Cherry Chap. 7

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."

"I will ask for the brand name drug Tylenol rather than acetaminophen since it works better and I won't be sick as long."

Lack of insurance, uninsured populations, and uncompensated care are covered by charging more to those who can pay. This practice is referred to as: 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. Charity is the donation or benevolent gift of money or tangible goods or services. Price sharing is not a standard term related to lack of insurance, uninsured populations, or uncompensated care. Governmental reimbursement is received when the government actually remits money to providers for services rendered.

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

Case Management

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 because it: a. mandates that all U.S. and legal residents must secure health insurance. b. replaces current Medicare and Medicaid plans. c. requires all citizens to participate in offered preventive services. d. prohibits use of health practices outside of Western medicine.

Mandates that all you U.S. and legal residents must secure health insurance

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

Medicare

1. An older adult client was admitted to the hospital with the condition classified as "pneumonia." Reimbursement was based on a predetermined fixed price. This classification system is 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 on the basis of his or her primary diagnosis at hospital admission. Medicare limits total payment to the hospital to the amount preestablished for that DRG. Subjective symptom management is not a reimbursement type that is based on predetermined pricing. Acuity classification system is not a reimbursement type that is based on predetermined pricing. Organized managed care is not a reimbursement type that is based on predetermined pricing.

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 this and efficiency?" The nurse explains that: 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. Effective does not refer to competence in clinical practice, and efficiency does not describes quick completion of the task. Effective does not mean wasting and meeting a minimum standard, and effectiveness does not refer to taking all the time needed to exceed expectations. Efficiency does not refer to speed, and effectiveness does not refer to the usefulness of the implementation.

Medicare would be responsible for: (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 27-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. The client does not meet the age or disability eligibility. Medicaid covers families with children meeting AFDC income eligibility. The client does not meet the age or employment status.

Which industrialized countries have a national health insurance system? (Select all that apply.) a. France b. Canada c. United States d. South Africa e. Great Britain

ANS: A, B, E France has a substantial amount of central government planning in its health system, leading to a fully centralized or nationalized system of health care. The United States and South Africa are the only industrialized countries without a national health insurance system that covers all of their citizens. Canada has a substantial amount of central government planning in its health systems, leading to a fully centralized or nationalized system of health care. The United States and South Africa are the only industrialized countries without a national health insurance system that covers all of their citizens. Great Britain has a substantial amount of central government planning in its health system, leading to a fully centralized or nationalized system of health care. The United States is a regulated market system in which federal and state legislation has some control. South Africa does not have national health care.

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 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. Health maintenance organizations (HMOs) require that the member pay a premium with a fixed copay and select a primary care physician approved by the HMO. The fee-for-service arrangement is one in which the member pays a premium for a fixed percentage of covered expenses and is allowed to choose physicians and specialists without restraint. A philanthropic agency provides care without fees, but the member does not select providers.

Diagnosis-related groups (DRGs) have attempted to reduce health care costs by decreasing: 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. Decreasing hospital admission rates has not been shown to reduce the costs of health care. Decreasing outpatient services would actually drive costs up because more services would have to be performed as in-patient procedures. Decreasing specialty groups would not affect hospital reimbursement, which is the focus of the DRG payment system.

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: 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 sued to pay back the insurance company for the extra fees incurred because smoking is a modifiable health risk for heart disease. d. the physician 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. The statement "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." The statement "The client will be sued to pay back the insurance company for the extra fees incurred because smoking is a modifiable health risk for heart disease." The statement "The physician who admitted the client will receive a reduced payment to cover the loss incurred by the hospital does not describe a currently allowable method of medical reimbursement."

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: a. prospective payment. b. retrospective payment system. c. diagnosis-related group payment system. d. capitated payment system.

ANS: B The 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; also known as the "fee-for-service" payment system. The prospective payment system is a method of reimbursing health care providers in which the total amount of payment for care is predetermined on the basis of the client's diagnosis. This is the predominant method of payment in today's health care system. The diagnosis-related group payment system refers to reimbursement for health care services that is based on a predetermined fixed price per case. This method of payment is also called the prospective payment method. The capitated payment system is a method of reimbursing providers (usually primary care providers such as physicians and 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 for the client enrolled in the insurance company's health plan.

A nurse who speaks at a health fair states that current attempts to increase efficiency of health care include: (Select all that apply) a. an increase in acute care, so that specialized care can be provided. b. the growing use of outpatient services. c. shifting toward health promotion and prevention. d. allowing physicians to control health care decision making. e. the use of technology to educate the public about cost-effective measures.

ANS: B, C, E Economic forces are motivating the shift toward a model of health promotion and preventive care to achieve cost-effectiveness, including a shift to provision of more services and procedures in outpatient settings. Economic forces are motivating the shift toward a model of health promotion and preventive care to achieve cost-effectiveness, including a shift to provision of more services and procedures in outpatient settings. The technology of the Internet offers promise for information and education that will allow consumers (or clients) to access health care educational resources more effectively. Health care is shifting from acute care services to preventive and community-based services such as ambulatory care and home care. Physicians no longer control all health care decision making; insurance companies play an increasingly stronger role in health care decision making through requirements for preauthorization of procedures and treatment plans. The technology of the Internet offers promise for information and education that will allow consumers (or clients) to access health care educational resources more effectively.

A young mother has detected a lump in her breast, and because she lives at the poverty level, she is covered under Medicaid. This individual: a. is more likely to participate in mammography screening than are individuals covered by private insurance. b. has designated primary care and a specialist as sources of care. c. will more likely wait to seek care and will require hospitalization for a mastectomy, which could have been avoided if care had been sought earlier. d. 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. The poor are less likely to participate in preventive services. The poor usually do not have a usual source of care. Through Medicaid the client actually has enhanced access to health care resources.

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

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. A case management nurse coordinates the client's care throughout the course of an illness. Case managers generally do not perform direct care duties but assume a planning and evaluation role and collaborate with the interdisciplinary health care team to ensure that goals are met, quality is maintained, and progress toward discharge is made. The quality assurance nurse facilitates client care delivery through quality monitoring and quality improvement initiatives. A cost-control nurse is not a standard role in hospitals.

When reviewing the literature on the effects of Medicaid on health care for the poor, the nurse researcher found that the poor: a. have less access than even the uninsured. b. receive many unnecessary treatments. c. lack consistent providers. d. abuse 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. The poor and uninsured may have limited transportation, limiting their access to health care facilities. The poor generally receive very few treatments because of lack of payment to the provider or facility. The poor rarely seek preventive services, which explains why their overall health status is lower.

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. Neither the client nor the health care provider is considered the third party in the health care triad. Neither the client nor the health care provider is considered the third party in the health care triad. The government that sets reimbursement rules is not part of the health care triad.

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. A prospective payment system is a method of reimbursing health care providers in which the total amount of payment for care is predetermined on the basis of the client's diagnosis. A retrospective payment system is a method of reimbursing health care providers which professional services are rendered and charges are billed according to each service provided. The single payer system is a method of reimbursement whereby one payer, usually the government, pays all health care expenses for all citizens with the use of funding acquired through taxes.

In February 2010, Congress passed legislation to support universal health care for all Americans. 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 is that: a. with universal health, one universal payer, usually the government, pays all expenses for health care. b. single-payer systems offer health care to only 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. Universal health can have multiple payers. Coverage is not based on income; rather all citizens are eligible. Insurance companies do not pay cost; rather one payer (usually the government) is financially responsible.

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 currently cover only disease management, not preventive care.

Health Maintenance Organization (HMO)

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

Near events

A nurse is newly employed by a state-owned hospital that provides health care insurance requiring a deductible paid by the employee with the majority of the premium cost covered by the employer. The insurance provided to the nurse is: a. private health insurance. b. a federal insurances program known as PPACA. c. state-subsidized Medicaid insurance. d. single-payer system coverage.

Private Health Insurance

Type of insurance that shifts the largest percentage of costs for goods and services to employees and consumers is

Private insurance

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 told that, based on this patient's information: 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.

c. Medicare will pay for home health services should these additional services meet the needs of the individual.

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. The group critiques the relationship between contemporary economic trends and professional nursing practice and finds: 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.

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.