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Chapter 6
Health Care
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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The Progression of Payment for
Health Care
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Up until the late 19th Century – Care was provided in
the home
Early 20th century - People paid for services in
hospitals
Mid 20th century – Medicare and private insurance
companies entered the health care arena
By the late 20th century – costs had risen
exponentially and insurance companies began to
look for more cost effective ways to pay for health
care
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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Factors That Influence the Financial Burden of
Health Care in the United States
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Demographic influences
Uninsured individuals
Medical technology
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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Health Insurance Plans
Private health care payment sources
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Private insurance
Point of service plans
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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Health Insurance Plans
U.S. Government Insurance Plans
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Medicaid
State Children’s Health Insurance Program (SCHIP)
Medicare
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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Medicare
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The U.S. government’s largest health care
financing program
Administered by the Social Security
Administration
Covers elderly and disabled people
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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Medicare (Cont’d)
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Part A – Hospital Insurance
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Pays for hospital stays
Pays for skilled nursing facility for up to 100 days
(not for custodial or long-term care)
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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Medicare (Cont’d)
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Part B – Medical Insurance
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Physician
Nursing services (home care for specific skilled need)
X-rays, lab work, diagnostic tests
Ambulance transport (limited)
 Flu and pneumonia vaccines
 Dialysis
 Medications for organ transplant recipients
 Chemotherapy
 Durable medical equipment (DME)
 Prosthesis
 Oxygen
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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Medicare (Cont’d)
Part C – Medicare Advantage Plans
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In order to reduce costs, Medicare participants were
given the opportunity to select a Medicare plan
through a private insurance company. These are also
known as Medicare+Choice plans.
These plans are similar to private insurance plans
where referrals are required to see specialists and
pre-authorizations are required for procedures.
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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Medicare (Cont’d)
Part D – Prescription Drug Plans
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Began January 1, 2006
Anyone using Part A and Part B coverage is eligible for Part D,
but they must enroll in a stand-alone prescription drug plan.
Anyone enrolled in a Medicare Advantage Plan will enroll in a
Medicare Advantage+Prescription Drug Plan.
Each Prescription Drug Plan chooses which drugs they choose
to cover and at what payment tier they wish to cover.
It is up to the insured to look over all of the plans to see which
plan covers the biggest portion of the drugs they use.
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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Medicare (Cont’d)
Hospice
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Additional coverage for Medicare recipients during
the last 6 months of life
Provides home care (on a 24-hour basis if needed)
Palliative management of pain
24-hour interdisciplinary team
Volunteers
Bereavement care to survivors after the death
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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Health Care Is Rapidly Changing
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Many changes in past 10 years
Nurse works with the case manager to
advocate for the care the patient needs
Sadly, the reimbursement method often
dictates much of the care available to the
patient
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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