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Chapter 7

Chapter 7. Health Care Organization and Financing. Historical Developments. National Health Insurance (social insurance) Germany, 1833 1921 Shepherd-Towner Act Gave matching funds to states that would provide prenatal and child health care. Historical Developments.

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Chapter 7

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  1. Chapter 7 Health Care Organization and Financing

  2. Historical Developments • National Health Insurance (social insurance) • Germany, 1833 • 1921 Shepherd-Towner Act • Gave matching funds to states that would provide prenatal and child health care

  3. Historical Developments • 1965 President Roosevelt’s Great Society • Medicare and Medicaid • States and federal government accountable for long term care • 1980s DRG’s • Determined length of inpatient care • Growth in home care

  4. Insurance-Based Care • Public insurance • Medicare • Medicaid • TRICARE • Insurance-based care • Purchased by employer/employee

  5. Private Insurance • Massachusetts Health Insurance Company • First private plan in the United States • Montgomery Ward first company to provide benefits to workers unable to work due to illness or injury • 1920s Blue Cross plan started

  6. Private Insurance • Third Party Payer • Company that pays for health care for a business or individual • Insured individual first party • Second party is the business/company individual works for

  7. Private Insurance • Retrospective payment system • Prospective payment system • Fee for service • Premiums • Deductibles • Copayment

  8. Private Insurance • Medical Savings Accounts • Tax exempt • Individual sets aside money to be used to cover cost not covered by insurance

  9. Private Insurance • Managed Care Plans • Form of private insurance • Gate keepers • Consumers have less choice

  10. Managed Care Health Plans • Preferred Provider Organizations (PPO) • Fee for service • Consumer chooses provider from a select group • Negotiated discounted rate • Consumers retain their ability to choose provider

  11. Managed Care Health Plans • Health Maintenance Organization (HMO) • HMO contracts with a group of physicians and specialist • Consumer does not have an option to choose provider • Fixed fee • Less flexible

  12. Public Insurance • Funded by state and federal governments • Medicaid • Title XIX • Determined by income and resources • No age limit • TANIF • State Child Health Plan • Spend down

  13. Public Insurance • Medicare • Title XVIII federal program for elderly age 65 and older • Three parts: • Hospital Insurance Part A • Medical Insurance Part B • Prescriptions Part D • Medigap

  14. Public Insurance • TRICARE • Active duty, retired service personnel, eligible family members, survivors • Funded through Department of Defense • Consumers have two options: • TRICARE Prime (managed care) • TRICARE Standard (fee for service)

  15. Noninsurance-Based Models • Managed competition • Supply and demand • Accountable Health Plans (AHP) • Health Insurance Purchasing Cooperatives (HIPCs)

  16. Noninsurance-Based Models • Universal coverage • Single payer system • Provides access to health care to all • One agency paying expenses rather than multiple payer system

  17. Challenges for Public Health Nurses • Shrinking funds • Minimal funding • Increase in health care cost • Organizational changes in the health care system

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