Chapter 10Policy, Politics, Legislation, and Community Health .docx

1. Chapter 10 Policy, Politics, Legislation, and Community Health Nursing Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. Nurses Who Made a Difference… Florence Nightingale Sojourner Truth Clara Barton Lavinia Dock Lillian Wald Mary Breckenridge Susie Walking Bear Yellowtail Florence Wald Ruth Watson Lubic Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 2 Nurses’ Historical and Current Activity in Health Care Policy Florence Nightingale First nurse to exert political pressure on a government Transformed military health Knew the value of data in influencing policy Collected and analyzed data about health services and outcomes, which now is a critical element of public health Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders,

2. an imprint of Elsevier Inc. 3 Photo credit: http://commons.wikimedia.org/wiki/Florence_Nightingale Nurses’ Historical and Current Activity in Health Care Policy (Cont.) Sojourner Truth Advocate for abolishing slavery Supported women’s rights Helped transform racist and sexist policies that limited health and well-being of blacks and women Fought for human rights Lobbied for funds to educate nurses and physicians Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 4 Photo credit: http://commons.wikimedia.org/wiki/File:Carte_de_visite.jpg Nurses’ Historical and Current Activity in Health Care Policy (Cont.) Clara Barton Organized relief efforts during U.S. Civil War Persuaded Congress to ratify the Treaty of Geneva, which allowed the Red Cross to perform humanitarian efforts in times of peace Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 5 Photo credit: http://commons.wikimedia.org/wiki/File:WcbbustCBarton.jpg

3. Nurses’ Historical and Current Activity in Health Care Policy (Cont.) Lavinia Dock Prolific writer and political activist Campaigned to allow nurses to control the nursing profession Advocated for women’s right to vote Worked closely with Isabel Hampton Robb and Mary Adelaide Nutting to found forerunner to NLN Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 6 Photo credit:http://commons.wikimedia.org/wiki/File:Lavinia_Lloyd_ Dock.jpg Nurses’ Historical and Current Activity in Health Care Policy (Cont.) Lillian Wald Recognized connection between health and social conditions Advocate for development of the Children’s Bureau in 1912 Frequently appeared at White House in development of national and international policy Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 7 Photo credit:http://commons.wikimedia.org/wiki/File:Lillian_Wald_- _William_Valentine_Schevill.jpg

4. Nurses’ Historical and Current Activity in Health Care Policy (Cont.) Mary Breckenridge Developed nursing in rural Kentucky Established Frontier Nursing Service Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 8 Photo credit: http://commons.wikimedia.org/wiki/File:WENDOVER.jpg Nurses’ Historical and Current Activity in Health Care Policy (Cont.) Florence Wald Nursing leader in establishing hospice care in the United States Modeled hospice after similar services offered in United Kingdom Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 9 Photo credit: http://commons.wikimedia.org/wiki/File:Hospice_Media_Logo. png Nurses’ Historical and Current Activity in Health Care Policy (Cont.) Susie Walking Bear Yellowtail Walked from reservation to reservation to improve health services for Native Americans Established Native American Nurses Association

5. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 10 Photo credit: http://commons.wikimedia.org/wiki/File:Ketchican_totem_pole_ 2.jpg Nurses’ Historical and Current Activity in Health Care Policy (Cont.) Ruth Watson Lubic Nurse-midwife who crusaded for freestanding birth centers in the United States Leader in community-based birth center movement Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 11 Photo credit: http://commons.wikimedia.org/wiki/File:Silverton_Hospital_birt h_center_-_Silverton,_Oregon.JPG Definitions to Know Social justice Laws Public health law Statutes Organizations Professional associations Policy Public policy Health policy Nursing policy Institutional policies

6. Organizational policies Social policy Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 12 Definitions Policy denotes a course of action to be followed by a government, business, or institution to obtain a desired effect. Public policy denotes precepts and standards formed by governmental bodies (legislative, executive, or judicial) that are of fundamental concern to the state and the whole of the general public. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 13 Definitions (Cont.) Health policy is a statement of a decision regarding a goal in health care and a plan for achieving that goal. Nursing policy specifies nursing leadership that influences and shapes health policy and nursing practice. Institutional policies are rules that govern worksites and identify the institution's goals, operation, and treatment of employees. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 14

7. Definitions (Cont.) Organizational policies are rules that govern organizations and their positions on issues with which the organization is concerned (Mason et al., 2007). Social policy is policy associated with individuals and communities. In very general terms, social policy can be defined as the branch of public policy that advances social welfare and enhances participation in society. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 15 Definitions (Cont.) Laws are rules of conduct or procedure; they result from a combination of legislation, judicial decisions, constitutional decisions, and administrative actions. Public health law focuses on legal issues in public health practice and on the public health effects of legal practice. Public health law typically has three major areas of practice: police power, disease and injury prevention, and the law of populations. Statutes are any laws passed by a legislative body at the federal, state, or local level. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 16 Definitions (Cont.) Organizations are associations that set and enforce standards in a particular area; a group of individuals who voluntarily enter into an agreement to accomplish a purpose.

8. A professional association is a nonprofit organization seeking to further a particular profession, the interests of individuals engaged in that profession, and the public interest. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 17 Policy is based on values, and the first step in forming policy is identification of the issue. Therefore, it would seem rational to define “health” as the starting point for any policy annexed to health care issues. Many Healthy People 2020 objectives directly or indirectly involve health policy. – Nies and McEwen, 2015 Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 18 Shifts in Philosophy at the CDC Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 19 From Centers for Disease Control and Prevention: State of the CDC: fiscal year 2008, The Author.From…To…Disease orientationHealth protection focusDesigning and implementing sponsored programsInforming and guiding health system actorsAllocating agency resourcesLeveraging resources to steer larger health systemEmphasis on clinical preventionFocus on prevention and health protectionTransaction-based relationshipsPartnerships and strategic alliancesProgram requirementsIncentives for participation/cooperationCollecting and analyzing health dataCreating integrated health information

9. systemsIssuing advisories and guidelinesBuilding decision- support system Healthy People 2020 Vision A society in which all people live long, healthy lives. Overarching Goals Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 20 Nies: Power Points, Evolve Resources for Nies/McEwen: Community Health Nursing, 4th ed. 20 Overview of Health Policy Public Health Policies Decisions made at all levels of government (local, state, or federal) Influence health care through monitoring, production, provision, and financing of health care services Everyone is affected, from providers to consumers Influence all health care organizations

10. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 21 Overview of Health Policy (Cont.) Public Health System Authority for public health vested with states Responsibility delineated by constitution Compliance with federal program standards is voluntary but impacted by revenue Policies influenced by social and political theories Economics is one factor in decision making Decisions are slow and deliberate and more reactive Needs determined by voting shifts, electoral realignment, and term limits Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 22 Overview of Health Policy (Cont.) Private Health Sector Includes employers, professional organizations, nonprofit health care organizations, and for-profit corporations that deliver, insure, or fund health care services outside of government control Policies evolve differently—influenced by economics and business management Economics is central factor in decision making Decisions are swift and proactive

11. Needs determined by consumerism, market trends, and economics Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 23 How a Bill Becomes a Law Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 24 Figure 10-1. From publicdomainclip- art.blogspot.com/2007_09_01_archive.html. Retrieved October 19, 2009. Impact of Federal Legislation on Health Care Prevention of illness by influencing the environment Provision of funding to support programs that influence health care Increased the involvement of state and local governments in health care Promoted similarities of services in all states Funding resulted in increased regulations Standardized U.S. public health policy Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 25

12. Critical Federal Legislation Related to Health Care Pure Food and Drug Act of 1906 Manufacturing, labeling, and sale of food Children’s Bureau Act of 1912 Regulated unhealthy child labor practices Shepherd-Towner Act in 1921 extended to infants Social Security Act of 1935; 1965; 1972 Benefits for mothers, children, elderly, disabled Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 26 Critical Federal Legislation Related to Health Care (Cont.) Medicare (Title XVIII) in 1965 Health care services for people over 65, with permanent disabilities, and those with end-stage renal disease Medicaid (Title XIX) in 1965 Combined federal and state program Access to care for poor and medically needy Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 27 Critical Federal Legislation Related to Health Care (Cont.) Public Health Act of 1944 Consolidated all existing public health legislation into one law

13. Health services for migratory workers Family planning services Health research facilities National Institute of Health (NIH) Nurse training acts Traineeships for graduate students in public health Home health services for Alzheimer’s disease patients Prevention and primary care services Rural health clinics Communicable disease control Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 28 Critical Federal Legislation Related to Health Care (Cont.) McCarren-Ferguson Act of 1945 Gave states right to regulate insurance plans Hill-Burton Act of 1946 Federal assistance in construction of hospitals with stipulations about service for the uninsured Health Amendments Act of 1956; Title II Funds for RN education in administration, supervision, and teaching 1964 Nurses Training Act: funds for loans and scholarships and to develop more nursing schools Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 29

14. Critical Federal Legislation Related to Health Care (Cont.) Occupational Safety and Health Act of 1970 Focused on health needs and risks in workplace and environment Health Maintenance Organization Act of 1973 Employers must offer federally qualified HMOs as health care option to employees States had oversight on HMOs Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 30 Critical Federal Legislation Related to Health Care (Cont.) National Health Planning and Resources Act of 1974 Assigned responsibility for health planning to states and local health system agencies Required health care facilities to obtain prior approval for expansion in form of Certificate of Need (CON) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 31 Critical Federal Legislation Related to Health Care (Cont.)

15. Omnibus Budget and Reconciliation Acts 1981, 1987, 1989, and 1990 Enacted to reduce huge federal deficit Impacted funding for nursing homes, home health agencies, and hospitals Established new guidelines and regulations including a move from process to outcome evaluation, use of restraints, and prescription drugs for Medicaid recipients Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 32 Critical Federal Legislation Related to Health Care (Cont.) Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) Amendment to SSA of 1935 Established PPS for Medicare, the DRG system COBRA of 1985 Requires all EDs that participate in Medicare to provide care for all, regardless of ability to pay Ensures continuation of insurance after loss of job Example of how federal government can affect state health care practices Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 33 Critical Federal Legislation

16. Related to Health Care (Cont.) Family Support Act of 1988 Expanded coverage for poor women and children Expanded Aid to Families with Dependent Children (AFDC) Health Objectives Planning Act of 1990 Response to the first Healthy People report (1979) United States began to identify and monitor national health goals; Healthy People 2000, 2010, and 2020 Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 34 Critical Federal Legislation Related to Health Care (Cont.) Health Insurance Portability and Accountability Act (HIPAA) of 1996 Ensured portability of insurance coverage Offered protection for patient privacy and confidentiality Welfare Reform Act of 1996 Restricted eligibility for AFDC, Medicaid, etc. TANF helped move recipients into work; welfare offered temporary assistance Many underserved lost Medicaid coverage Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 35 Critical Federal Legislation

17. Related to Health Care (Cont.) The State Child Health Improvement Act (SCHIP) of 1997; 2009 Provides insurance for children and families who cannot afford health insurance Medicare Modernization Act of 2003 Most significant law in 40 years for senior health care Provides seniors and disabled with some Rx drug benefit coverage, more choice, and better benefits Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 36 Critical Federal Legislation Related to Health Care (Cont.) Nurse Reinvestment Act of 2003 Funding provided to increase enrollments and number of practicing nurses Mental Health Parity and Addictions Equity Act of 2008 Financial requirements (deductibles, co-payments) and treatment limitations (number of visits; days of coverage) that apply to mental health benefits must be no more restrictive than the predominant financial requirements or treatment limitations that apply to substantially all medical/surgical benefits Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 37

18. Critical Federal Legislation Related to Health Care (Cont.) Patient Protection and Affordable Care Act of 2010 All U.S. citizens and legal residents to have qualifying health coverage Changes eligibility requirements for Medicaid and expands CHIPS Subsidizes premiums for lower and middle income families Requires coverage of dependent adult children up to age 26 Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 38 Critical Federal Legislation Related to Health Care (Cont.) Patient Protection and Affordable Care Act of 2010 (Cont.) Significant insurance reforms Established high-risk pools Covers preexisting conditions No lifetime limits on coverage Cannot drop policyholders when they get sick Must provide preventive care and screenings without customer cost-sharing Fosters nonprofit, member-run exchanges Implemented over several years Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 39 Critical Federal Legislation Related to Health Care (Cont.) Patient Protection and Affordable Care Act of 2010 (Cont.)

19. Funded through new fees and taxes. Taxes on indoor tanning Medicare taxes for higher income brackets Fees for pharmaceutical companies and medical devices Penalties for those who do not obtain health insurance Cost-cutting measures Cuts to Medicare Advantage programs Reductions in Medicare spending Reduce administrative costs, streamline care, reduce fraud and abuse Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 40 The health reform legislation in 2010 was strongly influenced by the rising number of uninsured and underinsured. The United States is only major developed country to not have universal health coverage. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 41 State Legislative Role Focus on financing and delivery of services and oversight of insurance to address the mission of public health throughout the state Assess health needs Ensure adequate statutory base for health activities Establish statewide health objectives Ensure appropriate organized statewide effort to develop and maintain essential services

20. Guarantee minimum set of essential health services Support local service capacity Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 42 Effective Use of Nurses: A Policy Issue Title VII funding (HRSA) provides the largest source of federal funding for nursing education Favors education for practice in rural and medically underserved communities Nursing shortage is a crisis Economic impact on positions Focus on hiring BSN graduates (not ADN) Shortage of nursing faculty Nurse Education, Expansion, and Development Act of 2009 amended above to increase funds for nursing schools Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 43 Nurses’ Roles in Political Activities The Power of One and Many …as Change Agents …with Coalitions …as Lobbyists …on Political Action Committees (PACs) …in Campaigning …in Voting Strength …in Public Office

21. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 44 Chapter 11 The Health Care System Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. U.S. Health Care System Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 2 Figure 11-1 U.S. Health Care System (Cont.) Private health care subsystem Focus on the individual Nonprofit and for-profit agencies Models of services Solo practice Single specialty group practice Multispecialty group practice Integrated health maintenance model Community health center Voluntary or nonofficial agencies Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

22. 3 U.S. Health Care System (Cont.) Public health care system Mandated by the U.S. Constitution Focus on the population “promote the general welfare of its citizens.” Federal policies and practices influence local and state governments Coordination of services under Department of Health and Human Services Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 4 Public Health Public health refers to the efforts organized by society to protect, promote, and restore the people’s health. Concerned with a healthy population Concerned with a healthy environment Scope is broad Encompasses activities that promote good health Organized into multiple levels (federal, state, local) Provides services for those unable to obtain health care without assistance Establishes laws, rules, and regulations to protect the public Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders,

23. an imprint of Elsevier Inc. 5 Public Health System Federal level subsystem U.S. Department of Health and Human Services Surgeon General and numerous other agencies Targets general population, special populations, and international health IOM Report, HHS in the 21st Century: Charting a New Course for a Healthier America (2008), recommended transformation of system Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 6 Current HHS Strategic Plan Transform health care Advance scientific knowledge and innovation Advance health, safety, and well-being of the American people Increase efficiency, transparency, and accountability of HHS Strengthen the nation’s health and human services infrastructure and workforce Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 7 Public Health System (Cont.) State level subsystem

24. State health departments Responsible for the health of their citizens Central authorities in the public health care system Dependent on federal level for guidance and resources Establish own state laws Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 8 Public Health System (Cont.) Local health department subsystem Local health departments (LHD) Responsible for direct delivery of public health services and protection of the health of citizens Not all communities have LHDs Responsible for: Community health services Environmental health services Personal health services Mental health services Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 9 Health Care Providers Provider organizations Any organization that provides health care to the community Health care professionals The interprofessional health care team

25. Professionals and nonprofessionals Nontraditional health care providers Complementary and alternative therapies Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 10 Quality Care To Err Is Human: Building a Safer Health System (IOM, 1999) focused on safety within the health care delivery system Crossing the Quality Chasm (IOM, 2001) focused on developing a new health care system for the twenty-first century, one that improves care Leadership by Example (IOM, 2003) was a report requested by Congress that examined the federal government’s quality enhancement processes Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 11 Quality Care (Cont.) Who Will Keep the Public Healthy? (IOM, 2003) brought public health into the forefront by focusing on issues including globalization, rapid travel, scientific and technological advances, and demographic changes In-depth exploration of educational needs for improved public health Need for appropriately prepared public health professionals Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

26. 12 Quality Care (Cont.) Who Will Keep the Public Healthy? (Cont.) New content areas for public health professionals: Informatics, genomics, communication, cultural competence, community-based anticipatory research, global health, policy and law, and public health ethics Old content areas for public health professionals: Epidemiology, biostatistics, environmental health, health services administration, and social and behavioral science Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 13 Quality Care (Cont.) Health Professions Education (IOM, 2003), the education of all health professionals is viewed as a bridge to quality care. Provide patient-centered care Work in interdisciplinary teams Employ evidence-based practice Apply quality improvement Utilize informatics Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 14 Quality Care (Cont.) Priority Areas for National Action (IOM, 2003) identified

27. priority areas that should be addressed to improve quality Patient and family engagement Population health Safety Care coordination Palliative care Overuse Access Health systems infrastructure capabilities Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 15 Quality Care (Cont.) Keeping Patients Safe: Transforming the Work Environment (IOM, 2004) addressed critical quality and safety issues with a focus on nursing care and nurses Focused on nurses in acute care and the work environment for safer patient care Also looked at nursing shortage, health care errors, patient safety risk factors, nurse’s role in quality improvement, and work environment threats to patient safety Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 16 Quality Care (Cont.) The Future of Nursing. Leading Change, Advancing Health (IOM, 2011) focuses on the nursing profession and how it might fit into the change process Nurses should practice to the full extent of their education and training.

28. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 17 Quality Care (Cont.) The Future of Nursing. Leading Change, Advancing Health (Cont.) Nurses should be full partners with physicians and other health professionals in redesigning health care in the United States. Effective workforce planning and policy making require better data collection and an improved information infrastructure. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 18 Accreditation Joint Commission National Committee for Quality Assurance (NCQA) Health Plan Effectiveness Data and Information Set (HEDIS) American Healthcare Commission Consumer Assessment of Healthcare Providers and Systems (CAHPS) Agency for Healthcare Research and Quality (AHRQ) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 19 … the ultimate test of the public health subsystem is whether it

29. effectively serves the people by their measurements, not those of the public health profession. – Koop (1989) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 20 Critical Issues in Health Care Delivery Managed care Information technology Telehealth Electronic medical records (EMRs) Social media Consumer advocacy and client rights Client/consumer-centered health care Coordination and access to care Disparity in health care delivery Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 21 Critical Issues in Health Care Delivery (Cont.) Globalization and international health World has no real boundaries CDC active in responding to preparedness and international travel WHO fosters collaborative global initiatives ICN gives nursing perspective Health care reform The Clinton Health Reform Initiative Patient Protection and Affordable Care Act of 2010

30. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 22 Future of Public Health Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 23 What services? Who has access? Who pays? How is it delivered? What is the role of government? Impact on Community Health Nursing Principles of change that focus on quality, access, and cost… The need for patient-centered care The need for stronger primary care services The need to deliver more care in the community The need for seamless, coordinated care The need for reconceptualized roles for health professionals The need for interprofessional collaboration – The Future of Nursing. Leading Change, Advancing Health (IOM, 2011) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 24

31. Economics of Health Care Chapter 12 Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. Factors Influencing Health Care Costs Historical payment systems Unnecessary use of services Lack of preventive care Lifestyle/health behaviors Societal belief that disease would be eradicated Technological advances Aging of society Utilization of drugs Shift from nonprofit to for-profit health care Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 2 Public Financing of Health Care: Medicare Entitlement program to provide health care to the growing population of those 65 years of age or older Part A Includes inpatient care in hospitals/skilled nursing facilities,

32. hospice care, some home health care Must pay a deductible for health services Does not pay for all health care costs of enrollees; co- payments required after 60 days Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 3 Public Financing of Health Care: Medicare (Cont.) Entitlement program to provide health care to the growing population of those 65 years of age or older Part B Purchased by monthly fee Not compulsory Helps pay for out-of-pocket costs for physician services, hospital outpatient care, durable medical equipment, and other services, including some home health care Enrollees must pay deductibles and coinsurance Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 4 Public Financing of Health Care: Medicare (Cont.) Entitlement program to provide health care to the growing population of those 65 years of age or older Part C

33. Medicare Advantage Plans Optional “gap” coverage Provided by private insurance companies approved by, and under contract with, Medicare May include HMOs and PPOs May include vision, hearing, dental care, and other services not covered by Medicare Parts A, B, or D Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 5 Public Financing of Health Care: Medicare (Cont.) Entitlement program to provide health care to the growing population of those 65 years of age or older Part D Initiated in 2006 to help defray costs of prescription drugs Optional; must enroll in an approved prescription drug plan Monthly premium, deductibles, and co-payments Must pay 100% of costs when costs reach “coverage gap” or “donut hole” Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 6 Public Financing of Health Care: Medicaid Title XIX of the Social Security Act—a public welfare

34. assistance program Provides universal health care coverage for the indigent and children A joint state and federal venture Eligibility for this program depends on the size and income of the family; federal government sets baseline eligibility requirements, but states can lower eligibility Priority participation is given to children, pregnant women, and the disabled Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 7 Public Financing of Health Care: Medicaid (Cont.) Federal government sets baseline services, but state governments may provide more services Must include inpatient and outpatient hospital care, pregnancy- related care, vaccines for children, family planning services, rural health clinics, home health care, lab and x-ray services, and EPSDT Care by pediatric and family nurse practitioners is covered Children under 18 also eligible for Children’s Health Insurance Program (CHIP) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 8

35. Public Financing of Health Care: Governmental Grants Directed toward funding large populations and different aggregates Historically for health promotion and disease prevention measures Administered by DHHS “Block grants” provided to states to impact the health of the public as a whole Health care providers and programs compete for funds through grant proposals and applications Closely related to Healthy People 2020 objectives Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 9 Philanthropic Financing of Health Care Often research or disease oriented Eligibility for services limited to the specific disease or population of interest May include services rendered plus ancillary needs like transportation, parental housing, or wigs Informational and research activities constitute the majority of services provided by these organizations Examples include American Heart Association and the Shriners Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 10 Health Insurance Plans First established in 1930s

36. Types of plans Indemnity, HMO, PPO, POS Private insurance, cooperatives, cafeteria plans Reimbursement mechanisms Retrospective and prospective plans Scope of services covered Routine care, catastrophic, ambulatory Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 11 Cost Containment Capitated reimbursement Prospective reimbursement for services Access limitation Primary care provider as gatekeeper Managed care plans—preauthorization requirements for additional services Rationing Determining the most appropriate use of health care or directing the health care where it can do the most good Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 12 Trends in Health Financing New and innovative health care approaches Cost sharing

37. Health alliances Self-insurance Flexible spending accounts Health promotion and disease prevention Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 13 Health Care Financing Reform Lack of insurance is the major factor associated with lack of access to medical care. The current dilemma is how to provide health care to all Americans that is acceptable and affordable. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 14 Caring for the Uninsured Should health care be one of those necessities available to all without cost? Should health care be a right for all rather than a commodity to be available only to those who can afford it? Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 15

38. Access to Health Care—Barriers Insufficient financial support Physical barriers Structural inaccessibility, lack of appropriate equipment, or inability to communicate Inequality in the distribution of services, transportation difficulty, conflict with work hours, and failure to provide services Sociological barriers Language difficulties and fear of reprisals Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 16 Health Care Reform 2010 Individual mandate Employer requirements Expansion of Medicaid Expansion of CHIP Premium and cost-sharing subsidies to individuals Changes to private insurance Cost-containment provisions Prevention and wellness Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 17 Nurse’s Role in Economics Researcher Investigate efficient, cost-effective care, culturally sensitive

39. treatment modalities, health education, disease prevention, and factors to change behaviors Investigate, develop, and evaluate the effectiveness of health promotion and disease prevention Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 18 Nurse’s Role in Economics (Cont.) Educator Health education is the foundation of community health nursing practice Understand that knowledge empowers clients to actively participate in their health care Demonstrate the effectiveness and value of education Outcome measures for health education need to be established Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 19 Nurse’s Role in Economics (Cont.) Provider of care Care must be appropriate, necessary, and cost effective. Judicious application of the nursing process is imperative. Serve as program service provider, health education provider, and heath program participant Participate in grant proposal process, program design, and evaluation of these programs Participate in statistical information–gathering process as basis for determining needs

40. Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 20 Nurse’s Role in Economics (Cont.) Advocate Become more involved in the economics of health care Increase knowledge of health care funding and policy making Use political power to influence health care funding Advocate for increase in health promotion/disease prevention funding Plan programs, seek funding, and evaluate program effectiveness through outcome measures Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 21

Chapter 10Policy, Politics, Legislation, and Community Health .docx

Chapter 10Policy, Politics, Legislation, and Community Health .docx

Chapter 10Policy, Politics, Legislation, and Community Health .docx

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Chapter 10Policy, Politics, Legislation, and Community Health .docx