Health Care Systems/Health Policy

1. The largest single payer of hospital charges in the United States is ___________.

ANS: Medicare Medicare is the largest health insurance program; it covers the disabled persons with end-stage renal disease, and persons 65 years of age and older who qualify for Social Security. Since enactment of this program in 1965, the population covered by Medicare has doubled.

2. A 72-year-old client is admitted to have the right kidney removed after a diagnosis of cancer. The surgeon removed the left kidney. Medicare will no longer pay for preventable medical errors known as ____________.

ANS: never events Medicare identified 28 medical errors that were preventable and with serious consequences for which they will no longer pay. These errors are called never events.

3. The type of insurance that shifts the largest percentage of costs for goods and services to employees and consumers is _____________ insurance.

ANS: private Private insurance shifts a more costs to employees and consumers than does any other type of insurance.

1. An older adult client was admitted to the hospital with the condition classified as "pneumonia." Reimbursement for care was based on a predetermined fixed price. What is this classification system referred to as? a. Diagnosis-related groups (DRGs) b. Subjective symptom management c. Acuity classification system d. Organized managed care

ANS: A DRGs are used in reimbursement for health care services based on a predetermined fixed price per case or diagnosis in 468 categories. Under DRGs, each Medicare client is assigned to a diagnostic grouping based on his or her primary diagnosis at hospital admission. Medicare limits total payment to the hospital to the amount preestablished for that DRG

11. A client who is reading a newspaper asks, "This article about health care states that many providers of health care lack effectiveness. What is the difference between effectiveness and efficiency?" The nurse best responses with what statement? a. Effective means performing the correct test or intervention whereas efficiency refers to the wise use of supplies and resources for the desired outcome. b. Effective refers to competence in clinical practice and efficiency describes quick completion of the task. c. Efficiency means wasting and meeting a minimum standard and effectiveness refers to taking all the time needed to exceed expectations. d. Efficiency refers to speed and effectiveness refers to the usefulness of the implementation

ANS: A Efficiency means using the right combination of resources—energy, time, and money—to accomplish a task, and effectiveness means doing the right thing right in health care.

18. A patient is eligible to change health care providers and insurance and asks, "I am interested in health promotion activities; I walk, swim, and eat healthy. Which health insurance plan would support these activities rather than just pay for services when I am sick?" Which, if any, health insurance plan would best meet the needs of this patient? a. Health Maintenance Organization (HMO) b. Fee for Service c. Preferred Provider Organization (PPO) d. None, because health insurance plans seldom cover preventive care

ANS: A HMOs encourage preventive care.

16. A nurse is newly employed by a state-owned hospital that provides health care insurance requiring a deductible paid by the employee with most of the premium cost covered by the employer. The insurance provided to the nurse is referred to by what term? a. Private health insurance b. A federal insurances program known as PPACA c. State-subsidized Medicaid insurance d. Single-payer system coverage

ANS: A Private health insurance is a method for individuals to maintain insurance coverage for health care costs through a contract with a health insurance company that agrees to pay all or a portion of the cost of a set of defined health care services and is typically provided through an individual's employer with a portion of the cost paid by the employer and a portion paid by the employee.

15. Certain groups of individuals are opposed to the Patient Protection and Affordable Care Act (PPACA) based on religious beliefs that prohibit circumcision and blood transfusions. These individuals believe the PPACA is unconstitutional bases on what premise? a. The act mandates that all US and legal residents must secure health insurance. b. The act replaces current Medicare and Medicaid plans. c. The act requires all citizens to participate in offered preventive services. d. The act prohibits use of health practices outside of Western medicine.

ANS: A The PPACA is a type of national health insurance program to provide funding for US citizens and legal residents to secure health insurance beyond the current programs such as Medicare and Medicaid.

4. Which of the following statements is true about health care in the US? a. The US spends more money on health care than any other nation. b. The US provides health care to every citizen. c. The US relies on government funding to treat most citizens. d. The US spends less money on pediatric care than other nations.

ANS: A The US spends more money on health care than any other country. The US does not provide health care to every citizen, nor does it rely entirely on government funding. The US does not spend less money on pediatric care but usually more than other countries.

20. A patient wants to reduce health care costs by being a model for making wise decisions that both promote health and reduce cost. Which statement by the patient would indicate a need for further teaching? a. "I will ask for the brand name drug Tylenol rather than acetaminophen since it works better and I won't be sick as long." b. "I looked up urinary tract infection prevention on the Internet." c. "I had my weight, body fat, and blood sugar measured at a local health fair." d. "My allergies are really bothering me. I spoke to the pharmacist, who recommended an over-the-counter antihistamine."

ANS: A Ways to reduce health care costs as a consumer include choosing generic drugs whenever possible.

2. Medicare would be responsible for fulfilling which client need? (Select all that apply.) a. A hospital stay following a total knee replacement for a 70-year-old client b. Nursing home cost for a 67-year-old adult receiving hemodialysis c. Rehabilitation care costs for a 24-year-old client with a broken femur resulting from a fall at work d. Prescription cost for a young mother who meets eligibility for Aid to Families with Dependent Children (AFDC) e. Home health services to administer heparin to a 55-year-old truck driver following a thrombus

ANS: A, B Medicare coverage is based on age and Part A covers inpatient hospital services. Medicare eligibility is based on age and disability with hemodialysis resulting from chronic renal failure classified as a disability.

6. A contractual agreement between the insurer and the provider in which covered members are encouraged to use specific health care providers in return for reduced rates is referred to as which type of arrangement? a. Health maintenance organization b. Preferred provider organization c. Fee-for-service arrangement d. Philanthropic agency

ANS: B A preferred provider organization is an arrangement by which the member pays a premium for a fixed percentage of expense coverage. This method includes a required deductible and a copayment. The member may select a physician but pays less for physicians and facilities on the plan's preferred list.

8. A physician bills the insurance company for a computed tomography (CT) scan, laboratory tests, chest x-ray, and an extended visit and receives revenue for each procedure billed. This type of payment system is a _____ payment system. a. prospective b. retrospective c. diagnosis-related group d. capitated

ANS: B A retrospective payment system is a method of reimbursing health care providers (such as physicians and hospitals) in which professional services are rendered and charges are billed on the basis of each service provided; this is also known as a fee-for-service payment system. Capitation is a method of reimbursing providers (usually primary care providers, such as physicians or nurse practitioners) in which the insurance company pays the provider a set payment each month to provide a defined set of health care services for the patient enrolled in health plan. DRGs (diagnosis-related groups) is a common method of reimbursement for health care services based on a predetermined fixed price-per-diagnosis. Prospective payment system is a method of reimbursing health care providers (e.g., physicians, hospitals) in which the total amount of payment for care is predetermined based on the patient's diagnosis.

5. Lack of insurance, uninsured populations, and uncompensated care are covered by charging more to those who can pay. What term is used to refer to this practice? a. Charity b. Cost shifting c. Price sharing d. Governmental reimbursement

ANS: B Cost shifting occurs when providers increase their charges against households and public and private insurers who pay for their own care while making some contribution to the care of the uninsured population.

19. A patient is upset because her health insurance plan refused to pay for a mammogram and services by a women's health specialist because the primary care physician did not order the referral or the mammogram. Which type of insurance plan adheres to this type of payment system? a. Fee for Service b. Health Maintenance Organization (HMO) c. Preferred Provider Organization (PPO) d. Point of Service (POS)

ANS: B HMOs require patients to select a primary care physician approved by the HMO who then must refer or order any test/diagnostic procedures before payment is approved or preapproval must be sought.

5. Two nurses are discussing health care in the past and the present. The two nurses know which to be true about health care in the present? a. Health care in the present is mostly provided by nurses. b. Health care in the present is controlled by third party payers. c. Health care in the present is controlled by physicians. d. Health care in the present is dictated by the patient.

ANS: B Health care in the past was controlled by physicians, because they provided the care. Health care in the present is controlled by third party payers, because they finance the care. Health care is provided by nurses, but patient care requires a team of health care workers to assist the patient. The patient is part of the team, but they do not dictate the health care. The patient works with the physician to bring about a good outcome.

3. Diagnosis-related groups (DRGs) have attempted to reduce health care costs by decreasing what component of care? a. Hospital admission rates b. Length of hospital stay c. Outpatient services d. Specialty groups

ANS: B Hospitals face a strong financial incentive from the DRG reimbursement system to reduce the client's length of stay and minimize procedures performed. If hospital costs exceed the DRG payment for a client's treatment, the hospital incurs a loss, but if costs are less than the DRG amount, the hospital makes a profit.

9. A client is admitted with chest pain. A series of diagnostic tests are ordered, and the client undergoes coronary artery bypass grafting. The cost of care for this client is increased because of a four-pack-per-day smoking history that resulted in extension of the client's intensive care unit (ICU) stay by 3 days because of respiratory problems. The case manager realizes that under the terms of the diagnosis-related group (DRG) payment system for this diagnosis that the client's past history and present care needs will have what affect on reimbursement? a. The cost of caring for this client was $5000 greater than the DRG reimbursement fee, and the hospital will be allowed to collect the additional fees from the insurance company. b. Although the cost of care for this client was greater than the DRG reimbursement amount, the hospital will be reimbursed only at the set fee. c. The client will be required to pay back the insurance company for the extra fees incurred because smoking is a modifiable health risk for heart disease. d. The primary care provider who admitted the client will receive a reduced payment to cover the loss incurred by the hospital.

ANS: B Since 1983, if hospital costs exceed the DRG payment for a client's treatment, the hospital incurs a loss, but if costs are less than the DRG amount, the hospital makes a profit. Hospitals face strong financial incentives to reduce the client's length of stay and minimize procedures performed.

2. An accountable care organization (ACO) seeks to deliver which of the following aspects of health care? (Select all that apply.) a. Lessen Medicare payments b. Integrate care c. Enhance evidence-based practices d. Manage acute conditions e. Support hospice charges

ANS: B, C ACOs work to integrate care, manage chronic conditions, and enhance the use of evidence-based practices. They do not have any involvement with Medicare payments, the management of acute conditions, or hospice care.

1. A nurse who speaks at a health fair states that current attempts to increase efficiency of health care include what actions? (Select all that apply.) a. Increasing assess to acute care, so that specialized care can be provided b. Increasing the use of outpatient services c. Shifting toward health promotion and prevention d. Allowing physicians to control health care decision making e. Using technology to educate the public about cost-effective measures

ANS: B, C, E Economic forces are motivating the shift toward providing more services and procedures in outpatient settings. Economic forces are motivating the shift toward a model of health promotion and preventive. The Internet can inform and educate consumers (or clients) about how to access health care educational resources more effectively.

1. A student nurse is discussing Medicare coverage with the clinical instructor. The instructor knows the student understands Medicare when the student makes this which statement(s)? (Select all that apply.) a. Medicare covers all patients while they are in the hospital. b. Medicare is funded by the federal government. c. Medicare is for persons 65 years old and older. d. Medicare is partially funded by private third-party payers. e. Medicare is for patients who are disabled and/or have end-stage renal disease.

ANS: B, C, E Medicare is funded by the federal government. It covers people who are 65 years old and older, disabled people, and patients who have end-stage renal disease. It does not cover all patients in the hospital, because some patients do not qualify for Medicare. It is not funded by third-party payers.

21. A nurse is very interested in learning more about health care economics and how she can use that knowledge to become a better patient advocate. She comments, "Nurses should not only deliver care one day at a time in one facility but should coordinate patient care as they move from acute care to rehabilitation to home care." This nurse would be a candidate for which nursing role? a. Disease management program (DMP) for chronic illnesses b. A hospital-based utilization management nurse who reviews medical records to determine the most appropriate DRG for patients c. Case management d. Reviewer for Managed Care Organization

ANS: C Case management offers nurses the opportunity to demonstrate cost-effectiveness by coordinating patient care at the appropriate level of care across the continuum of care. Patient advocacy and understanding current health care economics are critical to this role.

10. A young mother has detected a lump in her breast, and because she lives at the poverty level, she is covered under Medicaid. What is the most likely consequence of this woman's situation? a. She will participate in mammography screening more often than individuals covered by private insurance. b. She has both a designated primary care provider and a specialist as sources of care. c. She will wait to seek care increasing her risk of being diagnosed with advanced breast cancer. d. She has decreased access to health care when compared with the uninsured.

ANS: C Even with improved access as compared with the uninsured, Medicaid recipients are not as likely to obtain needed health services. The poor are more likely to lack a usual source of care, are less likely to use preventive services, and are more likely to be hospitalized for avoidable conditions than are those who are not poor.

2. The precise classification of clients according to the highest diagnosis-related group (DRG) has created a new role for nurses, known as a _____ nurse. a. case management b. quality assurance c. utilization review d. cost-control

ANS: C Hospital-based utilization review nurses review medical records to determine the most appropriate DRG for clients. Financial gains can be made through careful diagnosis of clients according to their highest potential DRG classification.

14. An elderly person, age 80, is finding it difficult to live alone and the family is considering long-term care. The elderly person is reasonably healthy, with only normal aging declines, and maintains a healthy appetite. All medications are administered orally and require only minimal assistance. She is financially secure with an income based on retirement from both the military and factory from her deceased husband and herself. The family contacts long-term care and is given what information, based on this patient's situation? a. Medicare will cover the cost of stay since skilled services are required. b. Medicaid is only for families with dependent children. c. Medicare will pay for home health services should these additional services meet the needs of the individual. d. Medicare will pay regardless of household income or financial status for nursing home care.

ANS: C Medicare does cover home health care.

3. The US health care system is different from that of other countries in which way? a. The US charges money from the private sector only. b. US health care is funded from private organizations. c. The US health care system is not entirely government funded. d. The US health care treats the older person first.

ANS: C Other countries fund the health care system so that every citizen may have health care. In addition they provide the option that citizens may purchase private health care too. The US has a combination of private companies and government agencies funding health care, so money is not coming from just the private sector. The older person in the population receives care according to the insurance coverage they have, but the care is not before anyone else.

17. Health care is one of the major stories in newspaper and television and a group of nurses are interested in how the economy impacts their nursing practice. When the group critiques the relationship between contemporary economic trends and professional nursing practice, what fact will they discover? a. The implementation of the DRG system led to the nursing shortage since cost of nursing care is not billed. b. Nursing care is focused on technologically advanced acute care rather than preventive, patient-centered care. c. With pay for performance, nurses have a significant effect on the quality of patient outcomes by reducing errors and providing care based on best practices. d. Economic issues have little or no impact on nursing practice.

ANS: C Pay for performance, where providers are reimbursed based on the quality of care, gives nurses an opportunity to reduce costs and adopt practices that improve quality of care.

1. What do the economics of health care include? a. Medicare and Medicaid dollars b. Patients' rights c. Equal distribution of health care d. Nurse salaries

ANS: C The economics of health care include the equal distribution of health care services so everyone may be served when services are needed. Medicare and Medicaid, patients' rights, and nurse salaries do not factor into the economics of health care; they are only parts of the health care system.

4. When reviewing the literature on the effects of Medicaid on health care for the poor, what common problem would the nurse researcher find? a. Less access than even the uninsured b. Receive many unnecessary treatments c. A lack of consistent providers d. An abuse of preventive services

ANS: C The poor are more likely to lack a usual source of care, are less likely to use preventive services, and are more likely to be hospitalized for avoidable conditions than are those who are not poor.

7. In the triad of health care, which would be considered the third-party payer? a. Client b. Health care provider c. Insurance company d. Government agency that sets reimbursement rules for services

ANS: C The third-party payer is an organization other than the client and the supplier (hospital or physician), such as an insurance company, that assumes responsibility for payment of health care charges.

12. A nurse is offered several health care plans as part of employee benefits. Which plan is based on a monthly fee per participant and offers a range of preventive, diagnostic, and treatment services? a. Prospective payment system b. Retrospective payment system c. Single-payer system d. Capitation

ANS: D Capitation is a method of reimbursing providers (usually, primary care providers such as physicians or nurse practitioners) in which the insurance company pays the provider a set amount of money each month to provide a defined set of health care services under this plan. Payment is generally received as a per-member-per-month payment. Defined health care services generally include preventive, diagnostic, and treatment services.

2. A student asks the instructor about health care economics. The instructor knows the student understands when the student makes which statement? a. "The elderly population uses most of the health care services." b. "Everyone should have health insurance to obtain services." c. "Health care dollars should be partitioned by the government." d. "Resources will be needed to serve health care issues."

ANS: D Every health care issue needs resources to bring it to fruition. Without the resources, the health care issue would not be served. The elderly are a large part of the population, but that does not change the economics of health care. Everyone does not have health insurance, so that statement would not enter into health care economics. Last, all health care dollars are not partitioned by the government; third party payers exist.

13. At a local health fair, an individual asks about the difference between universal health care and a single-payer system. The nurse explains the difference based on what fact? a. With universal health, one universal payer, usually the government, pays all expenses for health care. b. Single-payer systems offer health care only to eligible persons based on income. c. Single-payer systems rely on insurance companies to pay predetermined fees for services. d. With universal health, one payer is responsible for all health care costs, providing health care to all citizens.

ANS: D Universal health has one payer (usually the government) and provides health care for all citizens.