Online Companion: Fundamentals of Nursing Standards and Practice 2E
Health care services are delivered by a multidisciplinary team. Nurses are important members of this team. The roles and functions of other professionals on the team are described in Chapter 4.
The funding of health care comes from both private and public sources. In Canada, the government is the only source of health care costs reimbursement. The financing of health care in the U.S. is based on the private insurance model in which insured individuals pay monthly premiums for access to health care.
Managed care is a system of providing and monitoring care in which access, cost and quality are controlled before or during delivery of services. It is designed to provide cost-effective and coordinated services with emphasis on prevention and primary care. One variation of a managed care structure is the health maintenance organization (HMO). This is a prepaid health plan that provides primary health care services for a preset fee with a focus on cost-effective treatment. One common feature of HMOs is the use of primary care providers as "gatekeepers" to the health care system in that they determine which, if any, referrals to specialists are needed by the client. The most common managed care system is the preferred provider organization (PPO) which is a contractual relationship between hospitals, providers, employees and third-party payers to form a network of health services for a defined population at a predetermined price.
Despite cost containment efforts such as DRGs and managed care, the U.S. health care system continues to have problems providing adequate access to services especially for low-income and unemployed individuals. Health care costs continue to rise; attempts to control costs run the risk of compromising the safety and quality of care.
The major challenges facing the U.S.
health care delivery system are identified as the public's disillusionment with
providers, loss of control over health care decisions, decreased use of hospitals
and the impact on quality of care, changing practice settings, ethical issues
and vulnerable populations. The nursing profession has responded to these challenges
by proposing a plan for reform of the health care system. The proposed agenda
and its basic premises advocate for a health care system that is accessible
and user-friendly to the client. Empowerment of consumers for self-care is another
major feature of the plan. Other approaches supported by nursing include standardization
of care, use of nurses in advanced practice roles, integration of public and
private sector resources, a community-based approach to service delivery and
increased financial support for long-term care needs of older adults.