What every nurse needs to know about the healthcare system!

December 6, 2013 in Miscellaneous, On the Job

You got a job as a new nurse! Congrats! Or you’ve started clinical rotations again! Yay!  Now you have duties and responsibilities to the patients and families for whom you provide care.  One such area with which your patients may be struggling and will require your expertise as a healthcare professional is the United States healthcare system.  And not just patients, your friends and family members will turn to you and trust your informed opinions regarding anything from healthcare reform, the organizational structure of healthcare delivery, and much more.  Don’t you wish you had all the answers?

Here, I have provided a mini-FAQ list to get you started.

1. What is the difference between Medicaid and Medicare?

Medicaid is a federal and state program that helps with healthcare costs for some people with limited income.  The federal government sets a minimum standard of healthcare coverage and states may choose to provide additional coverage.  It was initially created and meant to be used for the welfare population (single parents, the aged, disabled, etc.) but has since expanded and is planned to be expanded even further.  Each state has different rules for people who can qualify and apply for their state Medicaid program.

Medicare is a program that covers healthcare costs of people who are older than 65 years old and who have paid Social Security for 10 years and certain younger people with disabilities.  Briefly and generally, 4 parts of Medicare cover different types of care. Part A, for people older than 65 years old, covers hospital and skilled nursing care and some hospice care and is funded by taxes (you’ll see this on your paystubs!); B: out-patient care; C: Medicare Advantage or managed care plans such as HMOs and PPOs; and D: Prescription Drug Benefit.

2. What is the Affordable Care Act?

The full name is the Patient Protection and Affordable Care Act (PPACA) which is a federal statute that was signed into law by President Obama on March 23, 2010. It is an act addressing healthcare reform.  Some parts of it have already been instituted and some changes are still to come.  It is a complex piece of legislature that, in general, aims to improve the access and quality of healthcare while decreasing costs.  As healthcare coverage expands, more patients will be seeking care, and we, the healthcare workforce, will need to meet the needs of the increased volume of patients.  Healthcare reform is certainly a hot-button issue, and it is important for yourself and your patients to be knowledgeable about the changes and why and how they are being instituted.

3. What’s the state of healthcare costs in the U.S.?

Last year, the U.S. spent more than 3 TRILLION dollars on healthcare; about 18% of the GDP (gross domestic product, an indicator of the nation’s economy); more than $8,000 per person; and about 2.5 times more than any other developed nation.

4. How does health insurance and having coverage actually work?  How are healthcare providers compensated?

Health insurance shields costs from the patient, finances healthcare, and determines the access and utilization of healthcare.  Here is a small, simplified figure that helped me to visualize exactly what goes between the 4 big players: government, business and individuals, private insurers, and health service providers (us!).  The color-coded arrows represent the payments made from one entity to another; look at one at a time to avoid confusion.

chart

Obviously, we can’t know everything and there is always more to learn.  So, here are a couple websites that provide reliable, current information that you may reference.

http://kff.org/ – This resource is one that I use most frequently.  They have clear graphs; concise, helpful lists and articles; and colorful, easy-to-find categories to locate the information that you seek quickly.  It is their goal and mission to be a trusted source of information in the healthcare world.  USE IT!

https://www.healthcare.gov – This is the official Affordable Care Act website.  Find out about new Health Care Marketplaces which went live on October 1st!

http://www.washingtonpost.com/national/health-science – Now, I may be biased because I studied and now work in our nation’s capital, but I believe the Washington Post provides some great articles and occasionally interactive quizzes or images to help readers digest the healthcare system and healthcare reform updates and opinions.  Even if the Post is not your cup of tea, read some newspaper often.  Big changes are happening so fast that it’s really the best way to stay current.

The websites for the Agency for Healthcare Research and Quality (www.ahrq.gov), the Center for Disease Control and Prevention (www.cdc.gov), or the U.S. Department of Health and Human Services (www.hhs.gov) may also meet your information needs.

As a nurse, you have a professional duty to your patients to advocate for them which includes helping them navigate our country’s very complex and ever-changing healthcare delivery system.  They will trust you to provide complete, accurate, and up-to-date information.  Take the initiative and educate yourself about these aspects and changes; it will make a significant, positive impact upon your practice and also on your patients’ coordination of care and healthcare experiences.

And, as always, if there is anything I missed that you think should be included, please do not hesitate to leave a comment or question below.

Happy and healthy nursing! <3