Using the information provided in class and resources, select one from the below topics and briefly make your discussion: 1.??? Differentiate

17 May Using the information provided in class and resources, select one from the below topics and briefly make your discussion: 1.??? Differentiate

Posted at 15:04h in Nursing by

Discussion:

Using the information provided in class and resources, select one from the below topics and briefly make your discussion:

1. Differentiate between private and public sector functions and responsibilities in the delivery of health care.

2. Describe the mechanisms by which health care in the United States is financed in both the private sector and the public sectors.

3. Analyze the influence of health legislation on the health care delivery system.

Instructions:

Post your discussion to the Moodle Discussion Forum. Word limit 500 words. Reply to at least two other student posts with a reflection of their response.

Please make sure to provide citations and references (in APA format) for your work.

Chapter 2

Emerging Populations and Health

� “Health disparities” is an umbrella term that includes disparities in health and in health care. Greater obstacles to health care Ø Obstacles commonly based on racial or ethnic group,

religion, socioeconomic status, gender, age, mental health, disability, sexual orientation or gender ID, geographic location

� “Health equity” is the accomplishment of the highest level of health for all people Ø Goal: elimination of health care disparities

Health Disparities and Health Equality

Emerging Populations

� Ethnic minorities Ø Asian Americans/Pacific Islanders Ø Blacks/African Americans Ø Latinos/Hispanic Americans Ø Native Americans Ø Arab Americans

� Homeless persons � Immigrants includes unauthorized immigrants

Ethnic Diversity Concepts

� Race—historically associated with power and privilege disparities, social injustice, and prejudice

� Ethnicity—commonalities of culture (language, history, customs, geographical origin, religion, or ancestry)

� Minority group—commonly disadvantage in relation to power, control, and wealth

Health Care Disparities

� Poverty, homelessness, and health care disparities disproportionately impact racial and ethnic minorities

Homeless man working as a day laborer with no health care benefits

Culture and Values Value Orientation

� Culture Ø Integrated patterns of human behavior (language,

thoughts, communications, actions, customs, values, institutions)

� Values Ø Belief about the worth of something Ø Standards which influence behavior and thinking

� Value orientation Ø Values learned and share through socialization Ø Reflect “personality type” of particular society

Culture

One cultural norm of the Moiri in New Zealand is to say good-bye by rubbing noses

� Culture may have impact on people’s Ø Health Ø Healing Ø Wellness belief systems Ø Perceived causes of illness and disease Ø Behaviors of seeking health care Ø Attitudes toward health care providers

� Cultural competency is one of the major elements in eliminating health disparities

Cultural Competency

Culturally Competent Care

� Knowledge of culture � Education and training in culturally competent care � Critical reflection � Cross-cultural communication � Culturally competent practice � Cultural competence in health care systems and

organizations � Patient advocacy and empowerment � Multicultural workforce � Cross-cultural leadership � Evidence-based practice and research

Folk Healing and Nursing Care Systems

� Folk healing practices Ø Reflect beliefs, values, treatment of cultural group Ø Unlicensed: lay midwives, herbalists, spiritualists

� Nurses must avoid ethnocentrism Ø Viewing other ways as inferior or unnatural Ø Obstacle in therapeutic provider-patient relationships

� Holistic approach Ø Incorporates family and support system in care Ø Considers patient viewpoint

Arab Americans

� Background Ø Three major waves of immigration from late 1800s to 1960s Ø Three largest groups: Lebanese, Syrians, Egyptians Ø Religions: Christianity, Judaism, Islam

� Health concerns and care issues Ø Adult-onset diabetes mellitus Ø Coronary artery disease Ø Role of acculturation Ø Mental health Ø Teenage smoking

Arab Americans (Cont.)

� Barriers to care Ø Islamophobia post 9-11 Ø Religious belief and practices Ø Cultural norms/modesty Ø Gender issues regarding providers Ø Communication difficulty Ø Folk remedies Ø Lack of culturally competent providers

� Selected health-related cultural aspects Ø Role of religion Ø Importance of family; male-dominated family structure Ø Present-oriented

Asian Americans/Pacific Islanders

� Background Ø Many diverse countries/cultures—100 languages Ø Largest groups: Chinese, Koreans, Filipinos Ø Often referred to as “model minority” Ø Value education

� Health concerns and care issues Ø Hesitancy to seek early diagnosis/screening Ø Higher rate of tuberculosis Ø Mental health problems due to adjustment issues Ø Lower rate of obesity, hypertension

Asian Americans/ Pacific Islanders (Cont.)

� Barriers to care Ø Language barriers Ø Hesitant to voice disagreement—noncompliance Ø Stigma to seeking mental heath services Ø Hesitant to seek GYN care—considered “private” matters Ø Mistrust and other stigmas with seeking care

� Selected health-related cultural aspects Ø Value of collectivism vs individualism Ø Family most important social institution; respect for elders Ø Cultural value of passivity to avoid conflict Ø Taoism: foundation of Chinese medicine “achieving harmony” Ø Use of folk medicine/alternative treatment modalities common

Latino and Hispanic Americans

� Background Ø Largest ethnic group; second fast growing minority Ø Mexican, Puerto Ricans, Cubans most common Ø High rates of poverty; highest rate uninsured

� Health vulnerabilities—higher incidence Ø Stomach cancer Ø Diabetes mellitus Ø Cardiovascular disease Ø HIV

Latino and Hispanic Americans (Cont.)

� Barriers to care Ø Lack of access to preventive care Ø Lack of interpreter services in health care Ø Lack of culturally appropriate health care services Ø Reliance on folk systems of healing

� Selected health-related cultural aspects Ø Family supersedes individual needs Ø Religion plays a key role Ø Hot and cold concept of disease Ø Illness due to supernatural and psychological force Ø Folk remedies in combo with professional care

Blacks/African Americans

� Background Ø Second largest minority behind Hispanic/Latino Ø Most descendants of enslaved persons from Africa Ø Inequities persists; substantial progress

� High rates for certain diseases Ø Cancer deaths Ø HIV Ø Hypertension Ø Obesity Ø Homicide

Blacks/African Americans (Cont.)

� Barriers to care Ø Poverty Ø Lack of health insurance Ø Inadequate or unsafe environments

� Selected health-related cultural aspects Ø Centered on family and religion Ø Family needs to be involved in care Ø Churches important in promoting health Ø Use traditional healing approaches

Native Americans/Alaskan Natives

� Background Ø Native to North/South America prior to arrival of

Europeans Ø Experience minority group status; lower education

and income levels compared to other groups � Health concerns and care issues

Ø Linked to social and economic conditions Ø Smoking, substance abuse Ø Deaths: unintentional injuries, liver disease, cancer

homicide, suicide, pneumonia, diabetes, CVA

Native Americans/Alaskan Natives (Cont.)

� Barriers to care Ø Difficult access to care Ø Underserved population

� Selected health-related cultural aspects Ø Present-oriented; take 1 day at a time Ø Value cooperation over competition Ø Share resources Ø Value families—form kinship systems Ø Believe health exists when person is in harmony with nature Ø Traditional health practices important (shaman)

Homeless Persons

� Characteristics Ø Lack of fixed, regular, adequate residence due to poverty Ø Considered temporary situation vs permanent condition Ø For veterans: mental illness, substance abuse, poverty

� Causes of homelessness Ø Changing housing markets—shortage of affordable rentals Ø Poor health both effect and cause homelessness Ø Widespread and unprecedented foreclosures Ø Poverty, unemployment, decline in public assistance Ø Substance abuse, domestic violence, mental illness

Homeless Persons (Cont.)

� Health concerns and care issues Ø Basic survival issues Ø Pneumonia, TB, HIV disease are widespread Ø Dental and vision problems Ø Mental health issues significant contributing factor Ø Substance abuse: both cause and consequence

� Barriers to care Ø Lack of access; lack of ID Ø Affordability issues, lack of health insurance Ø Lack of transportation Ø Lack of knowledge re where to obtain care

Strategies to Address Homelessness

� Community involvement in homelessness � Programs to provide food, clothing, shelter � Include rural homelessness in programs � Health care professionals have important

advocacy role � Educate community members re how to help

homeless persons � Strengthen professional curriculums and

research to address homelessness

Federal Response to Disparities

� NIH is devoting significant resources to reducing health disparities

� Congress created National Center on Minority Health and Health Disparities in 2010

� Healthy People 2020 lists as one of primary goals to reduce/eliminate health disparities

� Patient Protection and Affordable Care Act 2010 increases funding for indigent care

� Office of Minority Health reauthorized

Nursing’s Response to Emerging Populations and Health

� American Nurses Association (ANA) Ø Commitment to provide service regardless of

background or situation Ø Nurses are responsible to provide for culturally

competent care � ANA sponsored Ethnic-Minority Fellowship

Program to support minority health � Culturally relevant publications and journals

offered as resources to health care professionals

Publications Devoted to Culturally Competent Care

� Journal of Cultural Diversity � Journal of Multicultural Nursing and Health � Minority Nurse Newsletter � Cultural Care Diversity and Universality

Theory—Madeline Leininger (2001) � Current nursing texts from major publishers now

include chapters on culturally relevant care

Chapter 3

Health Policy and the Delivery System

The Patient Protection and Affordable Care Act (PPACA)

� New health care federal reform law signed in 2010 � Largest change in the financing of the American health

care system since Medicare and Medicaid (1965) � Focus on vulnerable populations: affordability,

accessibility, and financing of health care � Designed to reduce number of uninsured persons via

expanding Medicaid and establish subsidies � US Supreme Court upheld the ACA in June 2012 � Likely will change secondary to Trump presidency

Key Features of PPACA

� PPACA lacks bipartisan support � Change in political landscape may result in

repeal or significant changes � No exclusion for preexisting conditions � Health insurance is mandated for everyone � Marketplace exchange for insurance plans � All policies must cover essential benefits � Medicaid expanded; subsidies available

Measuring the Nation’s Health

� Health, United States report (annual) Ø Informs policymakers of trends in nation’s health

� Healthy People 2020 Ø 10-year agenda for improving nation’s health Ø Goal is to increase quality and years of healthy life,

and eliminate health disparities � Central Intelligence Agency (CIA) statistics

Ø Morbidity data Ø Compares United States with other countries

US Health Trends

� Successes in infection, other diseases � Concerns: sedentary lifestyle, obesity, chronic

illness � Health disparities persistent

Ø Contribute to unfavorable US health indicators Ø Compromise progress in world health

� Vulnerable populations due to age, education, language, location

� Rise in suicide and drug poisoning deaths esp involving opioid analgesics

Historical Role of Women

� Nurses have long tradition of health promotion � Nursing pioneers

Ø Florence Nightingale (Crimean War 1884)—crusaded for nutritious food, cleanliness, sanitation

Ø Lillian Wald (Henry St Settlement—NYC 1883) founded NYC visiting nurses association to provide health services for indigents in tenements

� Through the ensuing decades nurses developed unique role agents for health promotion

� US Health Care system undergoing changes Ø Sparked by health care reform politics Ø Large organizations involved in forming health policy

� Health and medicine division Ø Previously known as Institute of Medicine (IOM) Ø Research from a systems approach Ø Advisement on safe delivery of health care Ø Health care system (not practitioners) is basic cause

of medical errors

A Safer System

� Overriding objective is for all people (global) to attain highest possible health

� Current agenda—six goals Promoting development Enhancing partnerships Fostering health security Improving performance Strengthening health systems Harnessing research info

� Budget issues limit achievement of goals � Huge health disparities in developing nations

Global Health World Health Organization

� Earliest views were holistic, emerging from integrated worldview

� Hygiene incorporated into most religions � Primitive peoples had mystical view of sickness

and cure—tied to religion � During middle-ages widespread epidemic

diseases leading cause of death ( leprosy, plague, smallpox, TB)

Historical Influences Health Care

� Adequate food supply prolonged life span Ø Transportation enhanced food distribution Ø Technological advances improved food production

� Industrial advances prevented diseases Ø Flush toilet, sewer systems Ø Decrease in typhoid, paratyphoid, gastroenteritis

Historical Industrial Influences

� Elizabethan poor laws (1601) England Ø Relief for infants, sick, elderly, workhouse laborers

� New Law 1834—harsher philosophy Ø Pauperism in able-bodied workers viewed as moral

failing Ø Suspicious and punitive view of indigence

� Protestant work ethic (rewards work efforts) Ø Philosophy brought to United States by Puritans Ø Influences modern health care—fee-for-service

Historical Socioeconomic Influences

� Edwin Chadwick—father of public health � Disease viewed as impediment to ability to self-

support (Chadwick’s view) � Public health services and welfare combined

creating a more benevolent view of indigence � Puritan ethic in the United States offered a

harsher view toward indigence and health care � Health and welfare departments continue to

have contradictory approach to poor

Public Health Influences

� Prior to 20th century infectious diseases (ID) major cause of death

� Scientific advances → Improved health Ø Louis Pasteur—germ theory Ø Joseph Lister—antisepsis

� Innovations: safeguard water, food, and milk supply; sewage systems; urban housing regs

� Antibiotics (1936-1954) decrease in ID � ID death persists in vulnerable populations

Scientific Influences

Major milestones with effects on health care � New Deal (Great Depression) � Social Security Act 1935

Ø Grants-in-aid for state and local public health Ø Assistance programs: blind, elderly, disabled

� Medicare and Medicaid (1965) � Patient Protection and Affordable Care Act

(2010)

Political and Economic Influences

Preventative vs Curative Medicine

� Early prevention directed toward individuals Ø Originated in medical practice vs public health Ø Focus was on poor—state welfare programs

� Public health services eventually emerged Ø Focus on societal prevention vs individual cure Ø Immunizations, screenings, education Ø Education and career paths for pubic health vs medical

practitioners remained separate � 1960s emphasis shifted from individual to societal public

health goals � Evolution toward greater government in health care

Organization of Delivery System

� Huge system: public and private components � Multifaceted and complex interrelationships

Ø Providers and consumers Ø Varied settings: private and public services

� Public sector: nonprofit agencies, government agencies, organized at local, state, and national levels (US Department of Health and Human Services)

� Private sector: for profit services

Private Sector Independent Practice

� Independent practice—free-market system Ø Fee-for-service; hallmark is choice of provider Ø Managed care health organizations evolved Ø Prevention has gained importance

� Nurse-managed centers Ø Advanced Practice Nurse serve as primary care

providers Ø Multidisciplinary collaborative approach Ø Focus: vulnerable populations

Private Sector Managed Care

� Managed health care/health maintenance organizations (HMOs)—emerged 1990s Ø Groups of providers, contract with HMOs Ø Comprehensive care for prepaid fee Ø Motivation and goal is to control costs

� Managed care: key elements Ø Control costs, regulate health care utilization Ø PCP gatekeeper to system; coordinate care Ø Payment based on network status: in-network vs out

Private Sector Health Maintenance Organizations

� Capitation method of payment Ø Provider receives fixed payment per enrollee.

Provider provides all necessary care to enrollee � PCP is gatekeeper

Ø Specialist require referral Ø Members (patients) may have copays Ø Must use network providers

� Medicare Advantage plans are HMO alterative to traditional Medicare

Private Sector IPAs and ACOs

� Independent practice associations (IPAs) Ø Physician organizations Ø Care for HMO members in private office Ø Several models available

� Accountable Care Organization (ACOs) Ø Key component in Affordable Care Act Ø Not yet in place—Medicare reform Ø Structure will be similar to HMOs Ø Focus is cost-containment

Private Sector Concierge and Hospitalists

� Concierge medical practices Ø Membership fee for enhanced health care Ø Fewer patients—more time per patient Ø Focus: personalized, holistic care for higher income

individuals • Typical household income—$125,000-$250,000 • Typical patient—age 50 and older

� Hospitalist movement Ø Physicians or APNs who provide comprehensive

hospital care—improved quality and safety of care

Private Sector POS and HDHPs

� Point-of-service plans (POS) Ø Additional fee for providers outside of network Ø Increases consumer choice

� High Deductible Health Insurance Plans Ø High annual out-of-pocket deduction Ø Suitable for healthy persons—low monthly premium Ø Health Savings Account (HSAs)

• Employer contributions plus pretax deposits allowed • Withdrawals for health-related expenses • In-network providers offer enhanced savings

Private Sector PPOs

� Preferred Provider Organization—PPO � Key elements

Ø Contracted providers who will deliver member services at prenegotiated rate (discounted)

Ø Extra cost if non-PPO providers used Ø Copays by members required at time of visit Ø Preauthorization required for hospitalization or costly

tests and procedures Ø 52% of employer-sponsored plans are PPOs

Public Sector Power and Influence

� Source of power—shared federal/state Ø Federal: tax/spend general welfare Ø State: health authority based on 10th Amendment

� Influence of political philosophy Ø Each new administration since 1980s has introduced

new philosophy, bills, or components of health care Ø Most recent legislation: HIPAA (1996) Medicare

Prescription Drug Act (2003) Affordable Care Act (2010), Children’s Health Insurance Program (2015)

� National health care debate

Public Sector Current/Future Policy

� Current political issues re health care Ø Lack of political consensus—partisan discord Ø Major factors: cost, access, quality Ø Discordant partisan views concerning ACA

� Nurse’s role in health care reform Ø ANA: advocate for single-payer system Ø Focus on primary care, prevention Ø Push for nurses to function to full extent of education and

training—remove barriers Ø Nurses comprise largest segment of health care

workforce—3 million members

Official Health Care Agencies

Type of Agency

Key Characteristics

Local � Local health department � Direct services to public

State � State health department � Policy, planning, program coordination

Federal � Run by executive and legislative branches— determine health policy

� USHHS—administers policy

Official Health Care Agencies (Cont.)

Type of Agency/ Personnel

Key Characteristics

Chief Nursing Officer

� Serves in US Public Health Service � Works with US Surgeon General on nursing and public health policy

Federal Emergency Management Agency (FEMA)

� Part of Department of Homeland Security � Disaster-related services � Assists individuals, communities, states

Official Health Care Agencies (Cont.)

Type of Agency/ Personnel

Key Characteristics

Military Health System

� Comprehensive medical care for active duty personnel, dependents, retirees � Responds to natural disasters and humanitarian crisis throughout the world � Veteran’s Administration: independent agency under President to provide for veteran care

Wounded warrior care

� Extensive care and rehabilitation to return severely injured soldiers to active duty or transition to VA health system

Health Care Legislation and Agencies

Legislation/ Agencies

Key Information

Americans with Disabilities

� Prohibit job discrimination and require services to people with disabilities

Patient Self- Determination Act

� Advanced directives for health care

Federal Health Information Privacy

� Safeguards security/confidentiality of health information

International- WHO

� Worldwide guidance in promoting world health through standards, programming, and collaboration

Voluntary (not-for- profit) Agencies

� Influence policy/legislation � Philanthropic (nongovernmental)

American Red Cross

� Volunteer-led humanitarian organization � Congressional charter—officially sanctioned but

no direct government supervision � 700 local chapters, 500,000 volunteers, 35,000

employees � Responds to both small local disasters (house

fire) and large natural disasters � Blood products, health education,

communication for servicemen/families

Financing Health Care

� Costs Ø Increasing due to multiple factors Ø Less time in system for health promotion

� Sources Ø Federal government (Medicare, Medicaid) Ø State funded programs—Medicaid, CHIP Ø Third-party payment (insurance) Ø Employer provided health plan benefits Ø Independent sources Ø Out-of-pocket: deductibles, copays, health savings accounts Ø Affordable care act subsidies

Mechanism for Financing

� Independent practice with fee-for-service—physicians, APNs, health care professionals

� Salaried providers—nurses, APNs, physicians Ø Overtime is uncompensated Ø Often leads to burnout from overwork

� Hourly compensation Ø Most hospital and outpatient staff Ø Workers eligible for overtime

� Capitation—flat fee regardless of services used Ø Encourages preventive care to keep people healthy Ø Some individuals make unnecessary visits Ø HMO sponsors and bears risk of illness

Cost Containment � Cost-containment initiatives

Ø Prospective payment system, limits on provider payments, Medicare Advantage (MA) plans

� Care management Ø Determines and coordinates care Ø Across continuum of health care services Ø Reduce waste, improve quality, control costs

� Managed care

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17 May Using the information provided in class and resources, select one from the below topics and briefly make your discussion: 1.??? Differentiate

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