Nursing 102 Exam 2
What is the effectiveness of Primary Care
- Better continuity of care - Lower rate of hospitalizations if receiving PC - Lower cost of total health care - Higher ration of PCP to the population leads to ( lower smoking, obesity, higher seatbelt use and vaccine rates, reduction in low birth rates, infant mortality, better controlled hypertension)
Why is there a shift from inpt to outpt?
- Reimbursement: financial incentives and payer's preference - technology: less invasive surgical, shorter acting anesthetics, faster recovery - utilization controls: inpt stays strongly discouraged, prior authorization for inpt admission - social factors: most pt do not want to institutionalized, pt have strong preferences for receiving care in home or community based.
What are IADLs
- a person ability to perform household and social tasks (cooking, shopping, driving a car, managing Money)
What is Institutional LTC?
- appropriate for pt whose needs cannot be adequately met in community base setting - retirement facilities, residential personal care facilities, assisted living facilities, nursing homes
What is gatekeeping?
- arrangement that requires PCP to coordinate all health care services needed by an enrollee - controls access to costly medical services - emphasizes preventative care, routine physical exams, other primary care services - secondary care services provided by referral
What are some reasons for downsizing of hospitals?
- change in medicare reimbursements - managed care (emphasis on cost containment and use alternative services like outpt, home health) -prospective reimbursement method (cut operational cost, shorter hospital stay, hospital closing or taking unused beds out of service)
how do you measure the access of hospitals?
- discharge: total number of pt released from the hospitals acute care beds -the of discharges per 1000
What is ADL
- eating, bathing, dressing, using a toilet, maintaining bowel and bladder control, transferring
What are the challenges of MCOs
- enrollees are limited to the providers associated with their plans - restrictions in direct access to specialized services - physician dissatisfied with control over utilization and limits on reimbursement
How does managed care control healthcare utilization
- expert evaluation of medical necessity for each individual - providing acceptable standards of quality while being most inexpensive - review process of care and changes to the individual so that revisions to treatments course may be done as needed.
What Is the hospital accreditation?
- granted by private entity - if accredited can participate in medicare and medicaid programs without being certified.
What are included in community based LTC
- home health care - adult day care - adult foster care - senior centers - Emergency response systems - case managment
What are trands in hospital utilization
- older people spend more time than younger, - women admitted to the hospital more than men - high among blacks then whites - higher among poor then non-poor - medicare and medicaid beneficiaries use hospital more than others
What is the hospital certification?
- optional to participate in medicare and medicaid -granted by federal government
What are the benefits of change for private practice?
- patient referral networks - negotiation leverage with MCOs -sharing of overhead expenses -ease of obtaining coverage from colleagues for personal time off -salary, benefits, and profit-sharing plans
What are the reasons for hospital growth?
- private health insurance - Hill Burton act of 1946 (federal grant for beds, 4.5-1000) - medicare and medicaid
What is long term care?
- promote max possible functional independence -provide over an extended period of time - provided in both institutions and community based settings - mos LTC provider by family and friends
What is HMOs?
- provides medical care during illness while offering services that help people maintain health - emphasize and screening services through routine checkups and test - use in network providers -gatekeeper are used to manage coordinate the utilization of services
What are the changes and trends in private practice?
- shift from solo to group and institutional affiliations
What are the reasons for change in private practice?
- uncertainties of the health care delivery system - competition from larger health organizations - high cost of establishing a new practice - complexity of billing and collections -increased external controls over private practice
what is PPOs
- used both in-network and out-of- network providers -higher copayment for non-perrfered providers - no gatekeeping -unrestricted access to specialty services. - PPOs make discounted fee arrangements with providers.
What are the utilization trends of hospital services?
-inpt day: a night spent in the hospital -average length of stay: average number of inpt day -day of total care: total number of inpt days incurred by a population over a given period ( discharge x ALOS) -census: # of pt in hospital on a given day or # of beds occupied -occupancy rate: % of capacitiy
What Is hospital licensure?
-required and granted by state d
What is managed care?
A mechanism of providing health care service in a single organization takes on the management (financing, insurance, delivery, payment) - controls the utilization of health care services - determine amount of reimbursement to providers
What is medical loss ratio
A percentage of premium revenue spent on medical expenses
What is underwriting?
A systematic technique for evaluating, selecting, rejecting, classifying and rating risk
Which key integrated concept is this? - the purchase of one organization by another
Acquisition
What pt right is this? -allows pt to express their wishes in advance
Advance directives
How is LTC related to aging and chronic disease?
Aging increase the need for LTC increase due to ADL limitations
With key integrated concept is this? - a joint agreement between two organizations to share their resources without ownership of assets.
Alliance
What are the key concepts of integrated systems?
Alliance, Acquisition, Merger, Joint venture, Horizontal integration, Vertical integration
what method of delivery is this? - complementary and alternative medicine -Homeopahty -herbal remedies -natural products -acupuncture
Alternative medicine clinics
Who is the insurer?
An insurance agency that assumes the risk
What are the 8 requirements of being a hospital
Beds, licenses, staff, rn, chief executive, medical records, pharmacy, food services
What are the two ethical principles?
Beneficence (Do good) and Non-maleficence (do no harm)
What are the different types of reimbursement?
Bundled payments, resource-based ratline value scale, retrospective , prospective(diagnosis-related groups)
What are the two main payment/ reimbursement for providers under managed care?
Capitation- PMPM Discounted Fees
What is outpatient care?
Care that does not require an overnight stay in a health care institution such as a hospital or long-term care facility
What are the two different types of long term care?
Community based and institutional LTC.
What method of delivery is this? - supported by grant funding - required to be located in underserved areas - serve anyone seeking care regardless of insurance status. - provide preventative care, PC, and dental care.
Community health care
What is hospice?
Comprehensive service for the terminally ill who have 6 months or less, care for dying pt and their families, a method of care not a location
What type of utilization is this? - pt prognosis expected outcomes, - anticipated discharge day -discharge planning
Concurrent
What is moral hazard?
Consumers utilize more services than they would if they had to pay out of pocket
What method of delivery is this? - Walk in clinics - Retail clinics - Urgent Care - Surgicenters
Freestanding Facilities
What is the type of insurance? - Obtained through organization (an employer, union, profession org.) -Risk and cost is shared among group members
Group Insurance
What are the types of Private insurances?
Group Insurance, Self-Insurance, Individual private insurance, Managed care, HDHP
What is the type of insurance? - Consumer-driven health plans - Linked with a savings account (HRA funded by employer, HSA annual contributions have caps, mainly employee financed on tax deductible) -Minimizes moral hazard -Grown in popularity due to low premium cost
High-Deductiable Health Plans (HDHPs)
What method of delivery is this? - least restrictive environment -services brought into pt home
Home care
Which ket integrated concept is this ? - organization extends its existing core products or services.
Horizontal integration
What method of delivery is this? - services for terminally ill pt with 6 month or less. -method of care not physical location
Hospice care
What method of delivery is this? - Prominent particularly in-inner city - Community safety net for uninsured - A key source of profit for hospitals - clinical, surgical, home health, women's health, ER
Hospital Outpt Clinics
What is Part A of Medicare?
Hospital insurance
What are the four parts of the medicare system?
Hospital insurance, medical insurance, medicare advantage plans, prescription drug plans
What are the different types of outpt settings?
Hospital outpt clinics, freestanding facilities, mobile facilities, telephone or internet triage, alternative medicine clinics, home care, hospice care, outpt long term care, public health, community health clinics, private practice
What areas do we spend the most on in the National health expenditures?
Hospital-33% Physician, dental, professional services- 26% SNF, Prescription drugs- 13%
What is provider-induced demand?
If pt were paying out of pocket, many would not fill all prescriptions complete all tests and would further ask what is the bare necessities
What is the type of insurance? -For those who don't have group coverage -Main targets (family famers, early retiree, employee whose employer does not offer insurance, self-employed)
Individual Private Insuracne
Which pt right is this? - to be informed of treatment choices, to make an informed choice, including the right to refuse treatment.
Informed consent
What are the two pt rights?
Informed consent and Advanced directives
What are the 3 types of hospital status for admission?
Inpt, outpt, observation
Which key integrated concept is this? - two or more institutions share resource to create a new organization to pursue a common purpose
Joint Venture
What is the type of insurance? -Consists of HMOS/PPOs -Assumes risk in exchange for insurance premium -Contract with a network of providers -Monitor utilization
Managed Care Plans
What is Part B of Medicare?
Medical Insurance
What is the type of insurance? -Federal entitlement program -Three categories of people (65+, disabled who are entitled to SS, people with end stage renal disease) -Greatest challenge to continue funding due to the aging population.
Medicare
What is Part C of Medicare?
Medicare Advantage Plans
What are the type of public insurance?
Medicare, Medicaid, CHIP, Public financing support categorical programs
Which key integrated concept is this? - involved a mutual agreement to unify two or more organizations into a SINGLE entity
Merger
What method of delivery is this? - Mobile heath services transportation - health screening vans - volunteers and non-profit organizations
Mobile Facilities
What method of delivery is this? - Case management - adult day care
Outpt long term care services
What is the emphasis for hospice care?
Pain and symptom management and phsycosocial and spiritual support.
What is reimbursement?
Payment made by third party payers to the providers (insurance companies, managed care organizations, blue cross/shield, government)
What are the three types of cost sharing?
Premium, Deductible, Copayment/Coinsurance
What is Part D of Medicare?
Prescription Drug Plans
What level of care is this? - Conceptual foundation for outpt services (not all outpt) - Basic routine services - An approach to providing health care
Primary Care
What are the three levels of care?
Primary, Secondary and Tertiary
What is the type of insurance? - Voluntary health insurance - Health plan providers: commercial insurance, Blue cross/shield, self insured - Available for single or family benefits
Private Insurance
What method of delivery is this? - visits short duration - limited examination and testing - office-base physicians - vast majority of PC
Private Practice
What type of utilization is this? - may require per certification - approval before certain services are provided
Prospective
What type of reimbursement is this? -Use certain pre-established criteria to determine in advance the amount of reimbursement -Methods (Diagnosis-related groups (DRGs), Ambulatory payment classifications (APCs),Resource utilization groups (RUGs), Home health resource groups (HHRGs)
Prospective Reimbursement
What are the three type of utilization reviews?
Prospective, Concurrent, Retrospectove
what method of delivery is this? - local health department - range of services depends on the location - limited scope
Public Health Service's
What type of utilization is this? - Based on the examination of medical record - underutilization vs over utilization
Retrospective
What type of reimbursement is this? - Rates are set after evaluating the cost retrospectively - Per Siem rates based on actual costs - Providers had no incentive to control costs - Profits could be increased by increasing costs.
Retrospective Reimbursement
What level of care is this? - Short term - Involving sporadic consultation from a specialist/ or surgical interventions - Include hospitalization - Rehabilitation
Secondary Care
What is the type of insurance? -Provided by large employers -Assume risk rather than pay a dividend to the insurer -Better control for employees -Invest employers in reinsurance
Self-Insurance
What does stop loss do?
limits the total out of pocket costs.
What is a premium?
the amount charged for insurance coverage, cost sharing by employers and employees and is usually paid monthly.
What are the 4 fundamental principals of insurance?
1. Risk in unpredictable for an individual 2. Risk is predictable with reasonable accuracy for a group or population 3. Insurance allows transfer of risk from the individual to the group by pooling resources. 4. Actual losses are shared equally by all members of the insured group
What is the purpose of cost sharing?
1. reduce the misuse of insurance benefits 2. control utilization of healthcare services
What type of cost sharing is this? -A portion of health care charges that the insured has to pay under the terms of his/her health insurance
Copayment/Coinsurance
What type of cost sharing is this? - Amount the insured must pay first before insurance payments kick in -Paid annually
Deductible
What is the type of rationing? -Barriers to obtaining health care faced by individuals who do not have sufficient income -places the majority of the financial demand on the consumer -More likely scenario in the US. -PRICE
Demand-side rationing
What is ambulatory care?
Diagnostic and theraputic services and treatment for the walking pt
What is this type of rationing? - Called planned rationing - Restricting availability of expensive medical technology and specialty care - Tends to occur in countries with nation health insurance
Supply-Side Rationing
T or F Ambulatory care is used interchangeably with outpt care
T
What method of delivery is this? - provide expert opinions during closed office hours - primarily RNs
Telephone triage
What level of care is this? - Most complex level of care - Conditions are relatively uncommon - High specialized and technology driven
Tertiary Care
Which key integrated concept is this? - links service that are at different stages int he production process of healthcare
Vertical Integration
Who is the insured?
an individual protected by insurance (member or enrollee-private or beneficiary-public)