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Healthcare Delivery 2023 Flashcards

Exam 1

1
Q

JUSTICE IN HEALTH CARE ETHICS:

What does the principle of justice state?

A

The principle of justice states that there should be an element of fairness in all health care decisions:

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2
Q

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?

A

regarding burdens and benefits

equal distribution of resources and new treatments

responsibility for medical practitioners to uphold applicable laws and legislation when making choices.

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3
Q

HEALTHCARE POLICY

Policies: What are they?

A

Policies: set of principles that govern an action to achieve a given outcome, or guidelines that direct individuals’ behavior toward a specific goal

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4
Q

HEALTHCARE POLICY

Public Health policies are decisions that impact who?

A

Public health policies are decisions that impact the health of an individual, a family, and a population or community

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5
Q

HEALTHCARE POLICY

The U.S. healthcare system is a system of what?

A

The U.S. healthcare system is a unique system of both independent and collaborative power and action by both federal and state governments.

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6
Q

HEALTHCARE POLICY:

What are policies evaluated by:

A

Policies are evaluated for effectiveness, cost containment, and overall costs and benefits

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7
Q

POLITICAL PROCESS:

What is it?

A

Process of influencing the allocation of resources needed to enable policy and involves the strategies needed to achieve the desired goals

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8
Q

POLITICAL PROCESS

What does policy making involve?

A

Policy-making takes a great deal of effort, time, and commitment.

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9
Q

POLITICAL PROCESS

Policy-making takes a great deal of effort, time, and commitment.

What does it include:

A

Setting an agenda

Policy formulation

Policy adoption

Policy implementation

Policy assessment

Policy modification

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10
Q

HISTORICAL HIGHLIGHTS ON NURSING POLITICAL INVOLVEMENT

Mid-‘70s and early ‘80s:

A

Political involvement of nurses

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11
Q

HISTORICAL HIGHLIGHTS ON NURSING POLITICAL INVOLVEMENT

1976:

A

Important year of advocacy

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12
Q

HISTORICAL HIGHLIGHTS ON NURSING POLITICAL INVOLVEMENT

1990s:

A

Nurses included in healthcare policy formation

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13
Q

WHAT DOES IT MEAN TO BE POLITICALLY ACTIVE?

A

Personal and professional political involvement of nurses

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14
Q

WHAT DOES IT MEAN TO BE POLITICALLY ACTIVE:

What must nurses be knowledgable about?

A

Nurses must be knowledgeable about issues, laws, and policy

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15
Q

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?

A

Direct caregivers

Awareness of patient safety and satisfaction, access to services, clinical outcomes, and health disparities

Positioned to see impact of policy on individuals

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16
Q

HOW TO BE POLITICALLY INVOLVED?

A

Evidence-based practice examples

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17
Q

HOW TO BE POLITICALLY INVOLVED?

Nurses’ milestones in policy development have contributed to: what?

A

Quality outcomes

Decreases in cost

Expanded access

Major differences to the health of the nation

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18
Q

NURSING INVOLVEMENT:

What does it include:

A

Professional nursing organizations

Nursing involvement challenges and barriers

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19
Q

NURSING INVOLVEMENT:

Professional nursing organizations include:

A

American Nurses Association (ANA)

National League for Nursing (NLN)

International Council of Nurses

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20
Q

NURSING INVOLVEMENT

Nursing involvement challenges and barriers

A

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
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21
Q

HEALTH CARE FINANCING includes what?

A

Third-party payments

22
Q

HEALTH CARE FINANCING :

Third Party payments:

A

Private insurance companies (trend toward consumer-driven health plans and health savings accounts)

Independent or self-insured health plans

Government health programs

23
Q

HEALTH CARE FINANCING :

Government health programs include:

A
  1. Medicare, Medicaid, Federal Employees Health Benefits Plan
  2. Children’s Health insurance Program (CHIP)
  3. Other government programs
24
Q

BASIC CONCEPT

Fee-for-Service Reimbursement: What is it?

A

Payment is made for each specific service provided

ex; emergency care, elective procedure, and diagnostic services

25
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
26
PAYMENT CONCEPTS include:
Retrospective (Fee for service) Prospective (Value-based)
27
PAYMENT CONCEPTS Retrospective (Fee for service): How is fee established?
Fee established in advance
28
PAYMENT CONCEPTS Retrospective (Fee for service): When does reimbursement occur?
Reimbursed after service rendered
29
PAYMENT CONCEPTS Retrospective (Fee for service): What is there a potential of? Why?
Potential for abuse through requesting and ordering unnecessary tests
30
PAYMENT CONCEPTS Retrospective (Fee for service): What does this encourage?
Encouraged sickness rather than wellness
31
PAYMENT CONCEPTS Prospective (Value-based): Who sets rates?
External authority sets rates
32
PAYMENT CONCEPTS Prospective (Value-based): Where are rates derived from?
Rates derived from predictions set in advance
33
PAYMENT CONCEPTS Prospective (Value-based): How are the rates?
Fixed rates rather than cost coverage
34
PAYMENT CONCEPTS Prospective (Value-based): What does it impose constraints on?
Imposes constraints on spending
35
PAYMENT CONCEPTS Prospective (Value-based): What are providers at risk for?
Providers at risk for losses or surpluses
36
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
37
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.
38
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)
39
BUNDLED PAYMENTS FOR CARE IMPROVEMENT (BPCI) INITIATIVE What may it lead to?
may lead to higher quality, more coordinated care at a lower cost
40
MEDICARE: Created by who under what?
Created by Congress in 1965 under Title 18 of the Social Security Act
41
MEDICARE: Enrollment into Medicare is handled by what?
Enrollment into Medicare is handled by Social Security Administration
42
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
43
DESCRIPTION OF THE MEDICARE PROGRAM:
Medicare introduced regulations for home care practice as well as for reimbursement mechanisms
44
COMPONENTS OF THE MEDICARE PROGRAM include:
Part A (Hospital Coverage) Part B (Medical Coverage)
45
COMPONENTS OF THE MEDICARE PROGRAM include: Part A (Hospital Coverage)
Inpatient hospital services, skilled nursing facilities, home health and hospice care
46
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
47
MEDICARE COST SHARING: What is it?
Utilization of private insurance enhancements and supplements to help with the costs that traditional Medicare does not cover
48
MEDICARE COST SHARING Medigaps: What is it? What does it do?
Medicare Supplemental Insurance Pay deductibles, coinsurances, and costs after basic coverage is exhausted
49
MEDICARE COVERAGE OPTIONS
Option 1 Option 2
50
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
51
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

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