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Test 1 212 > Health Policy > Flashcards

Health Policy Flashcards

0
Q

Centers for medicare and medicaid services (CMS)

A

The federal government agency that administers Medicare and Medicaid

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1
Q

Capitation

A

A method of reimbursing providers 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 the insurance company’s health plan. The payment is typically expressed as a per member per month payment. The defined health care services generally include preventive, diagnostic, and treatment services.

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2
Q

DRGs (Diagnosis Related Groups)

A

Refers to reimbursement for health care services based on a predetermined fixed per price per case or diagnosis

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3
Q

Effectiveness

A

Doing the right thing right

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4
Q

Efficiency

A

Using the right combination of resources to accomplish a task

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5
Q

Medicaid

A

A jointly sponsored state and federal program that pays for the medical services for persons who are elderly, poor, blind, or disabled and for certain families with dependent children who meet specified income guidelines.

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6
Q

Medicare

A

A federally funded health insurance program for the disabled, persons with end stage renal disease, and persons 65 years of age and older who qualify for social security.

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7
Q

Patient Protection and Affordable Care Act (PPACA)

A

A United States federal statute enacted in 2010 that requires U.S. citizens and legal residents to have health insurance through comprehensive healthcare reform; expands health care coverage access to millions of people who were previously uninsured.

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8
Q

Private Health Insurance

A

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 such as routine, preventive, and emergency health care; hospitliazations; medical procedures; and/or prescription drugs. Typically the private insurance is provided though an individual’s employer with a portion paid by the employee. Private insurance policies can also be purchased by individuals but are generally much more expensive than when provided through an employer’s group plan.

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9
Q

Prospective Payment System (PPS)

A

A method of reimbursing health care providers in which the total amount of payment for the care is predetermined based on the patient’s diagnosis; provides for a “set price per diagnosis” payment system in contrast to the retrospective or “Fee for service” system; encourages increased efficiency in the use of health care services because providers are reimbursed at a set level regardless of how many services are rendered or procedures performed to treat a particular diagnostic category; the most common method of payment in today’s health care system.

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10
Q

Provider

A

An individual or an organization that receives reimbursement for providing health care services.

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11
Q

Retrospective Payment System

A

A method of reimbursing health care providers in which professional services are rendered and charges are billed based on each individual service provided; also known as the “fee for service” payment system. This system may encourage overuse of health care services because the more services rendered or procedures performed, the more revenue received by providers.

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12
Q

Single Payer System

A

A method of reimbursement in which one payer, usually the government, pays all health care expenses for citizens, funded by taxes. Decisions about covered treatments, drugs, and services are made by the government. Though the terms universal health care and single payer system are sometimes used interchangeably, the universal healthcare could be administered by many different payer groups, both offer all citizens health insurance coverage.

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13
Q

Third Party Payer

A

An organization other than the patient and the provider, such as an insurance company, that assumes responsibility for payment of health care charges. An individual’s health insurance plan provided by his or her employer is considered a third party payer.

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14
Q

What has driven health care prices to become so expensive?

A
  1. The physician’s role as being primarily responsible for health care decision making.
  2. The broad objective of providing “the best” possible care to everyone
  3. The rapidly increasing sophistication and cost of medical technology
  4. Economic incentives and the fee for service payment method that encouraged overuse of health care services.
    4
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15
Q

How was medicare changed once it got out of control?

A

Instead of medicare being a retrospective (fee for service) reimbursement it was switched to a prospective payment system (PPS) based on diagnostic related groups (DRGs). If hospital costs exceed DRG payment the hospital incurs a loss but if costs are less than the DRG amount, the hospital makes a profit.

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16
Q

Resource based relative value scale (RBRVS)

A

Goal is to bring payments for medical services in line with the physician skills required and the actual time spent on specific procedures. For example, when medicare initially covered payment for cataract surgery, it was a relatively rare and lengthy procedure. However, over time cataract correction became a frequently performed medicare surgical procedure, viewed by CMS as overpaid. The RBRVS system corrected the disparity between Medicare’s high payments for this type of procedure and relatively low payments for more hands on primary care.

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17
Q

What do HMOs, PPOs, and POS plans all have in common?

A

They all use some method to review and provide oversight for the use of health care services. The goal of managed care is to minimize payment of charges for inappropriate or excessive health care services.

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18
Q

Fee for service (Indemnity plan)

A
  1. member pays a premium for a fixed percentage of expenses covered.
  2. Includes deductible and copayment
  3. allows member to choose physician and specialist without restraint
  4. may only cover usual or reasonable and customary charges for treatment and services, with member responsible for charges above the payment
  5. may or may not pay for preventive care.
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19
Q

PPO (preferred provider organization)

A
  1. Member pays a premium for a fixed percentage of expense covered
  2. Includes deductible and copayment
  3. Member may select physician, but pays less for physicians and facilities on the plan’s preferred list
  4. may or may not pay for preventive care
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20
Q

HMO (health maintenance organization)

A
  1. member pays a premium
  2. Has a fixed copayment
  3. member must select a primary care physician approved by the HMO
  4. Member must be referred for treatments, specialists, and services by the primary care provider
  5. Services outside of the network must be pre approved for payment
  6. Plan may refuse to pay for services not recommended by the primary care physician
  7. encourages use of preventive care
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21
Q

Medicare (5 things)

A
  1. Federal health insurance plan for Americans 65 years of age and older and certain disabled persons
  2. member must be eligible for social security or railroad retirement
  3. Part A covers hospital stays
  4. Part B requires payment of a premium and covers physician services and supplies
  5. Carries a prescription drug benefit
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22
Q

Medicaid (2 things)

A
  1. Health care coverage for low income persons who are aged, blind, disabled, or for certain families with disabled children
  2. Federal program is delivered and managed by each state for eligibility and scope of services offered
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23
Q

TRICARE

A
  1. civilian health and medical health insurance program for military spouses, dependents, and beneficiaries
  2. program offered through military health services system
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24
Q

Patient Protection and Affordable Care Act

A
  1. universal health care insurance coverage for americans
  2. consumer rights and protections
  3. insurance choices
  4. insurance costs: get most for your money
  5. changes in medicare for persons 65 years of age and older
  6. Tax credits and new programs for employers and employees
25
Q

What is the problem with medicaid recipients?

A
  1. they are more likely to lack a usual source of care

2. less likely to be hospitalized for avoidable conditions than those who are not poor

26
Q

What is the problem with the uninsured or underisnured?

A

They cannot pay their medical bills so unpaid costs must be covered by those who do pay so the hospital can continue operating, a process known as cost shifting. providers increase their charges against households and public and private insurers who pay for their own care plus make some contribution for the care of the uninsured. This increases insurance premiums, making it even more difficult for many households and businesses to afford coverage.

27
Q

Pay for Performance (P4P)

A

Hospitals and other providers are rewarded for meeting standards of care for certain conditions such as diabetes, myocardial infarction, pneumonia, and heart failure. Nurses should stay alert for developments in P4P programs because they can have a significant effect on quality paitent outcomes and successful P4P reimbursement.

28
Q

Never Events

A

Medicare will no longer pay hospitals for the extra costs of teating preventable errors that are largely preventable and have serious consequences for the patients. The purpose of the never events payment policy is to eliminate payments for certain medical errors and encourage hospitals to direct resources to preventing errors rather than being paid for them. Never events include hospital acquired infections, injuries from falls, wrong site surgery, and mismatched blood transfusions.

29
Q

Changes in the financing of health care services directly affect professional nursing practie. The following are several reasons why payment reform is important to nursing (ON TEST)

A
  1. The rules of payment are important as a reflection of the value and worth society places on health care services for the public.
  2. Government policy influences the public’s openness to secure services from various professionals such as nurse practiotioners.
  3. Financing affects salaried employees because health care providers build job opportunities based on payment sources. For instance, if a professional service is covered under reimbursed allowances, jobs in that service will be offered by the provider
  4. Payment modes will determine whether a particular nursing role will be reimursed, affecting specialities and professional autonomy
30
Q

obamacare’s main focus is on providing more Americans with

A
  1. Access to affordable health care
  2. Improving the quality of health care
  3. Regulating the health insurance industry
  4. Reducing spending in healthcare
31
Q

What is Universal Healthcare

A

where everyone is covered for basic healthcare services and no one is denied care as long as they are legal residents in the geography covered. This may be paid by one or many different payer groups.

32
Q

Primary sources of healthcare financing

A

Private insurance, government, patients.
Government is the largest consumer of healthcare sources because of CMS. because they par for medicare, medicaid, tricare, and congressional/federal employees.

33
Q

How can nurses impact health care costs

A
  1. Care coordination: Coordinating care is one way to decrease duplication of services and reduce wasted health care resources
  2. Case Managment: ensure patients get effective treatment at the appropriate level of care
  3. Disease Managment: help manage and improve the health status of a defined patient population over the course of a disease
  4. Outcomes Managment: demonstrate efficiency of care with measurable effective outcomes
34
Q

Consumer directed health plans

A

Attempt to decrease health care spending by making consumers share more of the financial risk and burden. The logic is that as cost to the patient increases, so do the incentives to choose health care carefully. End result is less costly, less unnecessary care

35
Q

Price Transparency

A

Refers to providing patients with actual or, at least, estimated charges at or before the time of service

36
Q

Charity care and benefit to the community

A

There is an expectation that non profit hospitals return benefit to the community. Generally, this is defined in terms of the level of charity care provided to individuals. Charity care refers to pricing discounts to a patient that are typically determined by income, family size and, at times, debt level. Hospitals that don’t do this risk losing their non profit status!

37
Q

Speciality hospitals and outpatient surgery centers

A

Capitalize on a small but influential market, luring patients that the money to make a selection in health care provider and who want less of a big hospital environment. The emphasis is on costumer service,satisfaction, and outcomes. These facilities attract the healthier wealthier, leaving the sicker and poorer for the non profit facilities

38
Q

Market System

A

Involves buyer and seller. buyer purchases products from seller. Implies private ownership of resources and private decision making by consumers about what they want to buy and by sellers on what they want to sell

39
Q

What does medicare A cover?

A
  1. inpatient care in hospitals
  2. Inpatient care in a skilled/rehab nursing facility (not custodial or long term care)
  3. Hospice Care Services
  4. Home health care services
  5. inpatient care in a religious non medical health care institution
  6. Blood
40
Q

What does medicare B cover? (MADMPOGHL)

A

Free or approximately $100.00 a month. pt pays premium and or deductible.
1.medically necessary doctor’s services
2 ambulance services
3. durable medical equipment
4. mental health (inpatient, outpaitent, partial hospitilization)
5. preventive services
6. outpatient care
7. getting a second opinion before surgery
8. home health care
9. limited outpatient Rx drugs/clinical research

41
Q

What is covered by both medicare A&B?

A
  1. home health care
  2. blood
  3. chemotherapy (A in the hospital, B at home)
42
Q

What is covered by neither medicare A&B

A
  1. LTC
  2. routine dental or eye care
  3. dentures
  4. cosmetic surgery
  5. acupuncture
  6. hearing aids
  7. exams for hearing aids
43
Q

Medicare coverage is based on what 3 main factors

A
  1. Federal and state laws
  2. Medicare’s decision about whether something is covered
  3. Local coverage decisions made by companies in each state that process claims for medicare. These companies decided whether something is medically necessary and should be covered in their area.
44
Q

What is Assignment

A

Assignment means that the doctor, provider, or supplier agrees (or is required by law) to accept the medicare approved amount as full payment for covered services

45
Q

What happens if you doctor accepts assignment?

A
  1. out of pocket costs may be less
  2. they agree to charge only the medicare deductible and coinsurance amount and usually wait for medicare to pay its share before asking the pt to pay their share
  3. They have to submit a claim directly to medicare and can’t charge for submitting the claim
46
Q

What happens if your doctor does not accept assignment?

A
  1. may have to pay full charge at time of visit

2. doctor can charge up to 15% more than the medicare approved amount

47
Q

What is medicare funded by?

A

employee wages

48
Q

SCHIP

A

Federal/state program w/goal of reducing # of uninsured american children by providing access to coverage for children in families whose incomes were too high for medicaid but couldn’t afford private insurance.

49
Q

Supplemental security income benefits

A

taxes are used to provide services for individuals with special needs such as blindness, disablities, and age. usually eligible for medicaid

50
Q

Federal employees health benefit program

A

health care benefits are provided for all permanent civilian employees of the US government: postal workers, members of congress, federal prison workers

51
Q

Military health service system

A

US department of defense provides medical insurance coverage for the active duty and retired branches of the armed services. the military health plan is called tricare

52
Q

Veterans health care eligibility act of 1996

A

department of veterans affairs provides a medical benefits package for all enrolled veterans, including preventative and primary care as well as inpatient and outpatient services

53
Q

Indian health service of 1955

A

provides HC to American Indians and Alaska natives.descendants and recognized members eligible

54
Q

How can nurses participate in the management of health care costs?

A
  1. do a lot of education about preventative care
  2. educate about medications and importance for compliance
  3. get case management involved as soon as possible
  4. collaborations/communication making sure we are all on the same page
  5. monitor for adverse drug events and prevent medication errors
55
Q

Medicare C

A

includes benefits of part A,B, and D. HMO/PPO that requires the use of certain MDs, hospitals, etc. provided by private insurer. pt pays premium and or deductible.

56
Q

Medicare D

A

Outpatient Rx plan. voluntary. patient pays premium and deductible. complex system w/gaps in coverage

57
Q

medigap policy

A

can help pay some of the health care cots such as copayments, coinsurance, and deductibles. supplemental policy offered by private insurance companies.

58
Q

Kaiser Article

A

READ IT

59
Q

In the past 12 months what have families admitted to doing because of the cost of healthcare?

A
  1. 33% relied on home remedies or over the counter drugs instead of going to see a doctor.
  2. 31% skipped dental care or checkups

Test 1 212 (6 decks)

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