Issues, Trends, and Health Policy Part III Flashcards
“Healthy People 2020”
1. Access to health care and ____ health are both major issues for health policy.
improved
“Healthy People 2020”
2. ________ of Healthy People 2000; published in 1990 by the United States Department of Health and Human Services
Continuance
“Healthy People 2020”
- Goals (2):
a. Increase the ________ and years of healthy life
b. Eliminate health disparities among Americans
quality
“Healthy People 2020”
- Document contains ____ of health objectives based on numerous focus areas
hundreds
“Healthy People 2020”
- Objectives relate to _____ access, availability, cost, quality of care, etc.
equal
“Healthy People 2020”
- Used to understand health status of the nation and plan _____ programs
prevention
“Healthy People 2020”
- Individuals, communities, and organizations are responsible for determining how to meet the ____ of Healthy People 2020.
goals
“Healthy People 2020”
“_______” Statutes: Require practitioners to report specific health-related information; vary from state to state but commonly involve:
Reporting
“Healthy People 2020”
Reporting Statutes:
1. ___ ___ and injury from a dangerous weapon (police)
Criminal acts
Reporting Statutes:
- In most states, the NP must notify-the Department of Health of the following diagnoses:
a. Gonorrhea
b. Chlamydia
c. ______
d. HIV
e. TB
Syphilis
Reporting Statutes:
3. _____ bites (animal control; subsidiary of the DHHS)
Animal
Reporting Statutes:
4. Suspected or actual child or ____ abuse (police via social services)
elder
Reporting Statutes:
5. Domestic violence: NPs are ___ legally required to report in most states
not
Collaborative Practice
1. Exists to enhance the ___ of care and improve patient outcomes
quality
Collaborative Practice
2. ANA’s Nursing: A Social Policy Statement (1995) describes collaboration as a “___ ____” in which all players have and desire power, share common goals, and recognize/accept separate areas of responsibility and activity
true partnership
Navigating the Health Care System for Patients
- Social services
- Psychiatric services
- ______
- Security officers
- Physical therapy
- Occupational therapy
Police
Issues Regarding Access to Care:
- ___ ____
- Hospice
- Skilled Nursing Faciltiy
- Private duty nursing
Home health
Health Care Financing
- Coding: Evaluation and Management (E&M) codes identify the level of care provided
a. Codes match the level of service provided to the complexity of the presenting patient problem - Billing
- _________
- Third party payers
Reimbursement
- ______: Evaluation and Management (E&M) codes identify the level of care provided
a. Codes match the level of service provided to the complexity of the presenting patient problem
Coding
Categories of Third-Party Payers
1. Medicare
2. ______
3. Commercial indemnity insurers
4. Commercial management organizations [e.g. health
maintenance organizations (HMOs)]
5. Businesses or schools wanting health services for
employees or students
Medicaid
Categories of Third-Party Payers
________: Sets the standard for reimbursement and
cutting costs
Medicare
Medicare Rules for NPs
1. To qualify to be a Medicare provider, an NP must:
a. Hold a state license as an NP
b. Be certified as an NP by a recognized ___ ____
____
c. Hold at least an MSN degree
national certifying body
Medicare Rules for NPs
2. The NP meets Medicare qualification ________
requirements
Medicare Rules for NPs
3. The practice/facility accepts Medicare payment (i.e., _____% of physician schedule rate for bills submitted under the NP’s provider number)
85
Medicare Rules for NPs
4. ____ facility or other provider charges or is paid with respect to the furnishing of services
No
Medicare Rules for NPs
5. The services are:
a. “___ _____”: Those for which a physician can
bill Medicare
Physician services
Medicare Rules for NPs
- The services are:
b. Performed in ______ with a physician
collaboration
Medicare Rules for NPs
- The services are:
c. Within the NP’s scope of practice as defined by ____ law
state
Medicare Payments
1. Medicare reimburses NPs __% of the physician fee delineated in Medicare’s Physician Fee Schedule.
85
Medicare Payments
2. For a procedure, Medicare pays NPs ___% of the 85% of the Physician Fee Schedule rate.
80
Medicare Payments
3. Practices must bill under the provider of the clinician who performs a given service. The exception is “____ ____” billing. When billing “incident to” a physician’s service, a practice may be reimbursed 100% of the Physician Fee Schedule rate.
incident-to
Incident-to Billing: Services billed under the physician’s provider number to get the full physician fee (100%) given the following rules:
1. The services are:
a. An integral, although incidental, ____ of the
physician’s professional service
part
Incident-to Billing: Services billed under the physician’s provider number to get the full physician fee (100%) given the following rules:
1. The services are:
b. Commonly rendered ____ charge or included in
the physician’s bill
without
Incident-to Billing: Services billed under the physician’s provider number to get the full physician fee (100%) given the following rules:
1. The services are:
c. Of a type commonly _____ in physician’s offices
or clinics
furnished
Incident-to Billing: Services billed under the physician’s provider number to get the full physician fee (100%) given the following rules:
1. The services are:
d. Furnished under the physician’s direct personal
_______ and are furnished by the physician or
by an individual who is an employee or
independent contractor of the physician. Direct
supervision does not require the physician’s
presence in the same room but the physician
must be present in the same office suite and
immediately available.
supervision
Incident-to Billing: Services billed under the physician’s provider number to get the full physician fee (100%) given the following rules:
2. The physician must perform “the initial service and
subsequent services of a frequency which reflect his
or her active _________ in the management of the
course of treatment.”
participation
Incident-to Billing: Services billed under the physician’s provider number to get the full physician fee (100%) given the following rules:
3. The physician/other provider under whose name and
number the bill is submitted must be the individual
present in the ___ ____ when the service is
provided.
office suite
Incident-to Billing: Services billed under the physician’s provider number to get the full physician fee (100%) given the following rules:
4. *Incident-to billing is not allowed in the _____ setting;
an NP must bill under his/her provider number.
hospital
Incident-to Billing: Services billed under the physician’s provider number to get the full physician fee (100%) given the following rules:
5. An NP may bill for an assistant’s work (e.g., performing
an EKG) under the NP’s provider number as long as
the _____ for incident-to billing are followed.
roles
Other Rules for Billing
1. Physicians and NPs may see a patient on the same day
for their services; however, the two must _________
billing to avoid duplicate payments.
coordinate
Other Rules for Billing
2. For inpatients, physicians and NPs must decide for
which party (i.e., the NP or the physician) should bill,
given the amount of ________ rendered by each on
given day.
services
Other Rules for Billing
3. For home NP visits billable for Medicare A services,
NPs do not need a physician’s order to bill under the
NP’s provider number, unless the NP is providing
______ ______ exclusively.
moving services
______: Federally supported, state administered
program for low-income families and individuals
Medicaid
Medicaid:
1. Benefits vary from state to _______.
state
Medicaid:
2. Medicaid payments are made after other insurance or
_____ party payments have been made.
third
Case Management
1. Involves a comprehensive and systematic approach to
provide _____ care
quality
Case Management
2. _______: Mobilize, monitor and control resources that
a patient uses during a course of an illness while
balancing quality and cost
Purpose
________, __________, ________
1. A management process of monitoring, evaluating,
continuous review, and improving the quality in
providing health care
Quality Assurance (QA)/Quality Improvement
(QI)/Continuous Process Improvement (CPI)- ___ _____: A process for evaluating the care
of patients using established standards of care to
ensure quality
Quality Assurance
- Based on the methodology developed by Deming and
tested in ________ industry that quality can be
improved by continually monitoring structure, process
and outcome standards (CQI)
Japanese
a. _______: Inputs into care such as resources,
equipment, or numbers and qualifications of staff
Structures
b. ___ ___ ____: Include assessments, planning,
performing treatments and managing
complications.
Processes of care
c. ____: Include complications, adverse events,
short term results of treatment and long term
results of patient health and functioning.
Outcomes
Quality Assurance (QA)/Quality Improvement
(QI)/Continuous Process Improvement (CPI)
4. Used to assess, ______, and improve care provided to patients
monitor
Quality Assurance (QA)/Quality Improvement
(QI)/Continuous Process Improvement (CPI)
5. Components include monitoring of care ____, care appropriateness, effectiveness of care, cost of care, self-regulation and peer review to ensure compliance to care standards
quality
6.Steps of CQI/QA (outlined by the Joint Commission)
a. ____ _____ (i.e., developing a quality
management plan which assigns responsibility for
degree of involvement)
Quality planning
6.Steps of CQI/QA (outlined by the Joint Commission)
b. Delineate scope of care Identify important aspects of
care
i) Identify ____ aspects of care
ii) Identify related to aspects of care
i) important
ii) indicators
6.Steps of CQI/QA (outlined by the Joint Commission)
c. Establish ______ for evaluation related to the
indicators
thresholds
- Steps of CQI/QA (outlined by the Joint Commission)
d. _______ and organize data
Collect
- Steps of CQI/QA (outlined by the Joint Commission)
e. Evaluate care when ______ are reached
thresholds
- Steps of CQI/QA (outlined by the Joint Commission)
f. Take action to ____ care
improve
6.Steps of CQI/QA (outlined by the Joint Commission)
g. Assess the ________ of the action and document
improvement
effectiveness
- Steps of CQI/QA (outlined by the Joint Commission)
h. Communicate ______ information
relevant
- ____ ____: Contains key patient care activities and time frames for those activities which are needed for a specific case type or diagnosis-related group (DRG) 8.
Critical Path
- ___ ____: A newer version of the critical path and is a blueprint for planning and managing care delivered by all disciplines
Care Map
a. The Care Map contains a critical path section plus a
section that identifies common problems
encountered by patients of a specific case type, the
day-to-day goals that the patient must achieve, and
the final desired clinical ______.
outcomes
- Care Map:
b. Monitoring of ________ of care is a very important
goal
outcomes
___ ____ ___: A tool for identifying prevention strategies to ensure safety
Root Cause Analysis
Root Cause Analysis:
1. A process that is part of the effort to build a culture of
_____ and move beyond the culture of blame
safety
Root Cause Analysis:
- Involves and incorporates:
a. ____-_____ experts from the frontline services
Inter-disciplinary
Root Cause Analysis:
- Involves and incorporates:
b. Those who are the most ____ with a situation
familiar
Root Cause Analysis:
2. Involves and incorporates:
c. Continually digging _____ by asking why, why,
why at each level of cause and effect
deeper
- Involves and incorporates:
e. A process that is as _______ as possible
impartial
- Involves and incorporates:
d. Identifying changes that need to be made to ______
system
Sentinel Events
1. Unexpected occurrences involving _____ or serious physical or psychological injury, or the risk thereof
death
Sentinel Events
2. Serious injury specifically includes loss of _____ or function.
limb
Sentinel Events
3. The phrase, “or the _____ _____” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
risk thereof
Sentinel Events
4. Such events are called “‘_____” because these signal the need for immediate investigation and response.
sentinel
Sentinel Events
5. The terms “‘sentinel event” and “____ ____” are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events.
medical error
Sentinel Events
6. In response to a sentinel event (e.g., _____ in nursing homes or a colleague’s behavior that undermines a culture of safety), clinicians and institutions are expected to conduct a root cause analysis.
falls
