Foundational Knowledge and Basic Science: Health Care Systems and Settings

Health Care Systems and Settings

The medical field can seem overwhelming. New terminology, legal concerns, direct or
indirect patient care, unique processes, and high expectations can contribute to initial
apprehension. However, this new role can be better understood through a holistic
approach, looking at the health care system from all sides. In addition to understanding
the role and scope of practice, it is crucial to understand the importance of the entire
health care team. Knowing the skills and responsibilities of the various allied health and
specialty providers strengthens the effectiveness and cohesiveness of the health care
team. Each team member needs to respect and assist others in providing the best
possible care for the patient.

Medical Assistant Roles, Responsibilities, Scope of Practice, and Titles

MA Roles
The role of an MA is primarily to work alongside a provider in an outpatient or
ambulatory health care setting, such as a medical office. The MA can be cross-trained to
perform both administrative and clinical duties. Administrative duties include greeting
patients, scheduling, handling correspondence, and answering telephones. In addition,
the MA is often responsible for obtaining medical histories from patients, providing
patient education, performing laboratory tests, and preparing and administering
immunizations. An MA achieves credentialing by passing a national certification exam.
MA Responsibilities
The responsibilities of an MA vary based on the setting in which they work. Duties can
be primarily administrative, clinical, or a combination.
Administrative Duties

• Scheduling patient appointments

• Patient registration (demographics, payer information, compliance forms)

• Updating and working in patient records

• Sending claims to insurance

• Collecting patient responsibility amounts (copays, coinsurance, deductible)

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 Foundational Knowledge and Basic Science: Health Care Systems and Settings

Clinical Duties

• Collecting and processing lab specimens

• Performing diagnostic testing (EKG, spirometry)

• Preparing and cleaning examination rooms

• Preparing the patient for evaluation and procedure

• Measuring vital signs

• Preparing medications and administering immunizations

The medical assistant’s role is constantly changing and evolving. In addition to
traditional responsibilities, medical assistants are doing more patient navigation and
care coordination work. In this role, medical assistants can guide patients as they
journey through the health care system—helping them understand what is happening
and what steps they need to take and helping them connect to the right specialists. To
effectively support the patient in this way, the MA will often need to coordinate with
other members of the patient care team, both within the clinic and externally with
specialty care teams. The MA may ask questions on the patient’s behalf to nurses and
providers within the team to better understand the plan of care and provide the
information to the patient in a clear, easily understood way. When coordinating with
other teams, medical assistants can provide helpful context about the patient’s social
determinants of health and barriers to care, as well as support the patient in being
scheduled appropriately and in a timely manner with specialists.
Scope of Practice
Scope of practice describes the duties delegated based on education, training, and
experience. The scope of practice for the MA does not include the practice of
medicine. Medical assistants should not perform duties they have not been trained or
certified to do. Prior to practice, review the duties and restrictions related to medical
assisting, which vary by state. Health care organizations may have stricter policies and
procedures that they enforce, but they must comply with state regulations at minimum.
Variables for the Scope of Practice
Variables that affect the scope of practice for medical assistants include the regulations
and policies issued by state medical boards. An MA with appropriate training may safely
provide supportive services that are simple, routine medical tasks under the supervision
of a licensed physician. In addition, the MA may only provide supportive services set
forth by the medical office’s organizational policies. These often include measuring
height and weight, measuring vital signs, and performing various diagnostic and

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laboratory testing. Organizational policies must adhere to state and government

guidelines to comply with current laws.
Titles
Over 50 years ago, medical providers began hiring assistants to support their medical
practice. They recognized the need for administrative support. Over time, this turned
into the MA role, combining administrative and clinical responsibilities. In 1956, a formal
medical assistant association was formed and recognized by 15 states. The profession
continued to evolve and was recognized by the U.S. Department of Education in 1978.
At that time, training was completed on the job by the provider and other office staff.
This eventually became time-consuming and expensive for providers, at which point
formalized training and certification programs arose. Many clinical offices look to hire
only those who have completed formal training and certification, ensuring they have the
necessary skill set to work in patient care. Offices also follow specific guidelines
requiring medical assistants to have current certification to input data regarding
government insurance reimbursements into electronic health records.
Additional Certifications
Medical assistants can further their careers and extend their scope of work through
continued education, leading to additional certifications, including the following.
Certified medical administrative assistant (CMAA)
Certified phlebotomy technician (CPT)
Certified EKG technician (CET)
Certified billing and coding specialist (CBCS)
Certified electronic health records specialist (CEHRS)

Provider and Allied Health Roles, Responsibilities, Scope of Practice, Titles,

and Credentials

Physician Information
When most people think of health care providers, they think of physicians, also known
as doctors. All practicing doctors must be licensed in the state where they practice. To
pursue a license, they must first complete eight years of school—four years of
undergraduate college, followed by four years of medical or osteopathic school. Upon
graduation, prospective physicians then move on to residency. Residency is a two- to
seven-year training period where they receive intensive on-the-job training with the
direct oversight of a licensed physician. Finally, physicians must pass parts I, II, and III of

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the U.S. Medical Licensing Examination. There are two primary types of physicians:
medical doctor (MD) and doctor of osteopathy (DO). Their scope of practice and
responsibilities are nearly the same, though their training and expertise have slight
variations.
Medical doctors are allopathic providers and the most widely recognized type of
doctor. They diagnose illnesses, provide treatments, perform procedures such as
surgical interventions, and write prescriptions.
Doctors of osteopathy complete requirements like those of MDs to graduate and
practice medicine. In addition to modern medicine and surgical procedures, DOs use
osteopathic manipulative therapy to treat patients.
In addition to physicians, there are two primary types of midlevel providers: physician
assistants and nurse practitioners.
Physician Assistant
Physician assistants (PA) must practice medicine under the direction and supervision of
a licensed MD or DO, but they can make clinical decisions. In order to be licensed as a
PA in the state of practice, individuals must first complete at least four years of college,
followed by two years of PA school. Most PAs will focus on a specific specialty, such as
cardiology or orthopedics.
Nurse Practitioner
Nurse practitioners (NP) provide basic patient care services, including diagnosing and
prescribing medications for common illnesses. Nurse practitioners require advanced
academic training beyond the registered nurse (RN) degree and have an extensive
amount of clinical experience. In most states, NPs must work under the supervision of a
physician, but in some states they can practice independently.
Nurses
Nurses are found in almost every health care setting.
A licensed practical nurse (LPN) must be licensed in their state. Typically, one year of
schooling through an accredited program, along with passing a state board
examination, is required to obtain an LPN license. LPNs are somewhat limited in their
scope of practice, as the role is designed to be assistive. They can measure vital signs,
administer some medications, and perform clinical care such as wound care. Often, the
role of an LPN is to observe patients, recording and reporting on status changes. While
they may work in many different settings, a primary use of LPNs recently is in long-term
care settings due to the increasing number of older adults in the general [Link]
some states, and LPN may also be referred to as an LVN (licensed vocational nurse).

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 Foundational Knowledge and Basic Science: Health Care Systems and Settings

A registered nurse (RN) must complete more schooling in the form of an associate
degree, diploma graduate, or baccalaureate degree. They, too, must pass a state board
examination to be licensed. Due to the more intensive training, RNs have a much
broader scope of practice than LPNs. RNs can work in clinical settings, public health
agencies, administrative capacities, and educational settings.
Allied Health Professionals
Medical laboratory technicians perform diagnostic testing on blood, bodily fluids, and
other specimens under the supervision of a medical technologist.
Medical receptionists check patients in and out, answer phones, schedule
appointments, and perform other administrative tasks.
Occupational therapists assist patients who have conditions that disable them
developmentally, emotionally, mentally, or physically.
Pharmacy technicians may perform routine medication dispensing functions that do not
require the expertise or judgment of a licensed pharmacist. Pharmacy technicians must
work under the direct supervision of a pharmacist.
Physical therapists assist patients in improving mobility, strength, and range of motion.
Radiology technicians use various imaging equipment to assist the provider in
diagnosing and treating certain diseases.

Licensing Versus Certification and Maintenance of Certification

Licensure vs. Certification

A medical school graduate must be licensed before beginning the practice of medicine.
Being licensed by the state to practice medicine allows them to diagnose conditions
and provide treatment. Licensing helps ensure that anyone providing medical care has
the adequate knowledge and skill set to do so safely. It is important to understand the
laws and regulations within each state to avoid violations of any kind.
Health Care Licensure
Licensure is regulated by state statutes through the medical practice acts. An MD, DO,
or Doctor of Chiropractic degree is issued upon graduation from a medical or
chiropractic institute.
Licensure for physicians is mandatory and controlled by a state board of medical
examiners. Licensure may be accomplished by examination, reciprocity, or
endorsement. Every state requires a written examination for MDs to practice. Some

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states grant the license to practice medicine by reciprocity, which automatically

recognizes that the requirements were met by another state. Graduates of medical
schools in the U.S. are licensed by the endorsement of the national board certification.
Licensure by endorsement is granted on a case-by-case basis based on examinations.
Graduates not licensed by endorsement must pass the state board exam.
As of 2022, no state requires medical assistants to be licensed. However, some states
dictate that to complete specific services such as x-rays, individuals must have a license
to perform that particular skill. For example, Florida does not require a medical assistant
to have a license to collect prescribed routine laboratory specimens. However, in
Washington, even nationally certified medical assistants must get licensing credentials
through the Washington State Department of Health to perform phlebotomy or EKGs.
Certification
In addition, the government may require certification for the medical assistant to enter
prescriptions into a computerized order-entry system. Advantages of certification
include increased initial job placement, higher wages, and career advancement
opportunities.
Maintaining a Certification
Once certification is obtained, it must be maintained to stay current. This ensures that
medical assistants have the most up-to-date information about the medical field and
provides validity to the overall profession. Each certification has different requirements
for recertification, so medical assistants should understand and follow the recertification
process of the organization sponsoring their certification.

Types of Health Care Organizations and Delivery Models

Inpatient and Outpatient

Inpatient care occurs while the patient is admitted to a hospital or facility. Ambulatory
care refers to any care received in an outpatient facility. This includes many types of
care settings.
Primary Care Clinics
Primary care clinics are outpatient care settings where patients are seen for routine type
visits, including wellness checks, prevention counseling, chronic conditions, medication
management, and minor acute needs. Primary care will be discussed in more detail later
in the chapter.
Specialty Care Clinics

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Specialty care clinics are outpatient facilities where patients who have complex or
severe diseases and conditions are seen for routine visits by doctors who specialize in a
specific disease or condition.
Home Health
Home health refers to specific types of care provided to those who cannot leave their
home easily. Physical, occupational, and speech therapy are common types of home
care. Skilled nursing is also common in the home health setting. It must be prescribed
and overseen by a provider, typically a primary care provider (PCP). Home health is not
used on an ongoing basis for a patient but is ordered for a set period based on an
acute event, usually hospitalization. Home health orders include goals for the patient,
such as managing their medications and ambulating safely. The service is complete
when the goals are reached. Medical assistants working for the ordering provider are
often responsible for submitting the order for home health, coordinating to ensure the
patient is enrolled and scheduled, and assisting with the administrative aspects of the
orders.
Mobile Health Units
Mobile health units bring health care to the communities that most need it and may
otherwise lack access to the services provided. Teams working in a mobile health unit
are equipped with means of transportation that allow for the setup and use of
specialized medical equipment. There are mobile health units in the U.S. While this
concept has been in use for services such as mobile stroke units, mobile urgent cares,
and mobile mammogram buses, the COVID-19 pandemic brought this type of care to
much of the country in the form of mobile testing and vaccination options.
Hospice
Hospice care is end-of-life care focused on comfort rather than curative efforts. Patients
can qualify for hospice care if they have a terminal illness at the end stage. It can be
delivered as outpatient or inpatient care. Typically, a patient will begin hospice
outpatient but can transition to inpatient care as they need a higher level of care near
the end of life.
Patient-Centered Medical Home
The patient-centered medical home (PCMH) is a care delivery model in which a PCP
coordinates treatment to ensure patients receive the required care when and where
they need it and in a way they can understand. This encompasses all aspects of care,
from prevention and wellness education to acute illness and chronic disease
management to end-of-life care. The PCMH is a team-based approach to health care in
which a provider leads an interprofessional team to work collaboratively and effectively
for their patients. Medical assistants are an integral piece of the PCMH team—assisting

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with direct patient care, care coordination, patient education, and administrative tasks
essential to the model.

Technology-Based Methods for Providing Health Care and Information

Telehealth and Virtual Visits

Telehealth is health care delivered virtually, most commonly via video call. The increase
in telehealth expanded to eliminate patients from coming in contact with
communicable diseases, provide convenience, and allow patients in rural areas to
obtain specialty care where it may not have been offered before. Telehealth can be an
excellent option for patients and providers to review many aspects of care, but it does
come with limitations.
Medical assistants may have multiple responsibilities when it comes to virtual visits.
Scheduling virtual visits may require more time because the MA must gather or confirm
the patient’s email address, ensure the link has been sent, and review instructions.
Some offices offer patients a test visit in which an administrator or MA will log into the
link to ensure the patient can access it when it is time for their appointment. Medical
assistants may also participate in the actual visit, just as they would with a standard
office visit. This can include gathering a history, verifying medication and pharmacy
information, setting an agenda, and following up with the patient on the next steps,
such as referral or diagnostic testing coordination.
Patient Portals
Patient portals are a common feature in electric health records. This feature allows
patients to log into a patient-facing aspect of the EHR to view their personal health
information, such as test results, visit notes, and patient education materials. Many
patient portals include an option to securely message the health care team about
concerns and plans of care. Some portals also allow patients to schedule appointments
directly without needing to call the office. The benefits of patient portals include
increased transparency about care, decreased wait times for patients to receive results,
and reduced demand on the office staff due to direct access limiting the need for
phone calls.
The MA may be responsible for uploading information to the portal, as well as assisting
the patient with enrolling and getting set up with an account. Medical assistants should
understand the portal’s functionality and the clinic’s policies and procedures around
appropriate use.

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Health Care Payment Models

Fee for Service

The U.S. health care system is largely based on the fee-for-service model in which
providers and medical facilities bill insurance and patients for the services provided.
Every examination, medical service, test, and procedure has an associated procedural
code and charge. These charges are managed through the provider’s medical billing
department and sent to the insurance (or directly to the patient) for payment. The
insurance then charges the patient a predetermined amount for which they are
responsible.
Value-Based Plans
The health care system is increasingly moving toward value-based plans or care. The
goals of value-based care are summarized in the Quadruple Aim.

• Improved patient outcomes

• Improved patient satisfaction

• Lower cost

• Health care professional well-being

Rather than costs being determined by each service, the cost is more holistic. This
model prioritizes prevention and early intervention over complex intervention to
prevent unnecessary downstream costs. Clinics and health care systems that adopt this
model are rewarded financially for keeping patients healthy rather than making money
based on visits, procedures, and interventions once the patient has become ill.
Other Health Care Models

MODEL DESCRIPTION

Managed care An umbrella term for plans that provide health care in return for preset
scheduled payments and coordinated care through a defined network
of providers and hospitals.

Capitation (partial or Patients are assigned a per-member, per-month payment based on

full) age, race, sex, lifestyle, medical history, and benefit design. Payment
rates are tied to expected usage regardless of how often the patient
visits. Like bundled payment models, providers are incentivized to help
patients avoid high-cost procedures and tests to maximize their
compensation. Under partial- or blended-capitation models, only
specific types or categories of services are paid based on capitation.

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MODEL DESCRIPTION

Health maintenance This plan contracts with a medical center or group of providers to
organization (HMO) provide preventive and acute care for the insured person. HMOs
generally require referrals to specialists, as well as precertification and
preauthorization for hospital admissions, outpatient procedures, and
treatments.

Preferred provider These plans have more flexibility than HMO plans. An insured person
organization (PPO) does not need a PCP and can go directly to a specialist without
referrals. Although patients can see providers in or out of their
network, an in-network provider usually costs less.

Point-of-service (POS) POS plans allow a great deal of flexibility for patients. They can self-
plan refer to specialists and do not need an assigned PCP. Like PPO, the
cost depends on whether the providers they see are within the plan’s
panel.

General vs. Specialty Health Care and Services

General Health Care Services

General practitioners (GPs) are medical doctors who treat acute and chronic illnesses
and provide patients with preventive care and health education. A GP may take a
holistic approach to general practice that considers the biological, psychological, and
social aspects relevant to the care of each patient’s illness.
Family practitioners offer care to the whole family, from newborns to older adults. They
are familiar with a range of disorders and diseases. However, preventive care is their
primary concern.
Internists provide comprehensive care for adults, often diagnosing and treating chronic,
long-term conditions. They also offer treatment for common illnesses and preventive
care. Internists must have a broad understanding of the body and its ailments to
diagnose conditions and provide treatment. Internists may focus on pediatric or adult
medicine rather than provide care across the lifespan.
Specialty Health Care Services
Specialist care is used when a disease or diagnosis escalates beyond the area of
expertise of a PCP. Specialists are providers focused on diagnosing and treating
diseases and disorders of specific body systems.
Specialist Care

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SPECIALIST FOCUS

Allergist Evaluates disorders and diseases of the immune system, including adverse
reactions to medications and food, anaphylaxis, problems related to
autoimmune disease, and asthma

Anesthesiologist Manages pain or administers sedation medications during surgical procedures

Cardiologist Diagnoses and treats diseases or conditions of the heart and blood vessels

Dermatologist Diagnoses and treats skin conditions

Endocrinologist Diagnoses and treats hormonal and glandular conditions; often works with
patients who have diabetes

Gastroenterologist Manages diseases of the GI tract (stomach, intestines, esophagus, liver,

pancreas, colon, and rectum)

Gynecologist Diagnoses and treats internal reproductive system and fertility disorders

Hematologist Diagnoses and treats blood and blood-producing organs, patients who have
anemia, leukemia, and lymphoma

Hepatologists Studies and treats diseases related to the liver, biliary tree, gallbladder, and
pancreas

Neonatologist Provides care of newborns, specifically those who are ill or premature

Nephrologist Manages diseases and disorders of the kidney and its associated structures

Obstetrician Provides care of patients during and after pregnancy

Oncologist Treats and provides care for patients who have cancer

Ophthalmologist Diagnoses and treats diseases and conditions of the eye

Orthopedist Treats injuries and diseases of the bones, joints, muscles, tendons, and
ligaments

Neurologist Treats diseases and disorders of the brain and nervous system

Otolaryngologist Treats diseases and conditions of the ear, nose, and throat

Pediatrician Manages newborn to adolescent health

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SPECIALIST FOCUS

Psychiatrist Diagnoses and treats mental disorders and conditions

Radiologist Uses and interprets imaging to detect abnormalities in the body

Urologist Manages disorders of the urinary tract

Ancillary Services and Complementary Therapies

Ancillary Services
Providing ancillary services in the provider’s office adds convenience for patients and
increases revenue for the organization. Ancillary services meet a specific medical need
for a particular population.
Urgent care provides an alternative to the emergency department. They cost less, have
a shorter wait time, and are often conveniently located. Most have flexible hours and
offer walk-in appointments. They are appropriate to use for non-life-threatening acute
injuries and illnesses.
Laboratory services perform diagnostic testing on blood, body fluids, and other
specimens to conclude a diagnosis for the provider.
Diagnostic imaging machines such as x-ray equipment, ultrasound machines, magnetic
resonance imaging (MRI), and computerized tomography (CT) take images of body
parts to further diagnose a condition.
Occupational therapy assists patients who have conditions that disable them
developmentally, emotionally, mentally, or physically. Occupational therapy helps the
patient compensate for the loss of functions and rebuild to a functional level.
Physical therapy assists patients in regaining mobility and improving strength and range
of motion, often impaired by an accident, injury, or disease.
Complementary Therapies
Acupuncture involves pricking the skin or tissues with needles to relieve pain and treat
various physical, mental, and emotional conditions.
Chiropractic medicine diagnoses and treats pain and overall body function through
spinal manipulation and alignment.
Energy therapy is the calm method of clearing cellular memory through the human
energy field, promoting health, balance, and relaxation. It centers on the connection

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between life’s physical, emotional, and mental states found in various holistic healing
techniques.
Dietary supplements contain one or more dietary ingredients, including vitamins,
minerals, herbs, or other botanicals. A plant or part of a plant (flowers, leaves, bark, fruit,
seeds, stems, roots, amino acids) is used for its flavor, scent, or potential therapeutic
properties.

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