CH 12.

Which of the following statements best summarizes all of the changes resulting from attempts to control costs? a. Conflict between providers, patients, employer, and insurance plans raged. b. Costs were controlled, at least temporarily. c. Demand for health care drastically dropped. d. Most employers discontinued their insurance plans for employees.

A (All these changes resulted in conflicts among providers, patients, employers, and the insurance plans, particularly when services deemed necessary by the consumer and provider were denied insurance coverage. Everyone blamed everyone else. This did not allow for costs to be controlled, impact the demand for health care, or cause employers to discontinue their insurance plans for employees.)

Which of the following best describes how the federal government determines which projects are awarded special funding for health care? a. Those that are consistent with societal priorities, such as 2020 Health Objectives b. Those that are supported by legislators c. Those that are written by health care organizations that have special needs d. Those that are consistent with the state's long-term health goals

A (Allocation of federal resources is based on societal priorities, such as the 2020 Health Objectives. Legislative priority, priority within health care organizations, and priority within individual states are not as important for federal funding as the societal priorities outlined in Healthy People 2020.)

Which of the following statements best describes the message that public health leaders are trying to emphasize to the public? a. Assume responsibility for your own health by choosing healthy behaviors b. Have a primary physician and get yearly checkups c. Obtain immunizations and screenings when they are offered d. Support legislative efforts to improve our medical care system

A (Although there are many public health messages in the media, from quitting smoking to getting a checkup, the primary message currently being emphasized by public health, as well as all the media coverage of the constantly increasing cost for health care, is for each person to take responsibility for his or her own health through choosing healthy lifestyle behaviors. Supporting legislative efforts is not as important as the need for individuals to take responsibility for their own health.)

Which of the following best describes a carve-out service? a. A particular service that is offered only by a designated provider or group. b. A particular procedure that receives limited reimbursement. c. A particular treatment is not allowed within a particular diagnosis. d. A particular prescription drug that is only available to those with certain conditions.

A (Carve-out services might be designated for those who need the services the least. A carve-out service (for example, mental health care) is provided within a standard benefit package but delivered exclusively by a designated provider or group. The other definitions do not correctly describe a carve-out service.)

Which of the following conclusions can be drawn from reviewing how health care costs are spread over a person's lifetime? a. Health care expenditures increase with age. b. Premature newborns incur more costs than other children from birth through adulthood. c. The majority of cost is incurred during middle age when chronic diseases strike. d. Persons aged 85 years and above spend the most money on health care.

A (Expenditures increase with age. About one third of costs are incurred during middle age; half during the senior years; and, for those older than 85 years, one third of their lifetime costs occurs during their last year of life.)

Which of the following best describes how hospitals initially coped when Medicare reimbursement became based on diagnosis-related groups (DRGs)? a. Charged more for patients whose care was paid by insurance b. Decreased nursing staff to cut labor costs c. Lobbied politicians to increase Medicare reimbursement to reflect actual costs d. Refused to accept Medicare patients

A (Hospitals developed cost shifting to supplement losses caused by Medicare funding. Because private insurance reimbursements were cost based, hospitals included the loss in their total costs; therefore private insurance paid for covering care to both their enrollees and Medicare patients. The implementation of DRGs did not cause hospitals to decrease nursing staff, lobby politicians to increase Medicare reimbursement, or refuse to accept Medicare patients.)

Which of the following best describes what was done by large industrial giants to stop the constant increase in their costs for health insurance for their employees? a. Assembled their own health care programs b. Established health promotion programs that employees were required to attend c. Signed only certain providers to give care at a reduced rate in exchange for so many new patients d. Suggested that employees seek only the most necessary services

A (Large industrial giants, such as Kaiser Permanente, decided to assemble their own health care programs. They built hospitals, hired physicians, and provided health care services to their employees. In an effort to market this concept, the phrase health maintenance organization was created. These organizations were designed to provide comprehensive care to employees. As these large health care programs were established, enrollees had limited freedom of choice. Preventive care was covered and encouraged, but care was somewhat restricted, and care providers were encouraged to reduce costs by providing only the most necessary services.)

Which of the following actions would be the least expensive approach to treating chronic diseases? a. Choose healthy lifestyle behaviors to retain health b. Continue media campaigns encouraging early detection and treatment c. Encourage patients to seek care at a local neighborhood health clinic d. Suggest self-therapies that have been demonstrated to be effective

A (The five leading causes of death and illness can be positively affected by changes in lifestyle. Healthy lifestyles can modify or even prevent most chronic illnesses. Seeking care at a neighborhood health clinic, producing media campaigns, and engaging in self-therapies are all more expensive approaches to treating chronic diseases than choosing healthy lifestyle behaviors.)

A client living in the 1920s received health care services. Which of the following would have been the most likely form of payment? a. Patients paid out of their pockets for whatever care the provider charged. b. Public health employees gave care to those who needed it. c. There was little health care to be had, regardless of a person's wealth. d. Workers who belonged to a union had their bills paid by insurance.

A (Until the 1930s, the predominant method of health care financing was self-payment. Health care providers charged a fee for the services they rendered, and the patient paid the out-of-pocket expense. The assumption was that those who could pay would pay and those who could not pay should receive care and pay what they could. Insurance companies did not exist in the 1920s.)

Which of the following best describes what insurance companies did to decrease their constantly increasing costs? (Select all that apply.) a. Did not cover any illnesses that were diagnosed before the person (or his or her employer) purchased insurance b. Limited coverage to only certain services, eliminating any that were experimental, nontraditional, or too costly c. Reimbursed only the care that was requested by the patient's primary physician d. Limited providing insurance to companies who hired mainly young, healthy persons e. Required preapproval before expensive services were used f. Ceased coverage on any person who used an exorbitant number of services, whenever possible

A, B, C, E, F (Insurance companies attempted to reduce unnecessary use by limiting coverage for certain services and people. Restrictions such as the establishment of a gatekeeper that required preauthorization, limited coverage for preexisting illnesses, and exclusion of participants whose use was deemed exorbitant were instituted. Such restrictions increased resentment and resistance and were not very successful.)

Which of the following statements best describes what was unfortunate about the original private health insurance plans that were developed? (Select all that apply.) a. Because providers were paid for any service they gave, it was economically advantageous for them to give as much care as possible. b. Health care costs increased very rapidly. c. Health education and health promotion interventions were not included in the idea of health insurance. d. It was immediately seen how much profit could be made by owning or managing an insurance company. e. Patients wanted any and all care that might help, regardless of how expensive it was. f. There was no limit on what care could be sought and given.

A, B, C, E, F (The majority of the population was protected. The emphasis was placed on illness care, because providers received a fee only when a service was rendered, and all costs were reimbursed. Insulated from having to pay for health care, consumers demanded complex and technologically advanced services. These demands were a major force rapidly increasing health care costs because people with insurance felt entitled to care, and, after all, there was a guaranteed payer. Medical orientation was on curing at any cost. The profits of owning or managing an insurance company were not immediately seen.)

Which of the following best describes the strengths of the American health care system? (Select all that apply.) a. Offering the availability and use of technological advances in equipment and procedures b. Having the ability to overcome concerns regarding access and rationing c. Providing the highest quality of life among any industrialized nation d. Having the lowest maternal and infant mortality rate among industrialized nations e. Leading the world in laboratory and clinical research f. Creating the best patient care outcomes

A, E (The United States leads the world in laboratory and clinical research. The United States also exceeds other industrialized countries in the availability and use of technological advances. We do not rank near the top in length of life or patient care outcomes, although we spend far more on health care than other industrialized nations. We are just beginning to confront the issues of access and rationing.)

Which of the following best describes what physicians did to compete with new competition from health maintenance organizations (HMOs)? a. Accepted employment directly under the insurance company b. Organized preferred provider organizations (PPOs) to negotiate with insurance companies c. Created private practices with colleagues within hospital medical complexes d. Decided to strike and refused to work in the new HMOs

B (In an effort to compete with HMOs, physicians and hospitals organized the independent practice model, which provided services to enrollees of one insurance company. This model evolved into the PPO, which offered services at a reduced rate in exchange for a guaranteed increase in consumers. Physicians did not become directly employed by insurance companies, set up private practices with colleagues, or decide to strike in order to compete with the HMOs.)

Which of the following best describes why so many Americans continue to engage in unhealthy behaviors? a. Americans are not knowledgeable on how to change their behavior. b. Americans believe that most illnesses can be cured with insurance footing the bill. c. Health is not a concern to most Americans. d. Most Americans do not know which behaviors are unhealthy.

B (Society sees insurance as an economic shield protecting against all disease and illness. The belief in cure rather than prevention, combined with this financial safety net, encourages society to become a passive participant in health care. The pervasive societal thought is "I don't have to worry; I have insurance." Americans are aware of which behaviors are unhealthy, have knowledge on how to change their behavior, and are concerned about health, but insurance has allowed them to take a passive approach to health.)

Which of the following best describes the first government step in trying to stop constantly rising costs? a. Insurance companies were told to cease adding new members to their plan. b. Payment reimbursement was based on diagnosis and client characteristics rather than on treatment given. c. Physicians were limited to a maximum amount that would be paid for any particular service. d. Reimbursement was based on prospective payment; that is, in advance of admittance for care.

B (The first efforts to control costs were made by the federal government when Medicare hospital reimbursement was based on a prospective payment system. Payment would be based on a classification system that identified costs according to diagnosis and client characteristics. Restricting insurance companies to add new members to their plan was not part of the first steps to try to stop constantly rising costs.)

Which of the following best describes a current trend related to health care services? a. Nonprofit organizations are assuming responsibilities for service from for-profit organizations. b. Health care organizations are offering services low in cost and higher in reimbursement. c. Ways to minimize reimbursement using current procedural terminology (CPT) codes have been created. d. Postponing computerized medical record programs increases profitability.

B (There is a national shift from nonprofit health care to for-profit health care as large for-profit organizations take over smaller community organizations. Because emphasis is on profit, mechanisms of achieving higher reimbursement have been developed. Coding of the patient's illness from the CPT codes results in an increase in reimbursement. Use of computerized medical record programs almost ensures that service can be reimbursed at the highest rate possible. This has changed health care practices to the use of services that are low in cost and higher in reimbursement. High-cost services are limited or not offered.)

Which of the following statements best describes what happened to health care providers during the Great Depression? a. The amount of charity care greatly increased. b. Both hospitals and physicians went bankrupt. c. Government funding was legislated to assist those in need. d. Public health greatly expanded to care for those in need.

B (With 25% of the population out of work, the number of patients capable of paying their medical bills was reduced. Because public financing was limited, hospitals, physicians, and other providers went bankrupt. Because hospitals and physicians were going bankrupt, there was no way to increase charity care or services for those in need.)

Which of the following best describes how eligibility for Medicaid services is determined? (Select all that apply.) a. Anyone over age 65 years who is eligible for Social Security benefits may apply for Medicaid. b. Baseline eligibility is established by the federal government, but states may be more lenient. c. Children in low-income families are eligible for free care. d. Eligibility depends on family size and total family income. e. Federal government establishes eligibility and gives funds to the states in reimbursement for this care. f. State government establishes guidelines for whether to participate and who will be covered.

B, C, D (Medicaid provides universal health care coverage for the indigent and children. Eligibility is dependent on the size and income of the family. The federal government sets baseline eligibility requirements. State governments who wish to provide care to more citizens can lower the eligibility requirements. The federal government mandates covered services, but state governments may provide more services.)

Which of the following best describes the effects of Medicare and Medicaid? (Select all that apply.) a. All persons who were temporarily disabled now receive free care. b. A previously unseen rise in demand for services occurred. c. Many persons previously without access now receive health care. d. Medicare reimbursement rates became the standard for all insurance carriers. e. Indemnity insurance plans were offered. f. Public health education was now financed.

B, C, D, E (The enactment of Medicare and Medicaid created an unprecedented demand for services, and many persons without access to health care were now able to receive care using an indemnity insurance plan. Medicare reimbursement rates generally became the standard for all insurance carriers. These plans did not provide services for the temporarily disabled or change financing for public health education.)

Which of the following statements best describes an unfortunate consequence of using diagnosis-related groups (DRGs) to determine reimbursement? (Select all that apply.) a. Insurance companies had to greatly increase their funding from employers. b. The incentive was to undertreat and underuse health resources. c. Health care providers had to accept losses for each patient treated. d. Health care providers learned to cheat the system. e. Health care providers refused to accept more patients whose reimbursement was based on DRGs. f. High quality of care was no longer assured.

B, F (Because costs were contained by both the federal programs and insurance companies, the providers had a strong incentive to undertreat and underuse health resources. The public feared that the quality of care being provided was less to keep costs as low as possible.)

Which of the following is the best definition of economics? a. Assets that can be traded for different assets b. Income and outgo of monies c. Science of allocation of resources d. Study of goods, services, talents, and transportation

C (Economics represents the science of allocation of resources. Resources are goods or services. The other definitions do not fully describe economics.)

Which of the following best describes how having health insurance has affected lifestyle behaviors? a. Health promotion disease prevention programs are attended because they are reimbursable. b. Health education is widespread, because insurance companies promote such education. c. Medications and medical treatment are relied on for cure. d. Screening is widespread because of insurance sponsorship.

C (Funding for behavioral changes is limited, inadequate, or unavailable. Weight loss programs or smoking cessation programs are not reimbursable treatment regimens, although more expensive pharmaceutical interventions are reimbursable. Therefore, it is financially wise not to worry until illness strikes because illness care is reimbursable, whereas preventive health care is not.)

Which of the following statements best describes why nurses should be knowledgeable about health care funding? a. To be able to be an effective employee for insurance companies b. To be knowledgeable when media asks for opinions on some new legislation c. To better serve as patient advocates in policy making for funding that provides appropriate care for the greatest good d. To know how to write nursing notes that reflect higher reimbursement possibilities

C (Increasing knowledge of health care funding and policy making will empower nurses to advocate for the type of funding that provides appropriate care to obtain the greatest good. Nurses need to use their political power. Nurses must advocate for health promotion disease prevention funding. Although these skills are helpful when working for insurance companies, talking to the media, and writing nurses notes, the primary reason why nurses need this knowledge is to engage in the role as a patient advocate.)

Which of the following best describes the health care services that are provided by philanthropic groups? a. Direct care to patients with problems related to the group's primary interest area b. Legislative lobbying for increased funding for their special interests c. Informational and research activities d. Special services such as housing, transportation, or appearance aids

C (Philanthropic funding, whose services are typically research or disease oriented, pays a limited amount of health care. Services are limited to the specific disease or population of interest. Informational and research activities constitute the majority of services provided, although some give direct care or meet ancillary needs such as housing, transportation, or wigs. Legislative lobbying and special services are not the primary health care services provided by philanthropic groups.)

Which of the following actions would help decrease the total health care costs in the United States? a. Consolidate major health care facilities while expanding neighborhood primary care clinics b. Continue the move to computer-based medical records and other efficiencies in informatics c. Decrease current fraud and abuse d. Streamline and make more consistent all documents needed for third-party reimbursement

C (The billions of dollars spent on health care and struggles for control between providers, consumers, and health care organizations have increased the risk of fraud and abuse. The Federal Bureau of Investigation (FBI) estimates that health care fraud costs the U.S. $80 billion annually (FBI, 2012). Thus, decreasing the fraud and abuse in the system would have the largest impact over any of the other proposed actions.)

Who may receive benefits under Medicare? (Select all that apply.) a. Federal employees b. Persons aged 55 to 65 years who have bought into the system c. Persons with end-stage renal disease d. Those over 65 years of age, if eligible for Social Security benefits e. Those who are dependents of elderly grandparents, usually because their parents are in prison as a result of drug abuse f. Those with permanent disabilities

C, D, F (Medicare pays specified health care services for all people 65 years of age and older who are eligible to receive Social Security benefits. People with permanent disabilities and those with end-stage renal disease are also covered.)

Which of the following best describes how providers can legally improve their profit under the current reimbursement process? a. Accept more patients and work more hours so former high income is retained b. Order the cheapest generic medications and treatments possible c. Convince patients that they do not want expensive treatments d. Practice conservatively to earn an incentive payment

D (As a reward for conservative medical practices, health care providers may receive a specified amount of money or a percentage of the agreed reimbursement if services are delivered below the limit set by the third-party payer. Thus, it is the responsibility of the provider to use this conservative practice. Patient care should not be compromised as providers practice conservatively.)

Which of the following was a major change after Medicare began a prescription drug benefit? a. Number of prescriptions ordered by physicians decreased b. Medications increased without affecting patient care outcomes c. U.S. expenditures on drugs approached the same level as that of other industrialized nations d. Use of drugs and their cost immediately increased

D (As with other health care services, once a funding source has been established, usage and costs increase. Thus, the number of prescriptions ordered increased. For 2006, the United States expenditure for pharmaceuticals was 1.5 times that of other industrialized countries, and these expenditures continue to rise.)

When was the idea of national health care insurance first debated in the United States? a. Clinton's 1992 presidential campaign as he attempted to achieve such a plan b. During President Johnson's administration when Medicare and Medicaid were instituted in the 1960s c. President Franklin Roosevelt's attempt to include health insurance in Social Security legislation in the 1930s d. President Theodore Roosevelt advocated such national medical coverage in 1916

D (European countries began a social model of health insurance in the early 1900s. President Theodore Roosevelt advocated a similar plan for the United States in 1916. The other attempts mentioned came after Theodore Roosevelt's initial attempt in 1916.)

Which of the following best describes a flaw of indemnity plans? a. Blue Cross and Blue Shield had a great idea, but they went bankrupt. b. Cost sharing was expected of Blue Cross and Blue Shield enrollees. c. Enrollees could not choose their provider or manage their own care. d. Plans lacked any incentives to contain costs.

D (Indemnity plans paid all the costs of covered services provided to the enrollee. The enrollee enjoyed free choice of provider and services. They preserve the enrollee's right of choice and allow the person to manage his or her own health care. These plans lack incentives for cost containment. Today, cost-sharing efforts (e.g., copayments, deductibles) help contain costs. Blue Cross and Blue Shield continue to be a provider of health insurance.)

Which of the following best describes how the government was successful at containing costs? a. The original legislation for Medicare and Medicaid had built-in cost controls. b. Certificate-of-need requirements restricted provider overtreatment. c. Utilization review determined appropriateness of care. d. Prospective payments were based on diagnosis-related groups (DRGs). e. Peer standard review organizations were effective watchdogs.

D (Prospective payment based on DRGs proved to be effective. The cost reduction that resulted gave rise to the managed care revolution as providers searched for the most cost-effective mechanism of care provision. Various efforts from, for example, certificate-of-need, peer review, and utilization review were not effective.)

Which of the following best describes why large employers would decide to self-insure? a. To claim to offer more benefits to employees b. To have more control over health care providers c. To be more effective at keeping employees happy d. To reduce administrative costs charged by insurance companies

D (Some organizations have decided to self-insure their employees. This reduces the administrative cost of insurance. Self-insurance does not claim to offer more benefits to employees, allow for more control over health care providers, or do a better job at keeping employees happy.)

Why did employers decide to offer health insurance as an employee benefit? a. Hospitals and physicians quit offering charity care to those who could not pay. b. Society was focused on not having to pay for doctor visits and other needed health benefits. c. Teachers were role models for unions to demand insurance as a benefit. d. To obtain and retain the limited number of persons available to work when government rules prohibited raising wages, insurance was offered.

D (The idea of paying a small fee for guaranteed health care to have sickness cured was very popular. Health care providers liked knowing they would receive payment for their services. During World War II, faced with a limited workforce and governmental restrictions on wages, employers began to see health insurance as a means of supplying workers' benefits without granting a wage increase. Teachers were not demanding insurance as a benefit. Hospitals and physicians continued to provide charity care as they were able. Society understood that they needed to pay for health services; however, businesses realized that providing insurance was a way to keep their needed workforce.)

Which of the following statements best describes a major event that occurred in the 1960s that affected health care? a. The amount of charity care by health care providers greatly increased. b. Hospitals began to voluntarily pay taxes to the communities where they were located. c. Legislation greatly expanded funds available to train physicians, nurses, and other health care providers. d. The Social Security Act was amended to create Medicare and Medicaid legislation.

D (The popularity and benefits of employer-provided insurance plans were recognized, as was the reality that some segments of society were being neglected. The 1960s, with a pervasive thrust for social justice, presented the opportunity to move toward universal health care coverage. Titles XVIII and XIX of the Social Security Act created Medicare and Medicaid, respectively. There was no increase in funding for training of health care providers, voluntary payment of taxes by hospitals, and an increase in the amount of charity care provided in the 1960s.)

Which of the following best describes what happens when a health care organization receives federal funding for a special health care need? a. Other groups see the project and write grants wanting similar projects in their geographic area. b. Participants continue to demand the services so local funding has to be readjusted to continue the care. c. Research is done to demonstrate whether or not the intervention was successful and should be replicated. d. When funds cease, so does the health care; therefore, continuity is lacking.

D (When the funding is no longer provided, the programs cease, which results in lack of continuity of care. Research may be done related to the program, other programs may be developed because of the current program that is being implemented, and participants may encourage local funding to continue. However, the most likely outcome is that the program will end when the funding ends, so there is no continuity in the services that are provided.)