spending for wide
range of social programs
Are traditionally pro-choice, pro-gun control, anti-choice
on education
Populists:
Probably the most dominant political force in America
at the grassroots level
Oppose high taxes
Represent a variety of positions on most other issues
"the middle class is under siege" theme
Libertarians:
Both a political party and an ideology
Represent a political fringe element
Believe in fiscal conservatism and oppose high taxes
Believe in individual liberty and oppose big government
Radicals:
Exist at either end of the ideological spectrum in both
parties
Attempt to force their parties to the extreme ends of
the spectrum.
UNDERSTANDING THE PLAYING FIELD
Three branches of government:
EXECUTIVE BRANCH:
Federal level
President
Vice President
Cabinet
Various executive administrative bodies
State level
Governor
Boards and commissions because they are appointees of
chiefexecutive
Local level
County government
County commissions
Mayor of larger city
JUDICIARY BRANCH (court system)
Federal level
Supreme Court
Federal Courts of Appeal
District or Circuit Courts
State level
Supreme Court
Appeal Court
Lower Courts
(Federal and state are different…but appeals and supreme courts are found at both levels)
Several important issues have been decided by courts that have an effect on the practice of nursing
(eg: Supreme Court’s decision regarding the rights of nurses to organize into collective bargaining units; requirement of health care providers to report potentially violent parents to the police; obligation of nurses to refuse to carry out physician orders they deem dangerous; criteria for when nurses can withdraw life support measures)
LEGISLATIVE BRANCH
Federal level
House of representatives
Senate
State level
House
Senate
(except Nebraska)
Primary function of legislative branch is the formation
of plicy by the making of laws
KEY PLAYERS IN FORMATION OF POLICY (AGENDA) AND THE LEGISLATIVE PROCESS
Legislators are human and respond to the same forces as others (interpersonal dynamics, peer pressure)
Majority leader of the House supervises and directs the activities on the House floor
This is considered the most powerful job in politics
The majority leader has control over the legislative calendar which ultimately determines
Is responsible for collecting votes when legislators are
leaning toward voting against their party
Negotiates on the House floor for votes necessary to
pass a bill (calls in favors)
Minority leader
Represents party that does not have a numerical majority
Helps organize support against bills introduced by majority
leader
Presents alternative point of view
There is a saying: "The majority will have their way.
The minority will have their say."
Majority party has capacity to pass any bill. Minority
leader has capacity to speak out against it
Legislators almost never vote against "Mom, Pop, or the
Little Guy", even if they have to go against their party.
Caucuses
Formed when legislature divides into grou0ps made up of
people with mutual interests (eg blacks, women, Hispanics, business community)
Operate as a unit
Trade on their capacity to bring a block of votes for
or against an issue or bill rather than an individual vote
May be bipartisan
May be partisan
Largest caucuses are Democrats and Republicans
Media and voters are external factors that influence
policy makers
Media has become powerful. Often shapes public opinion.
Before TV, the newspaper printed candidates’ speeches. Public could read and make up their own minds.
Now TV gives a 30 second byte out of the speech and 30 minute to 1 hours interpretation by the commentator.
THE POLITICAL PROCESS
Who introduces legislation?
1. Any elected official, including governors, mayors, county commissioners, city council members.
They go to legislative leadership of the party and ask them to submit a bill or to help move the bill through the legislative process.
2. Lobbyists, constituency groups (eg AARP) and advocates (eg abortion rights) are a major source of proposed legislation.
3. Governmental agencies
What issues drive the development of legislation?
Any legislator can introduce any bill from any source
Additional legislators can be co-signers
After bill is introduced, it is taken to the chief clerk and assigned a number that permits tracking during the process.
After number is assigned, bill goes to committee (House or Senate decide which one)
Most bills die in committee. (If leadership wants bill to die, bill is referred to a committee where it will never be voted on or passed on to the House)
It is within the committee structure that most of the work of Congress is done
Committee action is where the most intensive consideration is given and where people are given the opportunity to be heard
The sub-committee studies the issue carefully, holds hearings and reports back to the full committee with recommendations.
In Congress the committees with greatest jurisdiction over health matters are:
If committed, the sponsor will trade on their Political Capital (favors)
After bill has been reported out of House Committee it goes to the Rules Committee which schedules bills and determines how much time will be spent on debate and whether or not amendments will be allowed.
(Exception to this: Ways & Means Appropriations Committee)
After a bill is debated, possibly amended and passed by one chamber, it is sent to another chamber and goes through the same process.
If the House and Senate have different versions of the same bill, the bill then goes to the Conference Committee to resolve the differences between the two bills.
If the bill passes both the House and Senate it is sent to the Chief Executive or at State level to the governor, who signs or vetoes.
President only can do a "Pocket Veto"… he simply does not sign the bill and it does not become law. If vetoes, it goes back to House and Senate.
To override a veto requires 2/3 vote of both chambers.
All bills passed need a fiscal note attached to them.
No note – does not become a reality.
THE FEDERAL GOVERNMENT’S ROLE IN HEALTH CARE
Federal legislation has affected nursing and health care in many ways.
Federal agencies related to health care:
Every two years, when the biennial budget is passed, nurse try to rally congressional support for additional funding for nursing education.
Funding for nursing research is increasing:
1998 - $63.5 million
1999 - $69.8 million
Required difficult and costly implementation.
Many feel that these regulations have positively affected the care environment in nursing homes.
The budget bill for 1999 established a prospective payment system for skilled nursing facilites that resulted in decreased payments from Medicare and Medicaid. Many groups lobbied Congress for change. Late in 1999, Congress amended the funding formula to restore some of the funds that had been cut.
The ANA is preparing to support some strongly and to monitor the progress of others.
These new regulations have been opened for comment. The
ANA has expressed concern over the impact of some of these regulations.
The final rules are expected to be completed in 2001.
Why Organize or Be Politically Active?
YOU can have an effect on such things as what health care legislation is submitted, the content of the legislation, and what legislation is passed.
But this takes effort and action. Each person must decide his or her own personal level of involvement.
Some ways to become involved include:
FIRST STEP IN BECOMING POLITICALLY ACTIVE: IDENTIFY GOALS THAT NURSES AS A GROUP WANT TO ACCOMPLISH
Nurses recognize important issues in today’s health care.
What can one nurse do?
Success in the political arena is contingent on
The first step in becoming successful in the politcal process is to BE INFORMED!!!
Recognize that anyone interested in being politically active needs
Know the issues. The best source of information on legislative issues affecting nursing is Capitol Update, the ANA legislative newspaper.
"Know thine enemy"
Demographics
Total population of the state
Total number of registered voters
Total number of registered voters by political party
Total number of likely voters
Total number of registered nurses
Support candidates who favor nursing and its agenda,
regardless of party.
Increased political power by making alliances with constituency
groups which support similar issues.
After organization – Drafting Legislation and Creating Change
Who is the decision maker?
eg: Board of Nursing
Each member is appointed by the governor
What is the basis of the appointment
How accessible is appointee’s benefactor?
May have been appointed by legislative leadership instead
of the governor.
Even if a bill favorable for nurses or health care does
not pass the first time
Primary purpose of ANA-PAC: To support and elect officials concerned about nursing issues.
The best way to influence the legislative process is to speak in a unified voice (ANA)
THE MOST EFFECTIVE WAY NURSES CAN INFLUENCE
POLICY AFFECTING NURSES AT THE NATIONAL LEVEL IS TO ALIGN THEMSELVES WITH
ANA-PAC!!!
HOW TO WRITE A LETTER TO YOUR LEGISLATOR
For State Senators:
The Honorable ____________
The Senate of Texas
P.O. Box 12068 – Capitol Station
Austin, Texas 78711
For State Representatives:
The Honorable _____________
Texas House of Representatives
P.O. Box 2910
Austin, Texas 78769
Where to write:
TEXAS
Governor:
Governor Rick Perry
State Capitol, Room 2S.1
Austin, Texas 78701
(800) 252-9600 (512) 463- 1849 (fax)
State Representative:
Barry Telford
105 NW Johnson
DeKalb, Texas 75559
(903) 667-5514
State Senator:
Bill Ratliff
P.O. Box 1218
Mt. Pleasant, Texas 75456
U.S. House of Representatives
Rep. Max Sandlin
214 CHOB
Washington, D.C. 20515
(202) 225-3035
www.house.gov/sandlin/
U.S. Senate
Senator Phil Gramm
370 RSOB
Washington, D.C. 20510
(202) 224-5922
(202) 224-2934
Senator Kay Bailey Hutchison
284 RSOB
Washington, D.C. 20510
(202) 224- 5922
senator@hutchison.senate.gov
ARKANSAS
Governor
Mike Huckabee
State Capitol, Room 250
Little Rock, Arkansas 72201
(501) 682-2345
State Representative
David Haak
1810 Gilliland Drive
Texarkana, AR 71854
State Senator
Barbara Horn
US House of Representatives
Rep. Mike Ross
2453 RHOB
Washington, D.C. 20515
US Senate
Sen.Tim Hutchinson
245 HSOB
Washington, D.C. 20510
(202)224-4843
senator.Hutchinson@hutchinson.senate.gov
Sen. Blanche Lincoln
359 DSOB
Washington, D.C. 20510
(292) 224-4843
blanche_lincoln@lincoln.senate.gov
President of the United States
President George W. Bush
1600 Pennsylvania Avenue NW
Washington, D.C. 20500
(202) 456-1414
Vice President of the United States
Vice President Dick Cheney
1600 Pennsylvania Avenue NW
Washington, D.C. 20500
(202) 456-2326
How to obtain a copy of a bill:
For a Senate bill, write or visit (no telephone requests filled) the Senate Documents Office, Washington DC 20510; for a House bill, write the Doorkeeper of the House, US Capitol, Washington DC 20515.
Ask for the bill by number and enclose a self-addressed and gummed label for fastest service. There is no charge.
Requests are normally filled the day received, unless the bill is out of print, and sent via first class mail. There is a limit of six items per day per person, and of three copies of one bill per person (or of one copy per bill if the bill is 60 pages or longer.)
Request a copy of a state bill from the appropriate state legislator.
Copies of a hearing record can be requested from the committee conducting the hearing although they usually are not ready for distribuion until several weeks after the hearing.
An alternate to the above procedures, for federal bills
and hearing records, is to request a copy from your appropriate senator
or representative.
HEALTH CARE DELIVERY SYSTEM
Required reading: Catalano, chapter 18
HISTORY OF HEALTH CARE
Has been evolving since before the Declaration of Independence was signed
Remedies and nursing procedures were originally handed down from one generation to another.
Remedies were combined with superstitious and spiritual rituals.
Health care was provided in the home by women and midwives
Early health care involved minimal knowledge.
Hospitals were places people went to die.
As technology and pharmaceutical industry evolved, however, hospitals evolved into acute care facilities for care, treatment, and recovery.
The American Hospital Association developed an important
document:
THE AHA Patient's Bill of Rights
(see Catalano, pp 126-127)
Among other rights, this document
outlines the patient's right to considerate and respectful care, the right
to expect that all communications and records pertaining to his care should
be treated as confedential, and the right to refuse treatment to the extent
permitted by law.
Acute care was gradually moved from home to hospital and became known as secondary intervention.
An undesirable outcome resulted from centralization of health care: a focus on ACUTE CARE ... individual responsibility for self- care was minimized.
To meet demands for interventions such as transplants
and open-heart surgery, centralized hospitals were developed to draw clients
from large geographical areas. (eg Methodist Hospital in Houston and Arkansas
Baptist)
Centralized hospitals offering advanced services provde
what is known as tertiary intervention.
As secondary and tertiary interventions became more popular,
less attention was devoted to primary intervention
(primary intervention focuses on health promotion, illness
prevention, early diagnosis and treatment of common health problems)
Delivery of health care became centralized within hospitals. Concerns about costs were diminished because third party reimbursers were responsible for paying for large portions of the bills.
Health care was removed from the hands of consumers as clients became pawns in an expansive, expensive, and highly technical system.
Consumers, health care providers, and third party reimbursers were satisfied with the system until it became obvious that costs were out of control and millions of Americans had little access to health care.
It also became apparent that failure to focus on promoting
health and preventing illness was resulting in unnecessary suffering and
death.
HOW TO SOLVE THESE PROBLEMS
Health care is moving toward a decentralized system or OUTPATIENT CARE.
This move to outpatient based care is an important recent change in the focus of health care.
Emphasis is on health promotion, illness prevention, and self-care.
Implementation of cost-containment measures
Nurses must understand the need to function independently and autonomously.
Third party reimbursers must be aware of important role of nurses.
MEMBERS OF HEALTH CARE DELIVERY SYSTEM
300 job titles used to describe health care workers
physicians, physicians assistants, social workers, physical
therapists, occupational therapists, respiratory therapists, clinical psychologists,
pharmacists, nurses (RN, LVN, case managers, nurse practitioners, clinical
nurse specialists)
Physicians (4 groups):
Chiropractor: has not attended medical school. not licensed to prescribe medications or to do surgery. Very limited in scope of practice. Focus is on spinal column and its effect on nervous system. Makes "therapeutic adjustments" of vertebrae.
Podiatrist: Some are Board certified Foot Surgeons or Board Certified Diplomate of Pain Mangement. Associate American College of Foot and Ankle Surgeons. Limited scope of practice.
Focus on diagnosis and treatment of feet. uses medications and corrective devices, special shoes and surgery to treat ordinary foot conditions (eg corns, callouses, bunions, heel and bone spurs, plantar warts, fungus, disorders of diabetics’ feet)
Among MD’s and DO’s, family practitioners are gradually becoming primary care providers.
They may refer clients to specialists (this channeling of clients came about because of efforts of managed care companies to limit high cost of specialists)
For many years, physicians were at the top of health care delivery system. They wrote orders and everyone else carried them out.
However, more and more today, assessments, diagnoses, interventions, and evaluations of outcomes are no longer exclusively carried out in hospitals or in doctor’s offices because:
Physician Assistants
Began after Vietnam War when medical corpsmen returned and wished to pursue further medical education.
Always closely aligned with physicians
Have no individual license. Practice under license of supervising physician as regulated by Medical Practice Acts in each state.
Responsibilities:
assessment
history taking
delineation of health problems
performance of routine procedures
implementation of individualized treatment plans
client education
counseling
Most commonly employed by hospitals, clinics, and group
practices
Well accepted by the public
Perceived to provide valuable and effective health care
services
Social Workers
Provide direct social services to clients in community
and hospital settings
Interventions are directed toward resolving problems
(financial, housing, employment, psychosocial*)
*psychosocial: mental health, social status, functional
capacity
Coordinate services in case management
Involved in discharge planning and transfers from one
care environment to another.
Physical Therapist
Focus on helping individuals maintain or regain the highest
level of function possible after stroke, spinal cord injury, arthritis,
residual effects of trauma (neurological & musculoskeletal)
Prevent physical decline
Assist to regain ability to groom, eat, walk, etc.
Accomplished through range of motion (ROM) and exercise
programs
Work in hospitals, clinics, community (home health) Temple
Memorial Treatment Center (tertiary care)
Train clients to use assistive devices (canes, walkers,
braces, wheel chairs)
Occupational Therapist
Focus on enhancing quality of life of individuals who
have had strokes or spinal cord omjuries that inhibit activities of daily
living (ADLs)
Care is directed toward maintaining or regaining meaningful
roles within and outside the home
Hone skills needed in work setting and home
Respiratory Therapist
Strive to restore normal or near normal pulmonary functioning
Conduct diagnostic tests
Administer treatments prescribed by physician (eg IPPB)…
once was part of nurses’ domain
Clinical Psychologist
Assist clients to manage mental health problems
Becoming harder to secure third party reimbursement for
out patient services
Psychologists formerly in private practice, now seek
salaried positions where focus is on diagnosis and short term interventions
Pharmacist
Monitor appropriate medication selection
Distributors of prescribed and over-the-counter (OTC)
meds
Educate clients
Detect interactions and untoward responses
Registered Nurse
These nurses traditionally worked in hospitals
Now, due to current trends in funding, community and increased the need for nurses who can function autonomously.
REASON FOR DECREASE IN PROFESSIONAL NURSING POSITIONS IS COST REDUCTION
Advanced Practice Nurses
Confusion between Clinical Nurse Specialists (CNS) and Nurse Practitioners (NP)
Nurse Practitioner:
Provides direct care in primary settings, focusing on health promotion, illness prevention, early diagnosis and treatment of common problems
Often employed in Dr’s offices and health clinics
Preparation: R.N., Nurse Practitioner Program, then certified by American Nurses Credentialing Center (ANCC)
Funding: 11 states now grant NP’s direct 3rd party reimbursement for services without a physician.
Clinical Nurse Specialist:
Practice in secondary (hospital) or tertiary (rehab, long term) care setting
Focus on care of individuals with acute illness or exacerbation of a chronic illness
Certified by ANCC
Highly skilled
Excellent health care educators and physician collaborators
Attempts have been made to combine roles of CNS and NP
Supported by NLN, ANA, AACN (American Association of Colleges of Nursing)
Titling is unconfirmed. State legislatures will make final decision
Titling, educational preparation, and practice will vary from state to state.
One argument for blended NP-CNS roles is the need for case managers.
Case Managers
Coordinate services for patients’ with high risk or long term health problems.
Provide services in acute care facilities, rehab centers, and community agencies
Work for managed care companies, insurance companies, and private case management agencies
Roles vary
Overall goal is to coordinate use of health care services in the most efficient and effective manner.
Managed care reduces costs by providing more health promotion, and illness prevention services.
Case Management
Is the glue that holds health care services together.
Case managers can be physicians, social workers, R.N.’s
and lay people with little health care education
ANCC has developed certification eligibility criteria
and an exam is available.
FACTORS INFLUENCING HEALTH CARE DELIVERY SYSTEM
1. Demographics
Age. By 2050 one of every 5 Americans will be 65 or older
(80 million)
Rural – remote areas
The most significant demographic factor in health
care is the rapidly increasing older age of population.
2. Long term, expensive problems (cancer, heart disease, Alzheimers, etc)
Environmental and occupational safety drug abuse, mother & child care
3. Health Care priorities
Health promotion
physical fitness, good nutrition, decreased us of alcohol and tobacco, family planning, preservation of mental health, and community support services
Health protection
Decreased numbers of accidents, occupational safety and health, improved oral hygiene, food & drug quality
Preventive Strategies
Cancer, HIV, mother & child care, stroke, heart disease, infectious diseases
Emphasis on access to services
4. Rising costs
1996: Health care costs exceeded $1 trillion ($3759 per
person)
Little attention paid to cost control
High cost of technology
Increased need for long term care
Uninsured
Limited ability and motivation of consumers to compare
health care prices
CAUSES OF RISING HEALTH CARE COSTS:
Who pays for health care?
All levels of government
Private enterprise
Innovative commercial financing
NURSES MUST BE FAMILIAR WITH REIMBURSEMENT PRACTICES BECAUSE:
Understanding health-care
reimbursement allows nurses to be informed client advocates!!
PRIVATE HEALTH–CARE INSURANCES
In 1998, 70.2% of Americans had insurance
Blue Cross/Blue Shield (not for profit)
Paid premiums and received hospital services (point of service plan)
Dr’s became involved when they saw a guarantee for their services and a chance to deter government sponsored national health insurance (socialized medicine)
Controlled by hospital board (made up of Dr’s) which poses ethical question… Those receiving payments had the most control over establishing prices.
Criticized due to treatment of illness. Little emphasis on prevention.
PROBLEM: doctors serving on Blue Cross board and administering federal health programs.
Blue Cross/Blue Shield size had an impact on legislation
but they have not led the way toward a primary health care focus.
Indemnity plans – client has a co-pay. Surplus is paid
to share holders (royalty vs quality care)
Advantages:
GOVERNMENT-FUNDED HEALTH CARE
Blue Cross/Blue Shield in 1930s slowed movement toward government involvement. By mid 1960’s it was evident that changes were need for elderly and indigent.
1965 Medicare-Medicaid was established.
Medicare
A federal program financed through employee payroll taxes.
It covers all persons over age 65, permanently disabled
and their qualifying dependents, and end stage renal disease patients.
Part A
Part B
Purchased monthly. Covers Dr’s services, outpatient care, lab tests, durable medical equipment.
Does NOT cover out patient medicines, long term care. Health promotion/illness prevention is limited.
Medigap policies are purchased to cover what is left in expenses.
When designed, no cost containment incentives were included – nor was the cost/benefit ratio of services taken into consideration.
(eg Heroic measures to save life with little consideration given to quality of that life.)
Prospective Payment System was implemented in 1983- system in which hospitals are reimbursed based on a fixed rate, with incentives to decrease length of stays (DRGs)
The primary form of prospective
payment system is Diagnosis-Related Groups (DRGs)
Reimbursement for hospital
services is made according to this classification system of disorders (DRGs).
Based on the particular DRG in
which a client is placed, hospitals are reimbursed for a predetermined
amount.
Medicare Utilization and Quality Peer Review Organization
was
instituted to prevent misuse of DRG and maintain quality care.
Cost shifting is common. To make up for loss due to DRG, clients with other forms of insurance are charged inflated prices, (eg $7 for one aspirin)
Under DRG’s, physician reimbursement was untouched. They continued to be paid based on customary, prevailing, and reasonable charges (geographic area).
AMA resisted attempts to control physicians’ costs and as a result 1961-1991 the price of physician services went up 6 fold.
1989 Congress passed legislation in an attempt to control physician costs.
The increased number of baby boomers and the decreased
number of those paying taxed may make national health insurance inevitable.
Congress passed legislation that penalizes any doctor for accepting out-of-pocket
payments for Medicare reimbursable service. Penalty – not eligible for
Medicare funds for 2 years.
Medicaid
State administered entitlement program for the poor
Each state customizes its program based on the needs of its residents
Eligibility and services vary because financial status of each state is different
1996 paid out $147.7 billion
Services covered include:
hospitalization
diagnostic tests
outpatient services
physicians’ visits
rehab
nursing home after pt’s funds are gone
States may offer Home Care for which they receive matching Federal funds
All doctors don’t participate.
Some states accept medically indigent. (not poor but medical expenses would create a hardship) This is an example of how health care financing is moving toward government controlled system.
Uninsured
1996: 12.7 million Americans were without health insurance
Insured receive 90% more hospital services and 54% more ambulatory services than uninsured.
Large number of uninsured was one of the reasons for health care reform.
White collar workers have better benefits than blue collar workers.
HEALTH CARE REFORM
For the past 10 years, attempts have been made to increase federal involvement in health care. Such attempts have been successfully thwarted by conservatives in the legislature who fear enormous tax increases with such a plan, as well as gov’t interference with private practice of physicians.
Nurses, through ANA, took an official stand calling for employer mandated coverage.
GROUP PRACTICE ARRANGEMENTS
Three or more doctors or NP’s formally organize to give medical care.
Distribute income according to pre-arranged plan. Share equipment, records and personnel.
Advantages:
preserve ideal of private entrepreneurship
attractive to providers who hire professional managers
offer prividers more time off, better client coverage
employ an array of specialists.
INDUSTRY’S EFFORTS TO MANAGE COSTS
Managed care
term used to describe health care services that are administered to enhance their efficient and effective use
primary purpose is to deliver, finance, buy and sell quality health care services.
Costs are limited by:
Pre-certification:
Managed care consists of administrators, providers, and
physical facilities (hospitals)
Managed care uses Case Management and Primary Care Nursing
Administrative structures characteristic of managed care include:
HMO – Health Maintenance Organization
IPA – Independent Practice Association
IPO – Independent Practice Organization
PPO – Preferred Provider Organization
POS – Point of Service
Health Maintenance Organization (HMO)
Primary purposes of HMO:
ensure profits by decreasing referrals to specialists
restricting diagnostic studies
decreasing client hospitalizations
decreasing length of stays
Capitated Payment System
Participants pay a flat rate,
usually through the employer, to belong to HMO for a prescribed period
of time.
Expenses incurred in excess of capitated rate during contract period are considered financial losses.
Amounts that remain after services are rendered are profit.
Ideal HMO is a large pool of healthy people who require few services and relatively few unhealthy clients who require expensive care.
Advantages of HMO:
premium is paid
care is free (small co-payment) ir designated providers
are used
cost containment incentives are in place
Disadvantages of HMO:
limited number of providers
client must select provider from a provider panel
Variation of HMO
organized by doctors
clients pay on a fee-for-service
basis rather than with prepaid premiums (this
is the primary difference between HMOs & IPAs)
hospitals and doctors adhere to utilization guidelines
Preferred Provider Organization (PPO)
Type of managed care
Contracts with limited number of health care facilities
Physicians paid fee-for-service and client is charged
each time
The PPO extends benefits
beyond the use of their services (at an increased rate)....
this is a major advantage that PPOs have over HMOs
Point of Service (POS)
Similar to PPO
Clients are allowed access to designated practitioners
outside the panel for an additional fee
Functional nursing is a task
oriented care delivery model, resulting in fragmentation of care
Primary care nursing focuses on the whole person.
The nurse is responsible for all client’s needs.
Quality Assurance = Low costs & Quality care
CQI – continuous quality improvement. Term borrowed from business
1994 – JCAHO began requiring hospitals to implement CQI strategies
CQI – also called Total Quality Management (TQM)
Emphasis is place on meeting and exceeding client expectations
Nurses are in excellent position to implement CQI strategies, since they assess on a daily basis how the health care delivery system is functioning and the effectiveness of care. (eg: saline flush instead of heparin … saved one hospital $70,000)
HEALTH CARE AGENCIES
Outpatient care
Also called alternative ambulatory service
Factors that led to outpatient care:
Nursing Homes and Long Term Care Facilities
Generally provide care for 2 types of patients:
5% of population is in nursing homes
Today 75% of nursing homes are for profit institutions, and rely heavily on Medicaid and Medicare reimbursements.
Assisted Living Centers
have the advantage of allowing clients to maintain the greatest amount of independence possible, while providing a protected living environment where assistive services are available as needed.
Adult Day Care Centers
In an attempt to meet the psychosocial needs of a growing number of individuals, adult day care centers are available for elderly clients who need supportive care for physical problems, organic brain syndrome, or mobility problems.
Care is available during the day. The client returns home at night.
Act as an alternative to a nursing home.
Home Care Agencies
Provide services previously provided by public health nurses
Nurses may work for hospital-based or local independent agencies, regional national chains, or private duty registries.
To supplement services home health aide and homemaker assistance is available.
Hospice
Philosophy originated in Great Britain
Designed to offer compassionate care to the terminally ill and their family members. (criteria for admission: must have only 6 months or less to live)
Services are provided in homes or institutional settings
Psychological support, respite care for family members, comfort and pain control measures are common interventions
Preservation of client and family dignity, integrity, and overall well-being is of utmost importance.
Community Health Centers
Provide services primarily for medically underserved and disadvantaged people
Supported by federal funds, and their focus is on health promotion and disease prevention
Some community centers offer emergency assistance, home care, mental health counseling and rehabilitation support, diagnostic lab and pharmaceutical services
Since Medicare funding has been cut, sliding-scale fees are relied on. Clients pay differing amounts based on their income.
School –Based Health Care
School nurse provide these services: screenings, health promotion, illness prevention programs, treatment of minor health problems
Emphasis is placed on physical, social, and psychological well-being
Workplace Health Centers
80% of businesses employing 50 or more workers have some
sort of health program
Nurses usually staff industrial centers
Nurse Run Health Centers
Similar to community centers, nurse-run centers focus
on health promotion and illness prevention... wellness services such as
wellness education, health screening, and annual physical examinations
are provided.
Nurses have autonomous practice
(eg Wadley Life Source in Central Mall)
Often owned and operated by nurses
Public Health Departments
Administered by state, county or city governments
Emphasis is now on prevention and management of acute
and chronic conditions rather than home care
Focus of public health depts. include: prenatal care,
children’s health, detection and treatment of TB, control of STD’s, mental
health problems
Parish Nurses
2000 Parish nurses
work part time or in conjunction with community based
centers and churches
Churches engage parish nurses to
Voluntary Health Agencies
Anti-TB Society of Philadelphia (1st)
American Cancer Society
The American Heart Association
The National Foundation of March of Dimes
The National Easter Seal Society
Alliance for the Mentally Ill
Rural Health Care
A challenge
rural hospitals closed
rural health care delivery problems are being overcome
through integrated delivery networks that provide primary, secondary, tertiary
care to residents in designated areas
paying for services is a problem - HIPC’s (health insurance
purchasing cooperative)
Study Questions