Chapter 7 The Health Care System. Three Models of Health Care: The Medical Model Focus on diagnosis and cure Care in hospital, doctor’s office, nursing

Chapter 7

The Health Care System

Three Models of Health Care: The Medical Model

• Focus on diagnosis and cure

• Care in hospital, doctor’s office, nursing home

• Drugs, surgery rehabilitation

• Physicians control most treatment

• Little focus on prevention or community-based care

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Three Models of Health Care: The Social Model

• Focus on person’s ability to function in the social world– Health is more than the absence of disease

• Focus on functional capacity

• Health care mostly takes place in community


Three Models of Health Care: The Health Promotion Model

• Focus on disease prevention and reduced disability

• With support, some can regain lost abilities

• Improving fitness and well-being


Figure 7.1 Hospital Discharge Rates, 2006


The U.S. Health Care System Today

• History of Health Care for Older People– Few options until mid 1960s

• About ½ older people had health insurance

– Medicare program passed by Congress 1965– AMA opposed Medicare at the time

• Called it socialized medicine• Feared government control of physicians fees


The U.S. Health Care System TodayMedicare

• Part A– Hospital Insurance– Funded by payroll tax– Eligibility– Benefits: 4 kinds of care

• Part B– Supplemental Medical Insurance


The U.S. Health Care System TodayMedicare

– Funded by– Eligibility– Benefits

• Part D (2006)– Prescription Drug Discount Card– Has reduced some costs for some older

people


Figure 7.2 How Is the U.S. Health Care Dollar Spent?


Figure 7.3 Number of Medicare Beneficiaries, 1970–2050


Figure 7.4 Total Medicare Expenditures 1970–2008


Figure 7.5 Medicare Costs as a Share of Gross Domestic Product


Table 7.1 Medicare Payments, Original Medicare Plan


The U.S. Health Care System TodayMedicaid

• Began 1965

• Serves low income Americans, all ages

• Funded by federal and state governments

• Eligibility– Income and asset limits– Income and asset limits different for each

state


Figure 7.6 Where the Medicaid Dollar for the Elderly Goes, 2002


Figure 7.7 Funding for Long-Term Care, 2004


The U.S. Health Care System TodayOther Health Care Plans

• Employer Sponsored Plans

• Medigap– Intended to reduce out-of-pocket costs due to

gaps in Medicare coverage

• Long Term Care Insurance– Vary widely in coverage and services

• Strong interest in buying LTC insurance


Figure 7.8 Total Health Expenditures as a % of Gross Domestic Product


The Cost of Care

• Since 1960 US leads developed nations in health care spending

• Costs expected to increase

• Federal, state, local governments paid nearly half the total health care bill in 2000

• Rising health care costs explain most government spending on older people


Figure 7.9 Out-of-Pocket Health Care Costs


The Rising Personal Cost of Health Care• Amount paid by individuals has increased,

despite federal payments

• Older people pay high out-of-pocket costs

• About 9% no coverage except Medicare

• Few have long term care insurance

• Results


Public Dissatisfaction & Health Care Reform

• Cost of care is high; weak return on cost

• Health Care Reform: National Legislative Action 2010

• Gains & Losses for Medicare Beneficiaries

• Summary of the Legislation

• Structural Flaws in the System


Institutional Care

• Insurance does not provide substantial nursing home benefits– Medicare– Medicaid

• Must spend down to qualify

– Private Long Term Care Insurance• Only pays about 45% of costs


Table 7.2 Long-Term Care Expenditures for the Elderly


Long Term Care: Community-Based Services

• In-Home care and Assisted Living

• Better community-based care accounts much of the decline in nursing home placement

• Olmstead Decision (1999)

• Types of HCBS


Long-Term Care

• Long-Term Care Insurance: A Good Bet?

• Adult Day Care

• Respite Services

• Home Health Care Programs

• Changes in Funding to Control Costs


Long Term Care: Managed Care

• Medical Care Settings– Some cost control– Capitated payments– Interdisciplinary approach– Early LTC planning– Keeps track of health records– Some focus on rehabilitation


Disease Prevention & Health Promotion

• Prevention catching on in United States!

• Examples– No smoking in restaurants– Magazines on fitness– Salads and low fat items in fast food

restaurants– Water and air quality standards


Beyond Fitness and Personal Health Promotion

• Typical health promotion efforts:

• Should also– Account for the social and economic contexts

of sickness– Account for environmental contexts

• Promotion and prevention must have impact on the production of illness


Future Issues in Health Care

• Availability– Existence of services; “no-care zones”

• Accessibility– Can people get the services that do exist?

• Coordination– Case management needed– Need for integrated system


Documents

Chapter 7 The Health Care System. Three Models of Health Care: The Medical Model Focus on diagnosis and cure Care in hospital, doctor’s office, nursing