Leadership: Fiscal Resources: Balancing Cost Control and Quality Care

Fee-for-service (FFS)

Choose the method of reimbursement that creates higher rates as more services are provided?

nurses, doctors, hospitals

Who is responsible for cost-containment?

government regulations to justify the need for services and to monitor their quality were introduced. Standardizing allowable services to provide per diagnosis and the associated costs per service were introduced.

What does Diagnosis-Related Groups (DRGs) mean?

rit is based on costs incurred to perform the health care service plus a profit. No ceiling on allowable charges. More services/patient = more $$. No incentive to provide focused, efficient care.

What does FFS Reimbursement mean?

it focus in on prevention, evaluation of the need for services, de-emphasis of inpatient care, and the use of clinical practice guidelines or critical pathways to ensure that the provided care is using best practices. There in concern that evaluation of the need for services is being done by insurance company staff who are either too far removed from the situation or simply not qualified enough to make decision. Like prospective payment system, there is a concern that the managed care system results in under-treatment of patients because facilities profit more by providing fewer services per patient.

What does Managed Care mean?

switch to payment according to DRG as opposed to actual costs incurred. Resulted in a dramatic decrease in the length of patient hospital stays, which had pros and cons. There is a lingering concern that patients are undertreated to contain in this system.

What does Prospective Payment System mean?

facility budgets for the current year are based on a certain percentage increase over the previous year. No incentive for efficiency.

What does incremental budgeting mean?

- Nursing education lacks preparation in fiscal planning. - Many nurses perceive that fiscal planning is difficult.

A new nurse manager is learning about fiscal planning. Which are barriers for nurse managers' participation in fiscal planning? (Select all that apply.)

Communicating budgetary planning goals to staff

A nurse manager is considering how to gain more staff involvement in meeting budgetary goals. Which activity is most likely to result in staff understanding and participating in budgetary goals?

true

Health care is not only financed by private insurance, government funding, and private donations but also by individual out-of-pocket expenses. True or False?

incremental budgeting > FFS reimbursement > diagnosis-related group (DRG) > prospective payment system > managed care

Progression of thinking about Health Care Reimbursement:

42%, however research shows that the US does not achieve the highest-quality health outcomes despite this spending.

The last report on global health spending was conducted by the World Health Organization in 2020. According to this report, approximately what percentage of the world's health care costs do you think the US accounts for?

- Higher spending may result in duplication of services. - Higher spending may result in overuse of technology. - Higher spending may result in overutilization of services.

A nurse manager is considering the reasons for the current problems with the health care system. Which are negative consequences of higher spending in health care? (Select all that apply.)

They can be used to monitor quality of care.

A nurse manager is considering the use of critical pathways for a nursing unit. Which statement regarding critical pathways is most accurate?

The health care resources that are available in the United States are not used cost-effectively.

A nurse manager is preparing a presentation to be delivered to a group of nurses in a nursing unit about the current U.S. health care system. Which statement about resource utilization is most accurate?

- more paperwork related to accounting for justifiable deviation from the pathway - sometimes seen as inflexible "coockie-cutter" medicine that limits the use of clinical experience - doesn't adapt well to unexpected changes in a pt's condition - requires large and longstanding commitment from administration and staff to develop and continually update - may be slow to adapt to new info or developed and updated collaboratively

What is the Critical Pathway Cons?

- a predictable process that can be used to train staff and educate pts on standard conditions - process supports continuity of care across disciplines - process supports standardization according to EVB practices and data - can be used by facilities to analyze both cost and quality of care variances - Can show proof that best practices were used or at least considered and potentially limit liability

What is the Critical Pathway Pros?

problem/condition > triage + imaging > MD/CRNP/RN rapid assessment + Hx & physical + imaging > button/batteries, coins/blunt objects, magnets: single or multiple, sharp object radiopaque or suspected radiotrasnslucent & non-radiopaque/special circumstances, food impaction

Which steps should be taken when a condition is presented by using a critical pathway to balance cost and care