Chapter 18

Front 1

Issues in health care

Back 1

Demand vs. Supply of health care
Paying for health care
separate Billing for Nursing services

Front 2

Cost containment strategies

Back 2

competition
Price Controls:
Diagnosis-related groups DRG established pre treatment diagnosis billing categories and a payment scheduale.
Prospective Payment system PPS- limits the amount paid to hospitals that are reimbursed by medicare.
Peer Review Organizations- to protect clients from DRG abuses, made up of physicians, nurses, and other health care professionals, intend to monitor hospitals and ensure high quality care under DRGs.

Front 3

Alternative Delivery Systems

Back 3

Health Maintenance Organizations (HMO)- are group healthcare agencies that provide asic and supplemental health maintainence and treatment sercices to voluntary enrollees
Preferred Provider Organizations—PPOs: consists of a group of physicians or a hospital that provides companies with health services at a discounted rate.
Physician/hospital organizations--PHOsL are joint ventures between a group of private practice physicians and a hospital.

Front 4

Managed care

Back 4

goals are to provide cost effective, quality care focusing on improved outcomes for groups of clients. HCPs and agencies collaborate to ender the most appropriate, fiscally responsible care possible.

Front 5

Case Management

Back 5

Integrated healthcare services for individuals or groups
Focuses on wellness

Front 6

Responsibilities of Case Managers

Back 6

Assessing clients and their homes and communities
Coordinating and planning client care
Collaborating with other health professional in the provision of care
Monitoring clients’ progress
Evaluating client outcomes
Advocating for clients moving through services needed
Seeking appropriate resources for clients
Serving as a liaison with third party payers.

Front 7

Billing Methods

Back 7

Fee-for-Service: clients pay their practitioner for each health service they receive.
Capitation: healthcare providers are paid a fixed dollar amount per person for providing an agreed-upon set of health services to a defined populaton for a specific period of time.
Fee-for-Diagnosis: type of prospective payment system.
Pay for performance

Front 8

Payment Sources in the United States

Back 8

Government Health Plans: Medicare; hospital insurance, supplemental medicar insurance.
Medicaid: paus for medical assistance for individuals and families with low income and few resources.
Private Insurance:
Personal Payment:

Front 9

Socialized Medicine- United Kingdom

Back 9

state owns and controls health care production

Front 10

Socialized Insurace - Canada

Back 10

all medically necessary services are covered

Front 11

Mandatory Health Insurance- Germany and Japan

Back 11

they have sickness funds. they have large nonprofit health insurance orgaizations.

Front 12

Voluntary Insurance- U.S. and South Africa

Back 12

provides no guarantee of universality.

Front 13

Return to the Community

Back 13

home health nursing
community nursing

Front 14

Perceived Susceptibility

Back 14

A family history of a certain disorder, such as diabetes or heart disease, may make the individual feel at high risk.

Front 15

Perceived Seriousness

Back 15

the question here is: in the perception of the individual, does the illness cause death or have serious consequences? Concern about the spread of acquired immune deficiency syndrome AIDS reflects the general public's perception of the seriousness of this illnes.

Front 16

Perveived Theat

Back 16

according ro becker, perceived susceptibility and perceived seriousness combine to determine the total perceived threat of an illness to a specific individuals in the community have AIDS may not necessarily perceive a threat of the disease.