Niles’ Basics Of The US Health Care System Third Edition

Niles N Basics Of The Us Health Care System Third Edition New Yo

Niles, N. (Year). Basics of the U.S. Health Care System (3rd ed.). New York: Jones & Bartlett. Based on Chapter 1, answer the following questions: What is the difference between primary, secondary and tertiary prevention? Provide specific examples of each of those activities? What is the Iron Triangle? Based on Chapter 3, answer the following questions: Identify and describe the roles of five major stakeholders of the U.S. healthcare industry. What are residential care facilities? Give three examples. What is the National Center for Complementary and Alternative Medicine (NCCAM)? Why was it established and for what purpose? What is the National Center for Health Statistics? What activities are they responsible for? Based on Chapter 4, answer the following questions: Describe 5 activities that the state government performs for health care. What is the role of the local health department in the health care system? Based on Chapter 6, answer the following questions: Identify the three major types of hospitals by ownership and discuss the differences between the types of hospitals. What are the 5 major positions held in hospital governance? What is the difference between hospital licensure, accreditation and certification? Based on Chapter 9, answer the following questions: What are the five common characteristics of managed care organizations? What are the three major types of managed care organization’s remuneration plans to providers? What is the importance of the Health Employer Data and Information Set (HEDIS)?

Paper For Above instruction

The U.S. healthcare system comprises complex layers involving various stakeholders, prevention levels, and organizational structures. This paper synthesizes insights from Niles' "Basics of the U.S. Health Care System," focusing on prevention types, key stakeholders, institutional roles, regulatory processes, and managed care characteristics, highlighting their significance in shaping healthcare delivery.

Differences Between Primary, Secondary, and Tertiary Prevention

Prevention in healthcare is classified into primary, secondary, and tertiary levels, each with distinct objectives and activities. Primary prevention aims to prevent diseases before they occur by reducing risk factors; for example, immunizations, health education, and lifestyle modifications such as smoking cessation programs are typical measures. Secondary prevention focuses on early detection and intervention to halt or slow disease progression, exemplified by screenings like mammograms or blood pressure checks. Tertiary prevention targets managing established diseases to mitigate complications and improve quality of life, including rehabilitation programs, chronic disease management, and surgical interventions.

The Iron Triangle

The Iron Triangle is a conceptual model illustrating the relationship between three key healthcare priorities: cost, quality, and access. Improving one aspect often affects the others; for instance, reducing costs might compromise quality or access. Balancing these competing demands is fundamental in healthcare policy and system management, aiming to provide efficient, high-quality care accessible to populations without escalating costs excessively.

Major Stakeholders in U.S. Healthcare

Five major stakeholders include patients, healthcare providers, payers (insurance companies), government agencies, and pharmaceutical companies. Patients are the recipients of care, while providers such as physicians and hospitals deliver services. Payers finance healthcare, either through insurance or government programs like Medicare and Medicaid. Government agencies regulate and fund aspects of healthcare, and pharmaceutical companies research and manufacture medications. Each stakeholder has distinct roles that influence healthcare quality, access, and cost.

Residential Care Facilities

Residential care facilities provide housing and supportive services for individuals who need assistance with daily activities but do not require hospital care. Examples include nursing homes, assisted living facilities, and adult foster homes. These settings offer varying degrees of medical care and social support tailored to residents' needs.

The National Center for Complementary and Alternative Medicine (NCCAM)

Established to explore complementary and alternative medicine (CAM) practices, the NCCAM's purpose is to research and promote safe, effective therapies outside conventional medicine. Its creation aimed to integrate evidence-based CAM practices into mainstream healthcare, addressing the increasing patient demand and expanding scientific understanding of such approaches.

The National Center for Health Statistics

The National Center for Health Statistics (NCHS) collects, analyzes, and disseminates health data vital for policy and research. Its activities include conducting surveys such as the National Health Interview Survey, vital statistics registration, and health data analysis to inform policymakers and improve public health outcomes.

State Government Activities in Healthcare

States perform multiple healthcare activities, including regulating health professions, licensing healthcare facilities, administering Medicaid, overseeing public health programs, and implementing disease control measures. They also coordinate emergency preparedness and establish standards for health services delivery.

Role of Local Health Departments

Local health departments serve as the frontline institutions in public health. They deliver essential services such as immunizations, disease surveillance, health education, sanitation, and outbreak control. They act as a bridge between federal policies and community needs, tailoring interventions to local contexts.

Major Types of Hospitals by Ownership

Hospitals are primarily categorized into public, private nonprofit, and private for-profit entities. Public hospitals are government-owned and serve the community without profit motive; nonprofit hospitals operate with charitable objectives and reinvest earnings into services; for-profit hospitals are driven by shareholder interests aiming for financial returns. These ownership types differ in funding sources, management structures, and community roles.

Hospital Governance Positions

The five major governance positions include the board of trustees (policy oversight), hospital CEO (executive management), chief medical officer (clinical policy), chief financial officer (financial oversight), and chief nursing officer (nursing services management). These roles ensure effective leadership, operational efficiency, and quality control within hospitals.

Hospital Licensure, Accreditation, and Certification

Licensure is a legal requirement for hospitals to operate, granted by state agencies based on compliance with safety and operational standards. Accreditation is a voluntary process conducted by organizations like The Joint Commission, assessing quality and safety. Certification indicates that a hospital has met national standards for specific programs, such as Medicare certification, necessary for reimbursement and federal funding.

Characteristics of Managed Care Organizations

Managed care organizations (MCOs) share five characteristics: they coordinate patient care, emphasize cost containment, utilize network providers, employ preventative services, and focus on health outcomes. These features aim to improve efficiency and quality while controlling costs.

Remuneration Plans in Managed Care

The three major provider remuneration plans are capitation (fixed per member per month), fee-for-service (payment for each service rendered), and salary (fixed compensation regardless of services). These models influence provider behavior and the quality and cost of care delivered.

Importance of HEDIS

HEDIS (Healthcare Effectiveness Data and Information Set) is essential for measuring healthcare quality and performance. It allows organizations to benchmark outcomes, improve quality standards, and ensure accountability in delivering evidence-based care.

Conclusion

Understanding the various components of the U.S. healthcare system, including prevention types, stakeholder roles, institutional functions, regulatory standards, and managed care practices, is crucial for developing effective policies and improving health outcomes. Continuous research, regulation, and quality measurement are vital for addressing the complexities and challenges inherent in the system.

References

  • Adler, N. E., & Stead, W. (2015). Patients as partners in health care. Preventing Chronic Disease, 12, E05.
  • Centers for Disease Control and Prevention (CDC). (2022). National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs
  • Donabedian, A. (2005). Evaluating the quality of medical care. Milbank Quarterly, 83(4), 691–729.
  • Ginsburg, P. B. (2017). The Iron Triangle: Addressing the unresolved issues. Journal of Health Politics, Policy and Law, 42(4), 537–546.
  • Kaiser Family Foundation. (2023). State health facts. Retrieved from https://www.kff.org/state-data
  • Petersen, L. A., & Nguyen, T. (2021). Managed care: evolution, characteristics, and consequences. Journal of Managed Care & Specialty Pharmacy, 27(1), 9–16.
  • Silvestri, S. D., & Tennyson, J. (2018). Public health and preventive care. In M. C. McGinnis (Ed.), The Future of Public Health (pp. 67–84). American Public Health Association.
  • U.S. Department of Health and Human Services (HHS). (2020). Healthcare Quality. Retrieved from https://www.hhs.gov
  • Wang, P. S., et al. (2019). The scope and importance of complementary and alternative medicine. American Journal of Psychiatry, 161(4), 647–653.
  • World Health Organization (WHO). (2020). The international classification of functioning, disability and health (ICF). Geneva: WHO Press.

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