Healthcare Delivery 2023 Flashcards
Exam 1
JUSTICE IN HEALTH CARE ETHICS:
What does the principle of justice state?
The principle of justice states that there should be an element of fairness in all health care decisions:
JUSTICE IN HEALTH CARE ETHICS:
The principle of justice states that there should be an element of fairness in all health care decisions: like what?
regarding burdens and benefits
equal distribution of resources and new treatments
responsibility for medical practitioners to uphold applicable laws and legislation when making choices.
HEALTHCARE POLICY
Policies: What are they?
Policies: set of principles that govern an action to achieve a given outcome, or guidelines that direct individuals’ behavior toward a specific goal
HEALTHCARE POLICY
Public Health policies are decisions that impact who?
Public health policies are decisions that impact the health of an individual, a family, and a population or community
HEALTHCARE POLICY
The U.S. healthcare system is a system of what?
The U.S. healthcare system is a unique system of both independent and collaborative power and action by both federal and state governments.
HEALTHCARE POLICY:
What are policies evaluated by:
Policies are evaluated for effectiveness, cost containment, and overall costs and benefits
POLITICAL PROCESS:
What is it?
Process of influencing the allocation of resources needed to enable policy and involves the strategies needed to achieve the desired goals
POLITICAL PROCESS
What does policy making involve?
Policy-making takes a great deal of effort, time, and commitment.
POLITICAL PROCESS
Policy-making takes a great deal of effort, time, and commitment.
What does it include:
Setting an agenda
Policy formulation
Policy adoption
Policy implementation
Policy assessment
Policy modification
HISTORICAL HIGHLIGHTS ON NURSING POLITICAL INVOLVEMENT
Mid-‘70s and early ‘80s:
Political involvement of nurses
HISTORICAL HIGHLIGHTS ON NURSING POLITICAL INVOLVEMENT
1976:
Important year of advocacy
HISTORICAL HIGHLIGHTS ON NURSING POLITICAL INVOLVEMENT
1990s:
Nurses included in healthcare policy formation
WHAT DOES IT MEAN TO BE POLITICALLY ACTIVE?
Personal and professional political involvement of nurses
WHAT DOES IT MEAN TO BE POLITICALLY ACTIVE:
What must nurses be knowledgable about?
Nurses must be knowledgeable about issues, laws, and policy
WHAT DOES IT MEAN TO BE POLITICALLY ACTIVE:
Why is nurse-informed political involvement:
Who are they? What are they aware of? How are they positioned?
Direct caregivers
Awareness of patient safety and satisfaction, access to services, clinical outcomes, and health disparities
Positioned to see impact of policy on individuals
HOW TO BE POLITICALLY INVOLVED?
Evidence-based practice examples
HOW TO BE POLITICALLY INVOLVED?
Nurses’ milestones in policy development have contributed to: what?
Quality outcomes
Decreases in cost
Expanded access
Major differences to the health of the nation
NURSING INVOLVEMENT:
What does it include:
Professional nursing organizations
Nursing involvement challenges and barriers
NURSING INVOLVEMENT:
Professional nursing organizations include:
American Nurses Association (ANA)
National League for Nursing (NLN)
International Council of Nurses
NURSING INVOLVEMENT
Nursing involvement challenges and barriers
Not enough time to get involved
Heavy workloads with understaffing Perception of powerlessness Gender issues Political action breaching family time Anxiety with public speaking Lack of knowledge in legislative process Fear of retaliation
HEALTH CARE FINANCING includes what?
Third-party payments
HEALTH CARE FINANCING :
Third Party payments:
Private insurance companies (trend toward consumer-driven health plans and health savings accounts)
Independent or self-insured health plans
Government health programs
HEALTH CARE FINANCING :
Government health programs include:
- Medicare, Medicaid, Federal Employees Health Benefits Plan
- Children’s Health insurance Program (CHIP)
- Other government programs
BASIC CONCEPT
Fee-for-Service Reimbursement: What is it?
Payment is made for each specific service provided
ex; emergency care, elective procedure, and diagnostic services
BASIC CONCEPT
Episode-of-Care Reimbursement:
Providers receive one lump sum for all the services they provide related to a condition or disease
The unit of payment is the episode, not each individual health service
PAYMENT CONCEPTS
include:
Retrospective (Fee for service)
Prospective (Value-based)
PAYMENT CONCEPTS
Retrospective (Fee for service): How is fee established?
Fee established in advance
PAYMENT CONCEPTS
Retrospective (Fee for service):
When does reimbursement occur?
Reimbursed after service rendered
PAYMENT CONCEPTS
Retrospective (Fee for service): What is there a potential of? Why?
Potential for abuse through requesting and ordering unnecessary tests
PAYMENT CONCEPTS
Retrospective (Fee for service): What does this encourage?
Encouraged sickness rather than wellness
PAYMENT CONCEPTS
Prospective (Value-based): Who sets rates?
External authority sets rates
PAYMENT CONCEPTS
Prospective (Value-based): Where are rates derived from?
Rates derived from predictions set in advance
PAYMENT CONCEPTS
Prospective (Value-based): How are the rates?
Fixed rates rather than cost coverage
PAYMENT CONCEPTS
Prospective (Value-based): What does it impose constraints on?
Imposes constraints on spending
PAYMENT CONCEPTS
Prospective (Value-based): What are providers at risk for?
Providers at risk for losses or surpluses
TRENDS AND ISSUES INFLUENCING HEALTH CARE ECONOMICS
High cost of health care in America
Cost-control measures
Access to health services
Medical bankruptcies
Managed care
Accountable Care Organizations (ACOs)
groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients.
BUNDLED PAYMENTS FOR CARE IMPROVEMENT (BPCI) INITIATIVE
links payments for multiple services beneficiaries receive during an episode of care (= a lump sum payment is made to a provider for the entire episode of care)
BUNDLED PAYMENTS FOR CARE IMPROVEMENT (BPCI) INITIATIVE
What may it lead to?
may lead to higher quality, more coordinated care at a lower cost
MEDICARE: Created by who under what?
Created by Congress in 1965 under Title 18 of the Social Security Act
MEDICARE:
Enrollment into Medicare is handled by what?
Enrollment into Medicare is handled by Social Security Administration
DESCRIPTION OF THE MEDICARE PROGRAM:
What exactly is Medicare?
Medicare is a federal health insurance program for people over the age of 65, the disabled, and for persons with end stage renal disease
DESCRIPTION OF THE MEDICARE PROGRAM:
Medicare introduced regulations for home care practice as well as for reimbursement mechanisms
COMPONENTS OF THE MEDICARE PROGRAM include:
Part A (Hospital Coverage)
Part B (Medical Coverage)
COMPONENTS OF THE MEDICARE PROGRAM include: Part A (Hospital Coverage)
Inpatient hospital services, skilled nursing facilities, home health and hospice care
COMPONENTS OF THE MEDICARE PROGRAM include: Part B (Medical Coverage)
Doctors’ services and outpatient care, out-patient surgery, out-patient lab work, x-rays, and diagnostics, out-patient therapies, durable medical equipment
MEDICARE COST SHARING: What is it?
Utilization of private insurance enhancements and supplements to help with the costs that traditional Medicare does not cover
MEDICARE COST SHARING
Medigaps: What is it? What does it do?
Medicare Supplemental Insurance
Pay deductibles, coinsurances, and costs after basic coverage is exhausted
MEDICARE COVERAGE OPTIONS
Option 1
Option 2
MEDICARE COVERAGE OPTIONS
Option 1: What is the primary coverage?
What else is there?
Basic Medicare (Part A and B) as primary coverage
Supplement (Medigap)
Part D Drug Plan
MEDICARE COVERAGE OPTIONS
Option 2: What is the primary coverage?
What else is there? What does it require?
Medicare Part C (Managed Care Plan) as primary coverage
Can include Part D coverage
Require enrollment in basic Medicare
