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an imprint of Elsevier Inc.

Chapter 1Chapter 1The Health Care System

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PretestPretest

1. Palliative treatment attempts to reduce symptoms but does not cure disease.

2. In the past 30 years there has been a trend to avoid admitting patients to the hospital if possible.

3. The first health insurance plans in the United States were provided by the federal government.

4. The managed care movement has put pressure on physicians to limit time spent with individual patients.

5. After graduating from medical school, a physician spends 2-5 years in postgraduate training called an internship.

True or False

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Pretest, cont.Pretest, cont.

6. If laboratory tests are done in the medical office, there is a specific room or area set aside for this.

7. Some medical offices use paper medical records, but other offices store patient records electronically.

8. The physician who provides general medical care to an adult is usually an internist or a family practitioner.

9. A group practice often consists of three or four physicians in the same specialty.

10. In addition to standard medical treatment, only a few patients also receive treatments that can be called complementary medicine.

True or False

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1. WHO (World Health Organization) definition of health: a. Absence of illness or disease b. Individual can carry out the daily functions of life

with no difficulties and no pain

Introduction to Health and the Health Care System

Introduction to Health and the Health Care System

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2. Western medical health care delivery based on scientific study

3. Hippocrates (fourth century BC) credited as the first “scientific” physician

Introduction to Health and the Health Care System, cont.

Introduction to Health and the Health Care System, cont.

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Shift from Hospital-Based to Community-Based Health Care

Shift from Hospital-Based to Community-Based Health Care

1. Designed to reduce costs of health care2. More extensive outpatient care reduces

hospitalization costs3. People feel better if they can avoid

hospitalization4. Modern hospitals primarily provide acute

care and diagnostic services

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Managed Care versus Patient Care: Competing Forces

Managed Care versus Patient Care: Competing Forces

Fee-for-Service Insurance Plans1. Traditional insurance paid for hospitalization

only2. Each service provided was reimbursed3. Health insurance became an increasingly

important job-related benefit in the 1950s and 1960s

4. Cost of health insurance has increased more rapidly than other goods and services

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Government Insurance Plans Government Insurance Plans

1. Federal insurance programs began in 1960sa. Medicaid

• Began for low-income children without parental support

• Now low-income population in general

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Government Insurance Plans, cont.Government Insurance Plans, cont.

b. Medicare—elderly, disabled, end-stage renal disease

c. CHAMPUS—families of those in the armed services

d. Included office visits for illness but not preventative

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Managed CareManaged Care

1. HMO (health maintenance organization) movement

a. Began as attempt to reduce cost of medical care

b. Emphasis on routine and preventative care

2. Utilization review of hospitalized patients a. Requires reason for continued hospital stayb. Means to shorten hospital stay

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Managed Care, cont.Managed Care, cont.

3. Routine care became included in traditional insurance

4. Managed care introduced as general term a. Care based on HMO modelb. Includes utilization review of hospitalizationc. May pay physician monthly amount (capitation)

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Managed Care, cont.Managed Care, cont.

d. Encourages use of less expensive generic medications

e. Controls access to diagnostic tests and additional services

f. Often based on a network of health care providers

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Types of Ambulatory Care Types of Ambulatory Care

1. Private physician offices2. Staff HMO3. Multispecialty group practice4. Clinic at a hospital

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1. Patient checks in at the front desk2. Patient is seen by the physician3. Diagnostic tests are ordered and/or

performed

Flow of Activity in an Ambulatory Care Setting

Flow of Activity in an Ambulatory Care Setting

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Flow of Activity in an Ambulatory Care Setting, cont.

Flow of Activity in an Ambulatory Care Setting, cont.

4. Follow-upa. New appointment, appointment for diagnostic

tests, and/or referral

b. Follow-up instructions

5. Billing process is begun

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Members of the Health Care Team in the Medical Office

Members of the Health Care Team in the Medical Office

1. Physicians 2. Medical assistants3. Nurses4. Business manager

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Members of the Health Care Team in the Medical Office, cont.

Members of the Health Care Team in the Medical Office, cont.

5. Secretary/receptionist6. Insurance specialist7. Medical transcriptionist8. File clerk

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Physicians and Other Primary Care Providers

Physicians and Other Primary Care Providers

1. Physician, may be MD or DO 2. Physician's assistant (PA)3. Nurse practitioner (NP)

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Effective TeamworkEffective Teamwork

1. Teamwork is important to provide appropriate care to patients

2. Medical assistant is an important team member but should not overstep his or her role

3. Effective teamwork requires good communication

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Effective Teamwork, cont.Effective Teamwork, cont.

4. Problems should be addressed without spending a lot of time assigning blame

5. Different points of view should be accepted when trying to find solutions to problems

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Parts of the Medical Office Parts of the Medical Office

1. Areas to receive patients, examine patients, and perform administrative tasks

2. Must meet requirements of regulatory agenciesa. OSHA (Occupational Safety and Health Administration)b. Americans with Disabilities Act c. Local and state board of health

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Waiting RoomWaiting Room

1. Should be clean with good lighting2. Furniture should be arranged neatly3. Up-to-date reading material should be

available4. Seating should be adequate5. Colors should be muted and music should

be soft

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Reception AreaReception Area

1. Place where patient checks in2. May be separated from reception area by a

glass window a. Prevents patients from overhearing office activities

3. Appointments are made in this area or a separate area

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Examination RoomsExamination Rooms

1. Designed for convenience of physician and staff

2. Should be comfortable and calming for patients

3. Reading material should be available

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LaboratoryLaboratory

1. Must meet requirements of CLIA ’88 a. Clinical Laboratory Improvement Act of 1988

2. CLIA-waived tests are most commonly performeda. Tests not regulated under CLIA ’88

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Medical Record Storage AreaMedical Record Storage Area

1. Medical record storage (if paper charts are used)

2. Contains current patient charts3. Location should be accessible to business

area4. Records of inactive patients may be stored

elsewhere

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Business Area or Business OfficeBusiness Area or Business Office

1. May connect to reception area or be separate room

2. Place for entering patient charges and payments and billing

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Billing and InsuranceBilling and Insurance

1. Billing and insurance may be done in several ways:a. In the officeb. In a central billing office for several medical

facilitiesc. Contracted to an outside firm

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Additional AreasAdditional Areas

1. Physician's private officea. Often a reflection of the physician's personal tasteb. For meeting privately with patients, patient's family, and visitors

2. Staff lunch and break room

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Additional Areas, cont.Additional Areas, cont.

3. Treatment/diagnostic test rooma. Best if located in separate roomb. Should be fully stocked for procedures

4. Special procedures room or surgery rooma. Depends on specialty of the office

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Medical SpecialtiesMedical Specialties

1. Usually have their own residency programs 2. Subspecialties require additional training

(fellowship)3. Based on patient age, body system, and/or

type of treatment

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Medical Specialties, cont.Medical Specialties, cont.

4. May focus on medical treatmenta. Example: neurology

5. May focus on surgical treatmenta. Example: neurologic surgery (neurosurgery)

6. May include both medical and surgical treatmenta. Example: ophthalmology

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Primary CarePrimary Care

1. Provides general care for patientsa. Internal medicine—adultsb. Pediatrics—childrenc. Family medicine—all agesd. Sometimes OB/GYN—female adults

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OsteopathyOsteopathy

1. Takes a holistic approach to primary care2. DO (doctor of osteopathy) licensed by the

state to practice medicine3. Manipulates bones and muscles to balance

the body

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PodiatryPodiatry

1. Treatment of the foot and ankle2. Both medical and surgical treatment

provided

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ChiropracticChiropractic

1. Spinal manipulation to treat musculoskeletal disorders

2. Practitioner is licensed by the state3. More limited role than an osteopathic

physician

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Practice TypesPractice Types

Solo Practice1. Limited in size 2. Medical assistant usually responsible for

administrative and clinical duties 3. Physicians share evening and weekend

responsibility with other physicians

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Practice Types, cont.Practice Types, cont.

Group Practice1. Several physicians share office space,

personnel, equipment, etc.2. Medical assistants usually specialize

a. Administrativeb. Clinical

3. Patients can be seen by any physician for urgent treatment

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Practice Types, cont.Practice Types, cont.

Group Practice, cont.4. Types of group practice

a. Single medical specialtyb. Multispecialty (several specialties within

one facility)c. Satellite offices in two or more locations

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Practice Types, cont.Practice Types, cont.

1. Traditionally, an ambulatory care facility that provides free or low-cost care

2. Physicians employed by the clinica. May be physicians (MDs)b. May be in a residency program (residents)

Clinic

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Complementary and Traditional MedicineComplementary and Traditional Medicine

1. Used in addition to standard therapies2. If studied scientifically, may be widely

accepted (e.g., acupuncture)3. Patients must often cover costs

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PosttestPosttest

1. In order to be hospitalized, a patient’s condition must be very unstable or require regulation of therapy.

2. Managed care insurance is another name for fee-for-service insurance.

3. A nurse practitioner manages routine patient care and can write prescriptions in most states.

4. When a patient enters the office, he or she is immediately taken to a treatment room.

5. The government agency that provides for health and safety in the workplace is CLIA.

True or False

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Posttest, cont.Posttest, cont.

6. Medical records for all patients who have been seen in the past 10 years are kept in the medical office.

7. The medical office may have a special room just for treatments or procedures.

8. An osteopathic physician (DO) provides primary care and has the same legal status as a physician with an MD degree.

9. The physician who specializes in diseases of the nervous system is a neurologist.

10. Acupuncture is considered to be a standard medical treatment.

True or False