Week 4: Paying Health Care Flashcards
_________ avoidable pt problems for which hospitals are not reimbursed by insurance
never events
______ payment for service upfront
Prospective
___________ Insurance for members of the US military, their partners, and dependents
Tricare
_____ insurance plan that is federally administered
Medicare
_____ insurance plan that administered JOINTLY by federal and state government
Medicaid
______ special approval from primary care provider required by HMOs and POs insurance
Referral
_________ is a synonym for universal health care
Single payer system
________ payment from a source other than the patient
Third party payer
______ lump insurance payments based on specific pt diagnosis
Diagnosis related group (DRG)
_________ insurance type that providers free or low-cost preventative services in their plan
Health maintain organization (HMO)
_______ insurance type that restricts pts to in-network providers. Out of network providers are costly to pt
Preferred Provider Organization, (PPO)
_______ Financial incentives to providers and hospitals for providing quality care
Value based purchasing
__________ payment for a service after the fact
retrospective
__________ review required by some insurance companies before agreeing to pay for certain procedures or meds
prior authorization
_______ state health insurance for children not covered by Medicaid
CHIPS
1929: First group health coverage for a monthly charge for teachers in Texas; the beginning of _______________
Blue Cross/Blue Shield
1965: ______________ programs, making comprehensive health care available to millions of Americans
Creation of Medicare and Medicaid
In ______ employee benefit packages were first offered
1950s
_____________ pay Not financially sustainable for government, or private insurers.
Retrospective
Retrospective payment became an _____________ model for paying for care in the US
unsustainable
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
Retrospective payment (free services)
_____________ 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
Prospective Payment Model
Payment to the hospital is set based on this ____________, regardless of length of hospital stay or # of procedures/tests preformed
Diagnosis Related Group
If hospital costs exceed the DRG payment, hospital incurs a loss; if costs are less than the DRG amount, hospital makes a ________
Profit
Hospitals face a strong financial incentive to reduce _________ and minimize procedures performed
length of stay
_______ serious, largely preventable, and of concern to both the public andhealth care providersfor 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,
Never events
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
Value- Based Purchasing (Pay for Performance)
_____________, 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
HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)
________ higher rated surveies mean better reimbursement for hospitals
HCAHPS
Primary groups with no insurance
Working poor employed by small firms without insurance coverage
Part-time workers and unemployed people
Homeless
Non-legal immigrants
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__________
“cost shifting”
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.
Patient protection and affordable care act
Largest single health insurance program in the United States
Entitlement program based on age or disability criteria
Medicare
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.
Medicaid
A ferdal and state funded
Medicaid
Children’s Health Insurance Program: Free or low-cost insurance coverage for children under 19 years
CHIPS
Readmission: defined as admission to a hospital within
30 days of a discharge from the same or another hospital
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
Pay-for-performance
Purpose is to encourage hospitals to direct resources to preventing errors rather than being paid for them
Never events
VBP better scores = ________
better reimbursement for the hospital
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
Consumer empowerment
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
Total Patient Care
Advantages of total patient care
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
Disadvantages of total patient care
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
Total patient care is used in areas such as:
ICU and post-anesthesia care units
Functional Nursing is when staff members are assigned _____
tasks for a group of patients rather than care for specific patients
Lines of responsibility and accountability for functional nursing
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
The cheapers nursing care delivery model is ___________
Functional Nursing
Disadvantages of patient care for functional nursing
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
_______ Rn functions as a team leader and coordinates care for a small group of patients
Team Nursing
Advantages of team nursing
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
Disadvantages of team nursing
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
What is Primary Nursing?
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
Advantages of Primay Nursing
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
Disadvantages of Primay Nursing
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”
Not a nursing care delivery model but a philosophy of care
Should be incorporated as an essential component of any nursing care delivery model
Patient-Centered care
What is a case management?
—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)
__________ concept used in most health care organizations including health insurance companies, hospitals, and home care.
Case management
__________ is generally reserved for the chronically ill; the seriously ill or injured; and long-term, high-cost cases
Case management
___________ help people “navigate” the complex health care system (physicians, clinics, hospitals, outpatient centers, insurance and payment systems, patient-support organizations, etc.)
Patient Navigators:
Transitional Care RN:
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
Nurses of the future must conduct focused assessments and set priorities to resolve before the patient is quickly transitioned to another ________
level of care
