Week 4: Paying Health Care

Question 1

_________ avoidable pt problems for which hospitals are not reimbursed by insurance

Answer 1

never events

Question 2

______ payment for service upfront

Answer 2

Prospective

Question 3

___________ Insurance for members of the US military, their partners, and dependents

Answer 3

Tricare

Question 4

_____ insurance plan that is federally administered

Answer 4

Medicare

Question 5

_____ insurance plan that administered JOINTLY by federal and state government

Answer 5

Medicaid

Question 6

______ special approval from primary care provider required by HMOs and POs insurance

Answer 6

Referral

Question 7

_________ is a synonym for universal health care

Answer 7

Single payer system

Question 8

________ payment from a source other than the patient

Answer 8

Third party payer

Question 9

______ lump insurance payments based on specific pt diagnosis

Answer 9

Diagnosis related group (DRG)

Question 10

_________ insurance type that providers free or low-cost preventative services in their plan

Answer 10

Health maintain organization (HMO)

Question 11

_______ insurance type that restricts pts to in-network providers. Out of network providers are costly to pt

Answer 11

Preferred Provider Organization, (PPO)

Question 12

_______ Financial incentives to providers and hospitals for providing quality care

Answer 12

Value based purchasing

Question 13

__________ payment for a service after the fact

Answer 13

retrospective

Question 14

__________ review required by some insurance companies before agreeing to pay for certain procedures or meds

Answer 14

prior authorization

Question 15

_______ state health insurance for children not covered by Medicaid

Answer 15

CHIPS

Question 16

1929: First group health coverage for a monthly charge for teachers in Texas; the beginning of _______________

Answer 16

Blue Cross/Blue Shield

Question 17

1965: ______________ programs, making comprehensive health care available to millions of Americans

Answer 17

Creation of Medicare and Medicaid

Question 18

In ______ employee benefit packages were first offered

Answer 18

1950s

Question 19

_____________ pay Not financially sustainable for government, or private insurers.

Answer 19

Retrospective

Question 20

Retrospective payment became an _____________ model for paying for care in the US

Answer 20

unsustainable

Question 21

Up until 1980, the _________ model was used. Doctors were free to order any test, any treatments. The more the better revenue for the doctors.
Medicare expenditures then increased rapidly
It ended because of the federal budget

Answer 21

Retrospective payment (free services)

Question 22

_____________ payment method is based on DRGs (diagnosis-related group)
The shift was critical for hospitals because medicare was the largest single payer for hospital charges

Answer 22

Prospective Payment Model

Question 23

Payment to the hospital is set based on this ____________, regardless of length of hospital stay or # of procedures/tests preformed

Answer 23

Diagnosis Related Group

Question 24

If hospital costs exceed the DRG payment, hospital incurs a loss; if costs are less than the DRG amount, hospital makes a ________

Answer 24

Profit

Question 25

Hospitals face a strong financial incentive to reduce _________ and minimize procedures performed

Answer 25

length of stay

Question 26

_______ serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability. Includes: foreign body left in during surgery, serious med errors leading to death or serious disability consequences, mismatched blood transfusions , wrong embryo implantation, death or disability after patient elopement, death or disability from electric shock, surgery wrong patient, wrong surgery, wrong body part, death or serious injury from air embolism, stage 3-4 pressure ulcer, maternal death in low risk pregnancy, infant death low risk delivery, death or injury from restraints,

Answer 26

Never events

Question 27

Hospital reimbursement for VBP & P4P based on: - Patient experience of care: based on the hospital’s scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), standardized patient satisfaction survey - Clinical processes of care: examples include: Discharge instructions for heart failure patients; fibrinolytic therapy received with 30 minutes of hospital arrival for a patient with strokes; antibiotics within 1 hour for sepsis…. - No pay for Never Events

Answer 27

Value- Based Purchasing (Pay for Performance)

Question 28

_____________, mandated by government. Measures frequency and is publicly reported ``` Communication with nurses Communication with doctors Responsiveness of hospital staff Pain management Communication about medicines Cleanliness and quietness of hospital environment Discharge information Overall rating of hospital ```

Answer 28

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)

Question 29

________ higher rated surveies mean better reimbursement for hospitals

Answer 29

HCAHPS

Question 30

Primary groups with no insurance

Answer 30

Working poor employed by small firms without insurance coverage Part-time workers and unemployed people Homeless Non-legal immigrants

Question 31

Underinsured and uninsured generate uncompensated care and “bad debt” for health care providers, who must then increase charges to paying customers in a process known as__________

Answer 31

“cost shifting”

Question 32

Provides affordable health insurance options through an insurance marketplace Requires U.S. citizens/legal residents to have a qualifying health insurance coverage or pay a penalty** Businesses with over 200 people must provide insurance via health insurance exchange options No lifetime caps or exclusions of people with pre-existing conditions. **Mandate (penalty for not having insurance) repealed in 2017, effective 2019.

Answer 32

Patient protection and affordable care act

Question 33

Largest single health insurance program in the United States | Entitlement program based on age or disability criteria

Answer 33

Medicare

Question 34

Joint federal and state-run program Low- income persons who are aged, blind, disabled, and certain families with dependent children Medicaid expansion: 14 states still have not expanded. Increases Medicaid to people at 138% of federal poverty level. Helped insure more people.

Answer 34

Medicaid

Question 35

A ferdal and state funded

Answer 35

Medicaid

Question 36

Children’s Health Insurance Program: Free or low-cost insurance coverage for children under 19 years

Answer 36

CHIPS

Question 37

Readmission: defined as admission to a hospital within

Answer 37

30 days of a discharge from the same or another hospital

Question 38

Value based purchasing (VBP) is ____________ method of reimbursing providers based on the quality of care provided with an emphasis on disease prevention and reducing complications

Answer 38

Pay-for-performance

Question 39

Purpose is to encourage hospitals to direct resources to preventing errors rather than being paid for them

Answer 39

Never events

Question 40

VBP better scores = ________

Answer 40

better reimbursement for the hospital

Question 41

Demonstrating the value of wellness and of teaching health consciousness e, dietary habits, sedentary behaviors, safety at home, and driving Some insurances will pay for gym memberships

Answer 41

Consumer empowerment

Question 42

Nurse is responsible for planning, organizing, and performing all patient care during the assigned shift Background - - Oldest method of organizing patient care, sometimes referred to as “case” nursing - -Nursing student typically performs total patient care for assigned patients

Answer 42

Total Patient Care

Question 43

Advantages of total patient care

Answer 43

RN maintains a high degree of practice autonomy Lines of responsibility and accountability are clear Patient receives holistic, unfragmented care Communication at shift change is simple and direct

Question 44

Disadvantages of total patient care

Answer 44

Number of RNs required is very costly Some tasks could be accomplished by a caregiver with less training and at a lower cost Nursing shortage will affect RN availability

Question 45

Total patient care is used in areas such as:

Answer 45

ICU and post-anesthesia care units

Question 46

Functional Nursing is when staff members are assigned _____

Answer 46

tasks for a group of patients rather than care for specific patients

Question 47

Lines of responsibility and accountability for functional nursing

Answer 47

RN assigns responsibility for completion of tasks to a group of licensed and unlicensed health care workers RN is responsible for planning care and supervising workers RN retains accountability for the patient care provided RN may have patient tasks as well such as IV med administration

Question 48

The cheapers nursing care delivery model is ___________

Answer 48

Functional Nursing

Question 49

Disadvantages of patient care for functional nursing

Answer 49

May be fragmented; possibility of overlooking priority patient needs Patient may feel confused because of many different care providers Caregivers may feel unchallenged when performing repetitive functions

Question 50

_______ Rn functions as a team leader and coordinates care for a small group of patients

Answer 50

Team Nursing

Question 51

Advantages of team nursing

Answer 51

High-quality, comprehensive care can be provided with a relatively high proportion of ancillary staff (can also be all RNs) Each member participates in decision making, problem solving Each member contributes his/her own special expertise or skills

Question 52

Disadvantages of team nursing

Answer 52

Continuity of care may suffer with daily team assignments Team leader may not have the leadership skills required to effectively direct the team Insufficient time for care planning and communication leads to unclear goals and fragmented care

Question 53

What is Primary Nursing?

Answer 53

Lines of responsibility and accountability - -RN primary nurse has 24-hour responsibility and accountability for patient care - -Primary nurse cares for patient when working - -Associate nurses are responsible for following the plan of care when primary ------nurse is off - -RN primary nurse is responsible for maintaining clear communication among all --members of the health care team

Question 54

Advantages of Primay Nursing

Answer 54

Direct patient care provided by a small number of nurses allows for high-quality, holistic patient care Patient able to establish a rapport with the primary nurse, and patient satisfaction is enhanced Job satisfaction high because nurses practice with a high degree of autonomy and feel challenged and rewarded Can be used adapted for Team nursing, total care models

Question 55

Disadvantages of Primay Nursing

Answer 55

Inadequately prepared primary nurse may not be able to make the necessary clinical decisions or to communicate effectively with the health care team RN may not be willing to accept 24-hour responsibility as required, especially when on night shift Common use areas: home health, hospice, long-term care, specialty inpatient units with “frequent fliers”

Question 56

Not a nursing care delivery model but a philosophy of care | Should be incorporated as an essential component of any nursing care delivery model

Answer 56

Patient-Centered care

Question 57

What is a case management?

Answer 57

---Collaborative approach to: provide and coordinate health care services identify and facilitate options and services for meeting health needs decrease fragmentation and duplication of care enhance quality, cost-effective clinical outcomes ----Nurse case manager “manages” a “case load” of patients from preadmission or admission to discharge. ---Does not provide direct patient care (like a primary nurse)

Question 58

__________ concept used in most health care organizations including health insurance companies, hospitals, and home care.

Answer 58

Case management

Question 59

__________ is generally reserved for the chronically ill; the seriously ill or injured; and long-term, high-cost cases

Answer 59

Case management

Question 60

___________ help people “navigate” the complex health care system (physicians, clinics, hospitals, outpatient centers, insurance and payment systems, patient-support organizations, etc.)

Answer 60

Patient Navigators:

Question 61

Transitional Care RN:

Answer 61

facilitate effective transitions for chronically ill patients to ensure good communication across settings and providers, appropriate follow-up, clear understanding of prescribed medications, assistance with referrals, and encouraging patients and families to take an active role in their health care

Question 62

Nurses of the future must conduct focused assessments and set priorities to resolve before the patient is quickly transitioned to another ________

Answer 62

level of care