PHS - Ch. 4: Professional Knowledge in HI (Slides 1-13)

Ch. 4: Professional Knowledge in HI
(Slides 1-13)

1. Healthcare Delivery & Payment Systems

   • Systems Theory

   • Provider Systems

   • Payment Systems

• 💬 What issues have people noticed with the U.S. healthcare system?

• 🔄 What recent reforms or changes have been made in U.S. healthcare?

Warm-Up...

Systems Theory

🏗️ System: A group of parts that work together

⚙️ Five Important Parts of a System:

• Input (what goes in)

• Throughput (what happens inside)

• Output (what comes out)

• Feedback Loop (how the system checks itself)

• Environment (what is around the system)

🏥 Two Big Systems in U.S. Healthcare:

• Healthcare Providers (doctors, nurses, hospitals)

• Healthcare Payment (insurance, bills, payments)

🏥 Healthcare Provider System: A group of people and places that give healthcare to patients

• 💊 What They Do: Medicine, check-ups, surgery, 24/7 care

• 🏨 Examples of Facilities:

  • Hospitals

  • Long-term care facilities

  • Doctor’s offices & clinics

  • Labs & EMS (ambulance services)

  • Home health & hospice

  • And more
    

Healthcare Provider Systems

Healthcare Providers Include:

• Outpatient/ambulatory care facilities

  • Care that doesn’t require hospitalization

• Clinics

  • Offices for one or more practitioners/DR's

• Behavioral health care

  • Substance abuse, mental illness

• Independent living support

  • Home health care, adult day care, therapy

• Long-term care facilities

  • For elderly/disabled unable to live alone

• Hospice care

  • End-of-life care for terminally ill

• Emergency medical services (EMS)

  • Emergency rooms / Ambulance

🌐 Other Parts of Healthcare Provider Systems:

• Government Agencies – Help manage public health

  • World Health Organization (WHO)

  • U.S. Department of Health and Human Services (HHS)

  • State & local health programs

• Nonprofit Organizations – Support health causes

  • Red Cross

  • March of Dimes

  • American Cancer Society

Healthcare Provider Systems Cont.

Researching and Testing🔬

• 💊 Medical research and clinical trials make medicines and treatments safer

• 🧪 Lab tests on blood, tissues, and fluids help find diseases

• 🏭 Pharmaceutical companies create and test new medications

• 💻 Engineering and software companies build medical equipment and computer systems for patient records

Match

Types of Providers:

• behavioral health care

• long-term care facilities

• hospice care

• care that does not require hospitalization

substance abuse, mental illness

for elderly/disabled, can't live alone

end-of-life care for terminally ill

outpatient care facilities

• substance abuse, mental illness

• for elderly/disabled, can't live alone

• end-of-life care for terminally ill

• outpatient care facilities

Insurance Basics (review)💳

• 🏷️ Premiums: Monthly fees you pay for insurance coverage

• 💰 Deductibles: The amount you pay yourself before insurance starts paying

• 🏥 Copay: Fee you pay at the time of a service (like a doctor visit or prescription)

• 📄 Explanation of Benefits (EOB): Shows what was paid, what you owe, and your deductible progress

Healthcare Payment Systems

🏦 Private Insurance:

• Pay premiums, coinsurance, and copays

👴 Medicare (Govt.):

• For people 65+

• Parts A, B, C, D

• Private Medigap plans help cover extra costs

🛠️ Worker’s Compensation (Govt):

• Covers injuries that happen at work

🏥 Medicaid (Govt):

• Helps low-income people, children, and those with disabilities

• CHIP also covers children

⚖️ Affordable Care Act (ACA) 2010:

• Requires all Americans to have health insurance

🎖️ TRICARE:

• Health insurance for members of the armed forces

Critical Thinking🧠

• 🏥 HMO (Health Maintenance Organization):

  • Must choose doctors from a set network

• ✅ PPO (Preferred Provider Organization):

  • Use contracted doctors/hospitals at lower cost, more flexibility

• 📄 POS (Point of Service):

  • Smaller deductibles/copays, but need a referral to see specialists

• 💳 EPO (Exclusive Provider Organization):

  • Pay an access fee for a network of providers at reduced rates

Match

Insurance basics:

• The amount you pay before insurance starts covering care

• out-of-pocket fee paid by the patient at the time of service

• Shows what was paid, what you owe, and deductible progress

• The monthly fee for insurance coverage

deductible

copay

Explanation of Benefits (EOB)

premiums

• deductible

• copay

• Explanation of Benefits (EOB)

• premiums

Multiple Choice

covers injuries that happen at work

• workers compensation

• medicare

• TRICARE

• Affordable care act (ACA)

Controlling Healthcare Costs💰
📈 U.S. healthcare costs are rising - reducing the cost ⬇️

🏥 Managed Care Systems

• Help limit overuse and reduce costs

🏩 HMO (Health Maintenance Organization)

• Network of providers

✅ PPO (Preferred Provider Organization)

• Contracts with providers for lower costs

📄 POS (Point of Service):

• Requires referrals to see specialists

💳 EPO (Exclusive Provider Organization)

• Charge access fee for provider network

Think Further🤔

How Can Costs Be Controlled?

🧍 Patients

• Regular checkups & preventive care

• Helps catch problems early before they become expensive to treat

❤️Healthy lifestyle choices

• Prevents chronic diseases like diabetes or heart problems, reducing long-term medical costs

🏥 Healthcare Facilities

• Combine related services: Makes care more efficient and saves money

• Bulk purchasing: Lowers supply costs, which helps keep overall healthcare prices down

Multiple Select

What can patients do to reduce the cost of healthcare? (Select all that apply)

• go to regular dr's check ups/preventative care

• make healthy lifestyle choices

• smoke tobacco and drink alcohol

• diet and exercise