HE 210 Final Exam Questions with 100% Correct Answers | Verified | Latest Update, Exams of Advanced Education

Download HE 210 Final Exam Questions with 100% Correct Answers | Verified | Latest Update and more Exams Advanced Education in PDF only on Docsity! HE 210 Final Exam Questions with 100% Correct Answers | Verified | Latest Update What is Health?? - Correct Answer-"Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." It was adopted in 1946 and has not been amended since 1948 (WHO, 1948, p. 100). Many subsequent definitions have taken an equally broad view of health, including: A state characterized by anatomical, physiological and psychological integrity; ability to perform personally valued family, work, and community roles; ability to deal with physical, biological, psychological and social stress; a feeling of well-being; and freedom from the risk of disease and untimely death. Determinants of Health - Correct Answer-Genetic Inheritance, Physical Environment, Social Environment, and Health Behavior. Health Care as a Determinant of Health - Correct Answer- Primary, tertiary, and secondary care. PRIMARY is PREVENTING. Health care is concerning with Secondary and Tertiary. Secondary prevention is concerned with reducing the burden of existing disease after it has developed; early detection is emphasized. Secondary prevention activities are intended to identify the existence of disease early so treatments that might not be as effective when applied later can be of benefit. Tertiary prevention focuses on the optimum treatment of clinically apparent, clearly identified disease so as to reduce the incidence of later complications to the greatest possible degree. In cases where disease has been associated with adverse effects, tertiary prevention involves rehabilitation and limitation of disability. The health care system is less spent on primary care. The Population Served - Correct Answer-12.6% was Black or African American, 4.8% was Asian, and 10.2% was some other race, or two or more races. About 16% of the population was of Hispanic or Latino origin. As a percentage of total population, every racial and ethnic group increased between 2000 and 2010 except for non-Hispanic Whites There is also a broad range of social classes with large income differentials that are becoming wider over time Unfortunately, the United States has the greatest disparity between the rich and poor of all the Western European countries and Japan These disparities add to the complexity and fragmentation of the U.S. health care system through effects such as differential care, payment issues, cost sharing, and access problems. Age structure also affects the U.S. health care system. The population forecast for the year 2020 undoubtedly foreshadows major changes on the A variety of medical products, including equipment and pharmaceuticals, are required in the health care system. They are generally categorized as prescription drugs, the largest of the categories; durable medical equipment; and other nondurable medical Organization of the U.S. Health Care System - Correct Answer-There is not a single national structure for paying for or operating the health care system. The federal government plays an important role, but the states do, too. There is no single-payer system. Rather, the system is a mix of private and public organizations providing, paying, and to varying extents setting policy for health care at every level of the system. In the United States, each of the three levels of government — federal, state, and local— provides leadership and governance directly and indirectly through the regulation of the delivery of health services, their suppliers, and payers with the opportunity to drive market shifts through the operation of their own health services delivery and payer programs. The principal health agency of the U.S. federal government is the Department of Health and Human Services, headed by a cabinet-level secretary. The agency is responsible for the federal Social Security program, the federal role in the state- run public assistance programs, and the main federal programs in biomedical research, regulation, financing, and public health. Many of the department's responsibilities are met by allocation of money and delegation of authority to the many other public and private entities throughout the nation that are concerned with health matters. In each of the 50 states, there is a major health agency that is part of state government. As at the federal level, in some states the agency is combined with agencies for social welfare or other functions. The administrative configuration and scope of functions of the state health care agencies are highly variable. The heads of these agencies are ordinarily appointed by the state's governor. Administratively, they are responsible entirely to the governor and not at all to the Department of Health and Human Services. Only insofar as certain s Types of Health Service Provided - Correct Answer- Primary: Common forms of personal preventive measures are the promotion of personal lifestyle/behavior change (e.g., becoming a regular exerciser), immunization, prenatal care, and periodic health examination for early disease detection. Most of the major causes of acute and chronic morbidity (sickness) are treated in the primary care setting. As of 1996 (the most recent year for which the following data were available at the time of writing), the major causes of acute and chronic morbidity were respiratory conditions, influenza, the "common cold," injuries, other infective and parasitic diseases, hearing impairment, chronic sinusitis, arthritis, hypertension, heart conditions, orthopedic impairments (including low-back pain), and asthma and hay fever. Secondary and Tertiary: Secondary care (the most difficult level to define) includes services that are available in both community hospitals and physicians' offices. Ideally, secondary care is arranged through referral or consultation after a preliminary evaluation by a primary care practitioner. Secondary services include most surgical procedures and the common diagnostic and treatment interventions of such specialists as radiologists, cardiologists, and ophthalmologists. Tertiary care consists of highly specialized diagnostic, therapeutic, and rehabilitative services, requiring staff and equipment "that transcend the capabilities of the average community hospital" (Rogatz, 1970, p. 47). Such care, available largely at major medical centers, includes organ transplantation, open-heart surgery, and other technically complex procedures, complex chemotherapy and radiotherapy for cancer, and the preservation of very-low-birth-weight premature infants. In the United States, both secondary and tertiary health services are highly developed. That development has not always occur Health Care System Performance - Correct Answer-Quality, Equality, Proficiency doctor in 1920 (Donabedian, Axelrod, & Wyszewianski, 1980). Most of these other personnel have skills learned through special training. Only about one fifth is "nonhealth care"—specifically clerical, custodial, or similar personnel. Physicians Historical Background - Correct Answer-The profession of medicine in America has changed dramatically over the course of history. The role, training, and expectations of pre-Revolutionary War physicians are practically unrecognizable to us today, The bulk of the practicing physicians in the colonies— including all of the independent New Englanders— were apprentice trained. Some had undergraduate degrees, whereas others were no more than 15 years old when starting their medical careers. Benjamin Rush noted that the only prerequisite for a "doctor's boy" was the ability to stand the sight of blood! His teacher was likely to be a prominent physician-surgeon, well qualified to guide the student through the maze of anatomy, osteology, the compounding of medicine, surgery, and the writings of Hippocrates. Toward the end of the 3- to 6-year apprenticeship, the doctor's boy was doing his own bloodletting, tooth-pulling, wound dressing, and some minor surgery. His certificate of proficiency gave the same practicing privileges as a medical student from the continent. Physician Licensure - Correct Answer-In the United States, the medical license is granted by the states. To qualify for a medical license in New York State, for example, one must hold an MD or DO (doctor of osteopathic medicine) degree or its equivalent from a school meeting the state education department's requirements; have certain postgraduate (residency) practice experience; pass a medical licensure examination as designated by the department; be a citizen or resident alien; be of "good moral character"; and pay a fee. In our time, few medical school graduates enter practice before completing at least 3 years of residency training. Private Medical Practice - Correct Answer-Overall, 67.9% of visits were made to physicians who were owners of the practice. More visits, 80.4%, were to practices that were either owned by a physician or a group of physicians than other ownership arrangements. Over one-half of office visits (56.6) were made to physicians who were part of a group practice, defined as having three or more physicians (NCHS, 2015b, Table 2). The percentage of U.S. physicians who own their practices has declined over the past two decades. The percentage of physicians practicing in independent, solo, or smallgroup practices declined, whereas the percentage of physicians practicing in larger practices increased. The percentage of physicians practicing in independent or solo practices declined from 37.2% in 2000 (NCHS, 2002 Table 2) to 31.5% in 2010 (NCHS, 2015b, Table 2), whereas the percentage of physicians practicing in larger practices (two or more) increased from 61.5% in 2000 to 68.1% in 2010. About one fifth, or 22.6 % of visits occured in multispecialty practices, and 45.8% were to single-specialty practices in 2010. The remaining 31.5% of office visits were to solo practitioners The trend toward group practice and away from physician ownership is especially true for younger physicians. Among the reasons for this mode of employment that younger physicians find attractive are receiving a regular income and comprehensive fringe benefits; the provision of medical malpractice insurance by the employer; regular hours and regular night and weekend coverage schedules; avoiding the difficulties associated with entering into private practice in many desirable living areas, many of which have an over- abundance of physicians; avoiding the high costs of starting a private practice, a particular burden to so many of today's new physicians who start professional life with a large debt accumu Patterns of Practice - Correct Answer-An important feature of medical practice organization in the United States is that most physicians see patients both on an ambulatory basis and as hospital inpatients. (A small percentage of doctors do not have hospital appointments. Another small percentage belongs to the growing subspecialty of "hospitalist," physicians who, usually working for the hospital, see only hospitalized patients; also see the later discussion.) In most healing ■ ■ Attention to the range of human experiences and responses to health and illness within the physical and social environments ■ ■ Integration of objective data with knowledge gained from an appreciation of the patient's or group's subjective experience ■ ■ Application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking ■ ■ Advancement of professional nursing knowledge through scholarly inquiry ■ ■ Influence on social and public policy to promote social justice. Categories of Nursing Education - Correct Answer-There were about 2.6 million active RNs in the United States in 2013, up from 2.2 million in 2001 (NCHS, 2015b, Table 96). In addition, there were 113,000 nurse practitioners, 35,000 nurse anesthetists, and 5,460 nurse midwives in 2013, who would formerly have been counted in the active RN category, but who were given their own categories starting in 2010. In 2010, close to 1.3 million of RNs had associate degrees or hospital-based nursing school diplomas, about 731,000 had baccalaureate degrees, and almost 235,000 had graduate degrees. The RN/population ratio was about 860 per 100,000 in 2010. There are three major groups of nurses: RNs (including nurse midwives, nurse pracp0485 titioners, and nurse anesthetists), licensed practical nurses (LPNs), and nurses' aides. RNs have the highest level of education, the most responsibility under the states' nurse practice acts, and the most authority. Generally, LPNs and aides function under the supervision of an RN. "Registration" in nursing was originally a voluntary function of the nursing profession. It now means licensure by the states, at a significantly higher level of responsibility and authority than that accorded to the "licensed practical" nurse. To be an RN, one must have a high school diploma and a diploma from a hospital-based programor a bachelor of science in nursing (BSN) degree from a college or university, or, since 1952, an associate degree in nursing (ADN) from a 2-year college program. An increasingly prevalent accelerated nursing program enables those with degrees in other fields to change to a nursing career. There are also traditional master's and doctoral programs for RNs. The master's degree in nursing (MSN) is the preferred preparation for nursing leaders and advanced practice registered nurse (APRN) preparation is preferred for positions with prescr From Nursing Shortage to Nursing Oversupply, and Back Again - Correct Answer-Nursing shortage started from poor working conditions, poor pay, poor professional image (Probably from tv lets be honest), and problems with the doctor nurse relationship, and better opportunities. They started creative solutions called 12 hour shift. They also closed hospitals and merged them to solve some problems since many nurses started to retire or leave. The University of California's Pew Center for the Health Professions (CHP; 1999) predicted that 200,000 to 300,000 hospital nurse positions could be eliminated by the year 2000. Suddenly, a vast surplus appeared to be on the horizon. They then again has a problem hiring nurses in 2001. Also due to the baby boomers needing help but many nurses did not want to work or many new nurses did not want to apply to school due to job dissatisfaction and retention. IN 1999 CALIFONRIA ELIMINATED NURSE TO PATIENT RATIO!!!! THIS IS NOT GOOD!!! Nurses in Expanding Roles - Correct Answer-Nurses in advanced practice, the nurse practitioners or advanced practice nurses, can provide primary ambulatory care, normal pregnancy care and delivery, and routine anesthesia at least as well as physicians. In each instance, the initial informal efforts to create a new arena for nursing were followed by the establishment of standards, formal curricula in approved programs, and, more recently, the preparation for advanced levels through master's and doctoral degree programs in universities. The development of each new form of and forum for nursing was also accompanied by a serious struggle for acceptance, especially within the medical profession. This was especially true if the new form was or could be taken to be in economic competition with physicians. (APRNs)—RNs with specialized training and advanced degrees— has risen from about 30,000 in 1990 to about 140,000 in 2010. In addition, APRNs are considered to be less rushed and more holistic in their approach to deployment of all resources, basic as well as specialized, directed at promoting, maintaining, and improving health. [Primary care is] the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health needs, developing a sustained partnership with patients, and practicing in the context of family and community. Primary Care Functions - Correct Answer-Primary care and ambulatory care go together like apple pie and ice cream. This is so even though not all primary care is delivered in an ambulatory setting, nor is all ambulatory care primary care. Nevertheless, because they are in most instances closely associated, they will be covered in the same chapter. The primary feature of comprehensive primary care is its integrating role in medical practice. In the past, when nearly all medical services were rendered by a family's general p ractitioner, coordination was almost automatic. Today, a primary care doctor or team can still provide most of the care that is necessary most of the time. But in the context of modern medical knowledge and technology, organization and planning for such a practice must be undertaken. They are GATEKEEPERS. Primary Care Historical Background - Correct Answer- Despite these recommendations, in the United States, as physician specialization and subspecialization increased dramatically in the period following World War II, much of the ambulatory care provided in private offices and groups and in hospital outpatient departments became highly fragmented (Freymann, 1974). The need to restore continuity and coordination was recognized in the 1960s and led to a revitalization of the primary care concept Many of the health services entities called neighborhood health centers that developed in the 1960s and 1970s fostered the primary care approach, as did many of the original health maintenance organizations developed in the 1970s and 1980s. Nevertheless, in the 1990s, it was still the case that most people in the United States did not have access to comprehensive primary care, even with insurance. Primary Care Workforce - Correct Answer-■ ■ Assessment of total patient needs before these are categorized by specialty ■ ■ Elaboration of a plan for meeting those needs in the order of their importance ■ ■ Determination of who shall meet the defined needs— physicians (generalist or spe■ cialist), nonphysician members of the health care team, or social agencies ■ Follow-up to see that needs are met ■ ■ Provision of such care in a continuous, coordinated, and comprehensive manner ■ ■ Attention at each step to the personal, social, and family dimensions of the patient's problem ■ ■ Provision of health maintenance and disease prevention at the same level of importance as the provision of cure and rehabilitation Primary Care and the Health Care System - Correct Answer-Some observers believe that the level and quality of primary care provision serve as good markers for the quality of a nation's health care delivery system as a whole. Countries with better primary care tend to be countries that strive toward equity in distribution of health services and toward more equitable income distributions. Second, it is not the number of primary care physicians, or even the ratio of primary care physicians to specialists, that accounts for the differential effects of the health services across those countries. Rather, the differences are a result of how the resources are distributed, whether or not they are organized to achieve the functions of primary care, and whether they clearly specify the roles and interrelationships between primary care and specialist physicians. Discuss historical background of hospitals - Correct Answer- The most intensive care is provided in hospitals and, although less than 10% of the population will experience an overnight stay in a hospital, they accounted for the largest portion of U.S. health care spending (32%) in 2013 (National Center for Health Statistics [NCHS], 2015, Table 103). In this section, we provide an overview of the conditions typical and other substance abusers, the disruptive psychiatric patients, and prisoners. Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail. action?docID=4558160.Created from stclaircc-ebooks on 2021-02-12 09:55:20. Identify common structures of hospitals - Correct Answer- Each hospital's structure will follow based on the scale and different lines of business. A small, acute care hospital with half a dozen nursing units will necessarily have a different structure than a large, multistate integrated delivery system. Most commonly, hospital departments will fall into a few divisions: ■ ■ Administration: including common corporate functions, such as finance and human resources ■ ■ Nursing: clinical departments such as inpatient nursing units ■ ■ Ancillary services: other clinical departments, such as cardiology and radiology, which may serve a mix of inpatients and outpatients ■ ■ Support services: facility services such as plant maintenance, housekeeping, and food service ■ ■ Outpatient services: typically ambulatory clinics and other outpatient-only departments. By Joint Commission standards, there should be three leadership groups: a governing body (typically a "board of directors"), a chief executive and other senior managers (often referred to as the "C-suite"), and the leaders of the medical staff. The medical staff should be both accountable to the governing body as well as self-organizing. Beyond that, Joint Commission standards require a chief nursing officer to whom all nurses have at least a dotted-line reporting relationship. Practically speaking, the organization must have a designated chief financial officer and supporting finance function. Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail. action?docID=4558160.Created from stclaircc-ebooks on 2021-02-12 10:32:29. Discuss who impacts direction, control and governance of hospitals: Modules - Correct Answer-Hospitals have three main entities that influence their direction, control, and governance: The Board of Trustees is ultimately responsible for all of the activities of a hospital. It is their job to set policy, hire an administrator to carry out that policy, and approve all physician admitting privileges. In addition, they play a large role in developing political and community liaisons. Administration carries out all policies and manages the hospital in accordance with all regulations in a safe, efficient, and cost-effective manner. The medical staff admits patients to the hospital and then orders/performs tests/procedures using hospital services. These test/procedures may also be done in an outpatient setting. Obviously without patients, a hospital does not need to exist, so patients are extremely important. In addition to the above components, hospitals employ many people for a variety of services. In fact, hospitals are usually a major employer in any community. For example, McLaren Port Huron Hospital is the second largest employer in Port Huron. Therefore, a hospital is very important to communities both as an employer and for economic survival when those employees spend their pay checks. Long-Term Care - Correct Answer-Chronic problems with the quality of long-term care provoke periodic exposés and outcries for reform (Eisen & Sloan, 1997; Pear, 2002). However, because any institutional care is expensive, the long-term solution to the long-term care problem probably lies with improved home-care services and significantly improved health promotion, disease prevention, and self- Hospital Outpatient Departments - Correct Answer-For a variety of reasons, most American hospitals traditionally have focused the bulk of their efforts and activities on inpatients who are acutely ill and confined to bed (Freymann, 1974). However, hospitals also have had to deal with other types of patients, with most classified as "outpatients." Hospital outpatients require either immediate treatment for an acute and sometimes serious illness or injury, or ongoing care for a more routine matter. Very often the services of the latter type are similar to those needed by patients who attend physicians' offices. In theory at least, there are two categories of hospital ambulatory services, corresponding to the two principal categories of patient needs: emergency services, provided by emergency rooms or EDs, and clinic services or OPDs. In the real world, overlap between the two categories of service is increasing. Patients, hospital staff, and hospital administrations, separately and together, are sometimes confused about the differences in role and function of the two categories. All three groups sometimes have trouble deciding which patients should go where for what. The original intended functions of hospital emergency service units were (a) to take care of acutely ill or injured people, particularly with life- threatening or potentially life-threatening problems that required immediate attention by personnel, or equipment not found in private practitioners' offices and (b) to offer prompt hospitalization if needed. Most hospitals have found it desirable or necessary (legally required in many states) to provide such services. In the past, it was easier for hospitals to determine that emergency services should be provided than that clinic services should be. One reason for this was that insurance companies were more likely to reimburse hospitals for emergency services t Neighborhood and Community Health Centers - Correct Answer-Health centers are characterized by five essential elements that differentiate them from other providers (HRSA, 2012): ■ ■ They must be located in or serve a high-need community, that is, "medically underserved areas" or "medically underserved populations." ■■ They must provide comprehensive primary care services as well as supportive services, such as, translation and transportation services that promote access to health care. ■ ■ Their services must be available to all residents of their service areas, with fees adjusted upon patients' ability to pay. ■ ■ They must be governed by a community board with health center patients constituting a majority of members. ■ ■ They must meet other performance and accountability requirements regarding their administrative, clinical, and financial operations. Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail. action?docID=4558160. Created from stclaircc-ebooks on 2021-02-12 12:21:01. Industrial Health Service Units - Correct Answer-"A range of industrial health hazards exist, from traumatic injury to occupational exposure to harmful substances (e.g., silica, asbestos, and lead). The number of "in-plant" health units in the United States is not known, but there are thousands of them. In small plants (fewer than 100 workers), health services are ordinarily quite rudimentary. They are often limited to a first-aid kit and arrangements with some local health facility to which injured workers may be sent. Very large plants (with more than 2,500 workers) usually have some systematic in-plant health service. Customarily, it is staffed with trained industrial nurses and part-time or full- time physicians. In a few companies, in-plant health services are comprehensive, providing employees with complete medical care for all disorders, job connected or not. The long-term trend in American industry is toward greater concentration of production in fewer large corporations. Although at one time it seemed that concentration might enhance the prospects for improving occupational health programs, in the 1980s there were reductions in service in many large corporations in the name of cost savings (D. Parkinson, personal communication, October 25, 1990). This situation may be changing because of increasing recognition Goldsteen, Raymond L., et al. Jonas' Introduction to the U.S. Health Care System, 8th Edition, Springer Publishing Company, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/stclaircc-ebooks/detail. action?docID=4558160.Created from stclaircc-ebooks on 2021-02-12 12:30:33. Mental Illness Historical Perspective Module - Correct Answer-Mental illness has always carried with it a negative stigma in our country, probably because people are afraid of it. In past years most people with mental illness were hidden away from the public in various places. Then the Quakers became involved to try to provide kinder custodial care - this era was known as the "Moral Era". Later we had the "Biological Era" where the emphasis was to treat mental illness like a physical disease by trying to stop the symptom. They used various methods of "shocking the nervous system" to stop the symptoms i.e. deep sleep therapy, insulin shock therapy and electroshock therapy. The 1950's "Institutional Era", was the time when our state mental hospitals were packed with patients. The only real treatment during this time was administering psychoactive medications to the patients-like Thorazine. These medications controlled the behavior and kept people from reacting to the overcrowded conditions. In 1955 a governmental committee-Joint Commission on Mental Illness and Health- was established and began to address quality of care and access to care. The federal government continued its involvement in the 60's and 70's. One result of this was that the federal government decided that individuals should be sent back to their communities for treatment rather than be housed in state mental hospitals (deinstitutionalization) - make sure you go to the article link at the top of the page under Module Requirements and review this concept. Thus, from the 70's until the present the majority of mental health services have been provided in communities through community mental health centers and other programs. The focus of all these programs is with severe mental illness. Focus Points psych Module - Correct Answer-Mental illness is associated with increased occurrence of chronic diseases such as cardiovascular disease, diabetes, obesity, asthma, epilepsy and cancer. Mental illness is associated with lower use of medical care, reduced adherence to treatment therapies for chronic diseases and higher risks of adverse health outcomes. Many people suffer from more than one mental disorder at a given time. Nearly half (45 percent) of those with any mental disorder meet criteria for two or more disorders, with severity strongly related to co-morbidity. Mental disorders were one of the five most costly conditions in the United States in 2006, with expenditures at $57.5 billion. Over 8.9 million persons have co-occurring disorders — that is, they have both a mental and substance use disorder. Access to treatment psych modules - Correct Answer-Up to one-in-four primary care patients suffer from depression; yet, primary care doctors identify less than one-third (31 percent) of these patients. Among the 8.9 million adults with any mental illness and a substance use disorder, 44 percent received substance use treatment or mental health treatment in the past year, 13.5 percent received both mental health treatment and substance use treatment and 37.6 percent did not receive any treatment. Four percent of young adults reported forgoing mental health care in the past year, despite self-reported mental health needs. People with psychotic disorders and bipolar disorder are 45 percent and 26 percent less likely, respectively, to have a primary care doctor than those without mental disorders. Depression module - Correct Answer-Major depressive disorder is the leading cause of disability in the U.S. for ages 15-44. Major depressive disorder affects approximately 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year. professionals who need up-to-date statistics and data sources around mental health and mental illness. However, these lists of reports and data tools are not exhaustive. The National Health Interview Survey (NHIS) has monitored the health of the nation since 1957. NHIS data on a broad range of health topics are collected through personal household interviews. For over 50 years, the U.S. Census Bureau has been the data collection agent for the National Health Interview Survey. Survey results have been instrumental in providing data to track health status (including mental health), health care access, and progress toward achieving national health objectives. The CDC: "The economic burden of mental illness in the United States is substantial—about $300 billi Resource allocation and provision of mental health services - Correct Answer-Payers of mental health services include private insurances, Medicaid, Medicare, V.A. Administration and some state/local programs. The problem here is while these insurances will pay, they will generally only pay for crisis management and stabilization of the client, therefore access to care for most clients is limited. Why do you think third party payers limit payment for services of mental health? (Length of treatment, difficulty in projecting outcomes). Is this OK? Moral? Ethical? Good business sense? Though your text doesn't address this, it is something important for you to think about. The following link will take you to a great reference for mental health services. Barriers to accessing care - Correct Answer-Limited insurance coverage has already been addressed as a barrier to accessing care. In addition, the stigma of mental illness prevents many people from seeking help; what are some others? Did you think of lack of transportation for care, lack of providers of care, denial of disease by patient and/or family, limited functional ability of patient? Providers of Care: Module - Correct Answer-The psychiatrist is a medical doctor focusing on diagnosing and treating the illness, using medical interventions. The psychiatrist can admit a client to an inpatient setting. The psychologist is also a doctor, but his/her doctoral degree is in psychology. This professional's focus in mental health is developing and interpreting psychological testing. These tests are given for a variety of reasons, but some help diagnose disease. Psychologists can treat clients, usually using counseling techniques. If medications are needed the client will be referred to a psychiatrist for medication management. Psychologists cannot admit a client to an inpatient setting. A psychiatric social worker is an individual whose education is in social work, with graduate work in psychiatric illness. This individual may treat clients with mental illness using counseling techniques. The mental health clinical nurse specialist has a basic nursing education in mental health nursing. These nurses can treat clients with mental illness, usually in group therapy but may also use individual counseling techniques. Registered nurses who work with mental health clients, usually do so in an inpatient setting and their main focus is administering and monitoring medication and addressing physical concerns. Mental health attendants/aides assist with physical care and supervision of clients in various settings. Primary care providers are usually considered "front line" in assessing and caring for those with non-severe mental illness. Structure - Correct Answer-■ ■ Administration: including common corporate functions, such as finance and human resources ■ ■ Nursing: clinical departments such as inpatient nursing units ■ ■ Ancillary services: other clinical departments, such as cardiology and radiology, which may serve a mix of inpatients and outpatients ■ ■ Support services: facility services such as plant maintenance, housekeeping, and food service ■ ■ Outpatient services: typically ambulatory clinics and other outpatient-only departments saying that health was a commodity to be bought, to be sold, to be conserved, or to be wasted. But he considered that health conservation was the responsibility of the individual, not of government. The local community was responsible only for the protection of its citizens against the hazards of community life. Thus government responsibility for health protection consisted of (a) promotion of sanitation and (b) communicable disease control. The Federal Constitution, as well as the Constitutions of most of the states, contains no reference or intimation of a federal or state function in medical care. The care of the sick poor was a local community responsibility from earliest pioneer days. This activity was assumed first by voluntary philanthropy; later, it was transferred, and became an official governmental obligation. (p. xiii) Nevertheless, the government at all levels — federal, state, and local— now plays a major role in the U.S. health care system. Although it is restricted compared wi THE HEALTH CARE FUNCTIONS OF GOVERNMENT: The Constitutional Basis of Governmental Authority in Health Care. - Correct Answer-It is argued that a very significant role for government in health care delivery is justified by the amount of money government spends on it. This says nothing about the calls for major reforms that could be undertaken by no agency other than government that echo down to us from the early 1930s and resonate in many voices today. But such a role has a constitutional basis as well. To understand government operations in the health care delivery system, it is to understand the structure of the government itself. 1 A basic principle of the U.S. Constitution is that sovereign power is to be shared between the federal and state governments, a principle called federalism . At its heart, the U.S. Constitution is an agreement among the original 13 states to delegate some of their inherent powers to a federal government, on behalf, not of themselves as separately sovereign entities, but of, as the Preamble to the Constitution says, "the people of the United States." As part of this agreement, in the Tenth Amendment to the Constitution, the states explicitly reserved to themselves the rest of the power: "The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people." Because it is not explicitly mentioned in the Constitution, among the powers reserved to the states is the "police power." It is the latter that forms the basis of the states' role in health (Mustard, 1945, pp. 17- 21). As Grad (2005) points out: In the states, government authority to regulate for the protection of public health and to provide health services is based on the "police power"— that is, the power to provide for the health, safety, and welfare of the people. It is not necessary that this power be expressly stated, because it is a plenary power that every sove The Legislative Branch - Correct Answer-At each level of government, federal, state, and local, the three branches of government have responsibility and authority for health and health services. Legislatures create the laws that establish the means to safeguard the public's health, in matters ranging from the assurance of a pure water supply to protecting the health of workers in their places of employment. The legislatures also enact the legal framework within which the health care delivery system functions, determining which individuals and institutions are authorized to deliver what services to which persons under what conditions and requirements. In the past, legislatures have imposed certain requirements for planning and development on the system, although in most jurisdictions that function has been minimized or has disappeared entirely. If the government is to participate in health care financing (see Chapter 5), directly deliver services, or support research efforts, the legislature must first establish the legal authority for those programs. The Judiciary - Correct Answer-The judiciary generally supports the work of the other two branches of government. The judicial branches at the three levels of government have important powers relating to health and health services. In the criminal law arena, working in concert with the law enforcement arms of the executive branches, under the authority granted to them by their respective legislatures, they can try apprehended transgressors of the criminal law the federal government's Veterans Affairs (VAs) hospital system or a municipal hospital serving primarily the poor. It also does this indirectly, for example, through the federal government's provision of grants to state governments to help pay for personal care in state mental hospitals and for the operation of the state's public health agencies at the community level. The states, in turn, indirectly support local governmental public health activities by providing money for that purpose. Second, through grants and contracts to nongovernmental agencies (and, in certain cases, other governmental agencies), governments support other types of health-related programs, for example, in biomedical research and medical education. Third, and this is by far the major role of government in financing, under such programs as Medicare and Medicaid, governments pay providers for the delivery of care to patients. As will be discussed in greater detail in Chapter 5, federal, state, and local public funds accounted for about 43.4% of national health expenditures in 2013, up from 35.5% in 2000 and 32.6% in 1990. Concomitantly, private business' contribution to the national health expenditures dropped from 24.6% in 1990 to 20.9% in 2013, and the household contribution declined from 34.9% in 1990 to 28.2% in 2013 (National Center for Health Statistics [NCHS], 2015, Table 109). The Federal Government and the Provision of Health Services. - Correct Answer-Many federal agencies are involved in the delivery of personal and community health serti0055 vices. The U.S. Department of Health and Human Services (DHHS) is the most important federal actor in health and health care. There are two other federal agencies with major health services responsibilities: the Department of VAs and Department of Defense (DOD). Other federal agencies with significant health-related responsibilities include the Department of Agriculture (nutrition policy, meat and poultry inspection, food stamps), the Environmental Protection Agency (EPA), and the Department of Labor (administering the Occupational Safety and Health Act). Department of Health and Human Services - Correct Answer-The central, though not only, federal agency responsible for health and health care in the United States is the DHHS. Its mission is "to enhance the health and well- being of Americans by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services" (DHHS, 2015a). Through 11 operating divisions, DHHS administers more than 115 health-related programs in a wide range of areas, including health and biomedical research, epidemiology and surveillance, disease prevention and immunization, food and drug safety, providing access to primary health care for certain populations, and bioterrorism response preparedness (DHHS, 2013). DHHS directly employs the full-time equivalent of approximately 77,865 people in 2015,and has a budget of $1,092.9 billion in 2016 (DHHS, 2015b). Out of the 11 operating divisions within DHHS, eight are components of the U.S. Public Health Service (Schmeckebier, 1923). There are three staff offices within the Office of the Secretary, which are also designated components of the U.S. Public Health Service and which operate to coordinate the agency's public health activities. These operating divisions and staff offices themselves each contain many subagencies and offices, administering hundreds of programs within DHHS. Table 4.1 lists the operating divisions and staff offices of the U.S. Public Health Service and their respective missions. As Table 4.1 indicates, the scope of activities and services undertaken by the DHHS is vast, and indeed, many of the identified subagencies and offices have their own branches and divisions, each with its own mission and program responsibilities. A comprehensive discussion of the activities and programs of the DHHS agencies is far beyond what can be accomplished here. W Substance Abuse and Mental Health Services Administration - Correct Answer-The Substance Abuse and Mental Health Services Administration (SAMHSA) works to improve the quality and availability of substance abuse prevention, addiction treatment, and mental health services. SAMHSA provides funding through block grants to state and local governments to support substance abuse and mental health services, including treatment for serious substance abuse problems or mental health problems; Child Care and Development (11%), Child Support (8%), LIHEAP (6%), Social Services Block Grant (SSBG; 3%), and Early Learning Initiative (3%). ACF has approximately 1,500 employees. National Institutes of Health (NIH) - Correct Answer- Through its multiple institutes, such as the National Cancer Institute and the National Heart, Lung, and Blood Institute, the National Institutes of Health (NIH) is responsible for supporting and carrying out biomedical research. Its primary mission focuses on basic biomedical research at the organ-system, tissue, cellular, and subcellular levels. NIH has its own (intramural) research program on its campus in Bethesda, Maryland, and provides funds for research at many other institutions around the country through (extramural) grants and contracts. NIH also fosters research by supporting training, resource development, and construction. Food and Drug Administration (FDA) - Correct Answer-The task of the Food and Drug Administration (FDA) is to protect the public against food, drug, and medical device and product hazards and to ensure drug potency and effectiveness. Thus, the FDA regulates prescription drugs and over-the-counter medications, biological products, and human blood and its derivatives. The focus is on the assurance of the efficacy and safety of a product before marketing and on the assurance of continuing quality after approval. Medical devices are regulated in a similar manner. Radiological equipment is also regulated, the goals being to control radiation exposure to the public as well as to ensure efficacy. The regulatory programs of the FDA, especially those focusing on the efficacy and safety of drugs and medical devices, are sometimes controversial. Industry spokespeople maintain that the entry of useful drugs to the market is at times unnecessarily delayed by a lengthy and expensive approval process. Supporters of that process recall, for example, the thalidomide disaster. Nevertheless, in the mid-1990s, the FDA did manage to introduce internal reforms, significantly speeding up the drug review process (MacPherson, 1996). Even so, there has been continued controversy over the FDA regulatory process since that time. For example, in 2005, Senators Samuel Brownback (R-KS) and James Inhofe (R- OK) introduced the Access, Compassion, Care, and Ethics for Seriously Ill Patients Act (S. 1956), which would make it easier for seriously ill patients to receive drugs that are not yet fully approved (GovTrack.US, 2006). In 2005, Senators Charles Grassley (D-IO) and Christopher Dodd (D-CT) introduced the FDA Safety Act of 2005 (S. 930), which established the Center for Post market Drug Evaluation and Research to address the problems of adverse drug effects after a drug has gone to market (Library of Centers for Disease Control and Prevention (CDC) - Correct Answer-The Centers for Disease Control and Prevention (CDC) is the national public health agency primarily responsible for prevention efforts. Its programs are aimed at preventing and controlling disease and personal injury, directing foreign and interstate quarantine operations, developing programs for health education and health promotion, improving the performance of clinical laboratories, and developing the standards necessary to ensure safe and healthful working conditions for all working people. Through the NCHS, the CDC collects and publishes a variety of vital health and health services data. It maintains the nation's reference laboratories and supports laboratory training programs. Indian Health Service - Correct Answer-The Indian Health Service serves Native Americans and Alaska Natives. It provides health care for about 2.2 million Native Americans and Alaska Natives, out of an estimated 3.7 million living in the United States (Indian Health Service [IHS], 2015a). In 2014, there were 44,677 inpatient admissions and 13.2 million outpatient visits (IHS, 2015b). The IHS is operated independently of other health care systems. "Most IHS funds are appropriated for American Indians and Alaska Natives who live on or near reservations or Alaska Villages (IHS, 2015a)." Congress also has authorized funding to support programs that provide some access to care for those who live in urban areas. Health services are provided eligible. The specific rules covering health care eligibility for the many classes of veterans are complex. They may be reviewed in detail on the VA website. A financial means test for certain classes was introduced by the Bush administration in 2003. The number of patients with service- connected disabilities treated in VA hospitals has been dropping over time, although with the advent of the Iraq war it is now again on the increase. The VA is the second largest federal department, with a workforce of over 327,000 employees. The VA operates the largest integrated health care delivery system in the United States and provides a wide range of primary and specialized medical care, as well as social services. Services and benefits are provided through a nationwide network of 151 medical centers, 300 veteran centers, 820 community-based outpatient clinics, 135 community living centers, 6 independent outpatient clinics, 103 residential rehabilitation centers, 139 integrated disability evaluation system sites, 131 cemeteries, State Government's Role in Health Services - Correct Answer-At the state level many different agencies are involved in health services. For example, in most states, departments other than the health department provide two of the important health-related functions managed primarily by the states: mental illness treatment services and Medicaid operations. Furthermore, the licensing authority for health personnel sometimes resides in the education department, vocational rehabilitation is often found in a special agency, occupational health in the labor department, environmental protection in a separate department, and school health with local boards of education. Most states also have a board of health, usually appointed by the governor, which has varying administrative, policy, and advisory functions. In the 1920s, political struggles with private practitioners led to a limitation of service responsibilities for both the state and local health departments (LHDs). Haven Emerson, a leading public health official of the time, defined the "Basic Six" services appropriate for departments of public health: vital statistics, public health laboratories, communicable disease control, environmental sanitation, maternal and child health, and public health education (Wilson & Neuhauser, 1976, p. 204). Some time ago, the Association of State and Territorial Health Officials (ASTHO) defined a state health program as [a] set of identifiable services organized to solve health related problems or to meet specific health or health related needs, provided to or on behalf of the public, by or under the direction of an organizational entity in a State Health Agency [SHA], and for which reasonably accurate estimates of expenditures can be made. (ASTHO, 1980, p. vii) Using this definition, ASTHO identified six program areas for SHAs: "personal health, environmental health, health resources, laboratory, Health Statistics - Correct Answer-Among the oldest of public health functions is the collection and analysis of vital and health statistics. Data on births, deaths, marriages, and divorces (the "vital" statistics), and incidence of the several reportable (primarily infectious) diseases, are collected by the local health authorities and forwarded to the state level. There they are codified and analyzed, often by various demographic characteristics, such as age, gender, marital status, ethnicity, and geographic location. Each state then forwards its collected data to the NCHS of the CDC for further analysis and publication. Licensing - Correct Answer-Licensing is a basic government function in health care. The licensing process for individual practitioners first establishes minimum standards for qualification. It then applies those standards to applicants to determine who may and who may not deliver what kinds of health services. Licensing of health care institutions sets minimum standards for each facility and their personnel as a group, applies the standards, and determines whether the institution may operate. The licensing authority is one of the most significant of the health powers residing with the states. The manner in which it is used is a major determinant of the character of the health care delivery system. The medical licensing system is particularly significant in that regard. Because no one can practice medicine without a license, the system has given physicians tight control over the central product of the health care delivery system, medical services. By exercising this control, physicians have largely determined the structure of the health care delivery system: how it is organized, the types and functions of the unnecessarily threatened as a result. Successes as great as those of the past are still possible, but not without public concern and concerted action to restore America's public health capacity. This [report] envisions the future of public health, analyzes the current situation and how it developed, and presents a plan of action that will, in the committee's judgment, provide a solid foundation for a strong public health capability throughout the nation. (pp. 1, 2) The committee's report is commended to those readers who are concerned with the future of public health in the United States. These observations are certainly still valid. If anything, the situation has gotten worse, as witnessed by the disorganized response to the 2001 anthrax outbreak. Summary - Correct Answer-Although government is heavily involved in health and health care in the United States, politics and the economic system significantly limit the degree of that involvement. Government provides the legal underpinning for the system through the licensing laws. It regulates the financial workings of the system and its quality of care. It also regulates the causes of potential environmental and occupational hazardous exposures and the possible responses to them. In addition, government is a direct financier and a direct provider of service. It is preeminent in community health services and plays an important role in supporting health sciences education and research. Most health care providers of both the individual and corporate variety recognize (often grudgingly) the reality that government is already heavily involved in the health care system. As noted, they welcome participation in certain critical areas: licensing; care of the mentally ill, the tubercular, and the poor; and community health services. SQ 1) What are the primary concerns of those who oppose an expanded role of government health care? - Correct Answer-In the book it stated that the Government had some role but its services are known as "Police Power" that is used for the health and safety of the people to help the people with medical needs and to ensure that the people are getting what is needed in their medical life. Although there is the "Police Power" the government also made another thing known as the local government to help ensure that the people are receiving the help they need. This came down to a separation of powers so that the government could not get to involved. The primary concern was that the government may get to involved and steal some of the money. Therefore there is a separation of powers. There was a court trial stating that the Government could stay involved with just the 2 powers with the Federal legislative and the executive branches staying in the checks and balances. Another concern was that the government sometimes "blurs" their powers and delegates to ensure that they stay in some sort of power. SQ 1) Based on the U.S. Constitution, what do you think the proper role of government in the health care and why? - Correct Answer-The U.S. Constitution does not state that there is a specific right to the health care system. But in my opinion, I think that there is some benefit to them being involved. I do think that there is some benefit to the government being involved. Such as with the Legislative branch ensuring that there is health care for everyone and protection to ensure that everyone has a right to some sort of health care. I think this is a proper role. I also agree that the Executive Branch should ensure that there is health care since the chapter states that the executive branch was the "government" of the chapter. Since it makes sure that everything is regulated. If the government was not involved there would not be certain things such as Medicaid to help insure that low income families would have universal health care. I think that the proper role of the government should ensure that everyone has access and the government has done some good in making it so that this is in place. I do not agree with some of the prices since it makes it hard for people such as diabetics to get the medication needed but there are some policies being put in place to make this happen. I do think that the government is slow moving in this but as long as they are taking action in some way I am happy. SQ 1) Describe the role of the Department of Health and Human Services in health care in the United States. - federal, state, and local governments. In many cases, several of these parties— patient, provider, and third-party payers — come together to pay a single bill. To use a typical example, a child might visit a pediatrician who would then receive a small "copay" from the mother ("out-of-pocket") during the visit. Then the pediatrician's office would bill a private insurance firm, which would pay some or the remainder of the bill. If the pediatrician is not fully reimbursed by the third-party payer, he or she would absorb the unpaid balance as charity care or forgiven debts. Very complicated relationships can enjoin three or more payers. In the United States, third-party payers (or "payers") are generally categorized as private or public. Within the private sector, private health insurance companies and outof-pocket expenditures are primary. Within the public sector, federal, state, and local governments all provide funding for health care. The public sector may act as a provider of services or as a third-party payer. For example, some health care programs are operated and paid for directly by the government: the federal Department of Veterans Affairs health care system, state mental hospitals, and Private Health Insurance - Correct Answer-The salient feature of private insurance in the United States is that most people obtain it through their employer (or spouse's or parent's employer). One can almost say that employers (and employees, through their contributions to health insurance premiums) are the true payers in this case and that private insurance companies are the administrators of payments. Outside of employer-sponsored plans, private health insurance can be difficult to obtain because of the inherent problems of moral hazard and asymmetries of information discussed earlier. For example, a "Standard Individual [not part of a group] Point of Service" insurance plan to cover a family starts at more than $4,500 per month with some options exceeding $8,000 per month in New York County, even though the benefits are not more generous than a typical employer plan, which would cost far less to the same family (New York State Department of Financial Services [NYSDFS], 2012). About 61.8% of Americans age 14 to 65 have some type of private health insurance coverage (National Center for Health Statistics [NCHS], 2015, Table 111). This is a decrease from 76.8% in 1984 and 71.5% in 2000. Generally speaking, insurance companies are either for-profit or nonprofit. Blue Cross Blue Shield (BCBS) has been a major private health insurer since 1929. The BCBS system consists of 36 independent and locally operated BCBS companies, a federal employee program, and an association that serves the collective needs of BCBS plans and covers more than 106 million people— one third of all Americans. The BCBS system is the nation's oldest and largest family of health benefits companies. Nationwide, more than 96% of hospitals and 92% of professional providers contract with BCBS companies— more than any other insurer. The BCBS Association (BCBSA) owns and manages BCBS trademarks and Out-of-Pocket Expenditures - Correct Answer-Out-of- pocket expenditures include direct payments to providers for noninsured services, extra payments to providers of insurance-covered or managed care-covered services that bill at an amount higher than the insurance/managed care company pays for that service, and deductibles and coinsurance on health insurance/managed care benefits. A deductible is a flat amount; for example, $200 per individual or $500 per family, that a health care beneficiary must pay out-of-pocket before the insurance company will begin paying for any health services received during some time period (usually a calendar year). Coinsurance is a share of the cost— for example, 20% of the payment for each service covered by insurance— for which the beneficiary is responsible. Under managed care, beneficiaries receiving health services from a provider of their choice within the plan (a so-called "point-of-service" arrangement) or out-of- plan entirely will usually pay for some or all of the excess charges out-of-pocket. Today, however, there are an increasing number of "luxury" managed care organization (MCO) plans, available at an extra cost above that normally borne by the beneficiary's employer. They provide for unfettered patient choice of physician, without prior authorization and without additional payment beyond the usual deductible or coinsurance. Out-of-pocket expenditures accounted for about 12% of national health care Therefore, to receive Medicaid coverage, unlike Medicare coverage, a person must apply for it. Also, in contrast to Medicare, the Medicaid program then applies a series of income-level determinations to each applicant, thus "testing their means." Only those persons whose incomes and other assets fall below a certain level as specified by law or regulation (varying from state to state) are declared eligible for coverage. Medicaid is supported by federal and state tax levy funds and is administered by the states. Each state program is distinct and unique. Therefore, benefits and coverage vary widely from state to state. Like Medicare, Medicaid generally reimburses providers on a fee-for- service/episode-of-care basis, although in the mid-1990s managed care was introduced into the Medicaid program, as it was to Medicare, and each year the proportion of fee-for- service beneficiaries has been declining. Title XIX, as amended, requires a state to provide a set of 14 services in order to be eligible to receive federal funds for its program, with a very complicated set of requirements governing just who may be considered eligible for Medicaid and who may not. The 1996 Welfare Reform Act has had a major impact on Medicaid because of its elimination of the Aid to Families with Dependent Children (AFDC) program, the principal welfare program in the United States since the time of the New Deal. A combination of low income eligibility requirements and low fees paid to providers (many of whom have therefore chosen not to particip Chips - Correct Answer-Created as the State Children's Health Insurance Program by the Clinton Administration's Balanced Budget Act (BBA) of 1997, the Children's Health Insurance Program provides health coverage for uninsured children who are not eligible for Medicaid. It is jointly financed by the federal and state governments and administered by the states. Within broad federal guidelines, each state determines the design of its program, eligibility groups, benefit packages, payment levels for coverage, and administrative and operating procedures. SCHIP provides a capped amount of funds to states on a matching basis for federal fiscal years (FYs) 1998 to 2007. Federal payments to states are based on state expenditures under approved plans. "Though an optional program, all states expanded coverage under SCHIP, with an estimated 6.7 million children and 700,000 adults enrolled in SCHIP at some point during 2006" Where the Money Goes - Correct Answer-NHE are calculated by the CMS, Office of the Actuary, National Health Statistics Group. NHE comprise the following two major categories: (a) Health Consumption and (b) Investments, a category made up of Research and Structures and Equipment. Most expenditures fall within Health Consumption, and most of these are for personal health care (hospital care; physician and other professional services, including dentistry; nursing home and home health care; and medical products, including prescription drugs and durable medical equipment). Complementary and alternative medicine (CAM) is included under Other Professional and personal health care Services, and vitamins and minerals supplements are included under other medical products. The other two categories within Health Consumption are: (a) Government Administration and Net Cost of Health Insurance; and (b) Government Public Health Activities. NHE does not include expenditures for a much broader definition of health care that might include (nonmedically supervised) dieting and weight loss, health and fitness clubs, sporting goods and related recreation, and healthy foods. How does the United States spend its health care dollars? Figure 5.1 provides an overview. In short, hospital care is the largest single category at 32% of total, followed by physician and clinic care at 20%, and prescription drugs at 9%. Then about 22% went for all other clinical and professional care, nonacute facility care such as skilled nursing facilities, and durable and nondurable equipment. Administration (including both government and private insurance) is relatively high at 7% compared to the OECD country average of 3%, though not much higher than other multipayer insurance health systems such as France and Germany (OECD, 2011, 2015). How are NHE allocated by health condition and characteristics of Provider Payment Approaches - Correct Answer-In the health care market, professional services from physicians, therapists, dentists, and so forth accounted for 27% of time, which then must cover his vehicle, all his tools, any assistants he might employ, and so forth. Time and materials tends to be the system of choice in cases where the scope of work is not clear to either party. Per diem (by the day) reimbursement remains a very common payment method for hospitals (Kaiser Family Foundation, 2002). Although such a system encourages the hospital to work hard to minimize overhead expenses, payers will always worry that the hospital is not looking for ways to increase efficiency. Fee-for-Services - Correct Answer-The fee-for-service method is common when the scope of work is clear to both sides. It is the oldest form of payment for health services and the predominant system of paying physicians, dentists, and private providers in the Other Professional Services category of the NHE. For example, a dentist will typically have a set price for a cleaning and checkup. If additional services are needed, those will be performed at essentially published prices. In such a system, the risk of inefficiency is borne by the provider and the risk of bad advice is borne by the customer. Whether a root canal requires 1 hour or 2 hours to perform and whether or not a root canal is the best use of the patient's money, the dentist receives the same payment. The local market and the dentist's reputation drive the rates he or she can charge. According to some observers (Jonas, 1978; Roemer, 1962), in the past this piecework system was a major cause of many of the observed problems in the health care delivery system. Although the patient's risk that he or she overpays for a service is reduced, such systems do not reward the providers for better quality service. Nor do they reward the provider for steering the patient toward more efficient services. A frequent complaint is that preventive medicine is completely ignored. Fixed Price - Correct Answer-A service is called productized when it can be marketed or sold as a commodity, which implies that a fixed price will buy a known quantity of that service. Critically, the known quantity is a customer-centric outcome (or in the case of health care, treatment of a disease or condition on a per-episode basis). This can be compared with the provider-centric fee-for-service system, which focuses on what the provider does, whereas a fixed-price, productized approach is nominally focused on the condition presented by the patient. The PPS was adopted for Medicare by the federal government in 1983 for Medicare Part A benefits (i.e., payments to hospitals) as a way to control costs. It can be seen as forcing productization on the hospitals— at least with respect to the patients covered by Medicare. With PPS, the hospital is paid a predetermined rate for each Medicare patient based on the patient's presenting condition. Each patient is classified into a DRG, a preset list created by the CMS. Except for certain extremely high-cost patients, the hospital receives a flat rate for the DRG, regardless of the volume of actual services provided to a patient. CMS's DRG system historically covered only acute care and only the hospital or facility-related charges. Charges from providers received pre and post discharge, even if related to the episode of care, have been billed separately. Recently there has been a movement to bundle patient and episode-of-care payments for the most well- understood treatments such as joint replacements. In such a system the provider is rewarded for how efficiently the patient is treated. Quality is emphasized to the extent that it affects the efficiency of the treatments for the initial diagnosis. The negative side of this type of system is that it intrinsically rewards providers who exaggerate the reported Capitation - Correct Answer-Capitation is a fixed prepayment per person to the health care provider for an agreed-on array of services. The payment is the same no matter how many services or what type of services each patient actually gets. In theory, such a system encourages the selection of the least expensive treatments as well as promotes services likely to result in the lowest overall cost during the contract period. However, such a system has no reinforcement for promoting the long-term health of the patient. With capitation, providers are likely to be rewarded for enrolling patients least likely to consume many health services, that is, the healthy. One can also see global budgeting (a payment method common to government-run facilities) as a simplified form of capitation— one with only one payer. The provider receives a global budget, which must cover all costs of treatment needed by the eligible population. This is the common way of paying for Veterans even when the payment methods match (e.g., the patient and the provider operate under a fee-for-service contract), either side may wish to use an intermediary. The introduction of health savings accounts (HSAs) has essentially created an opening for a different type of institution in health care that starts to resemble something like American Express as opposed to United Health. So one sees banks— experts in low-risk, high-volume transactions such as managing payments for product purchases— entering the health care market. It should be noted that how we pay for health care has both short-term and long-term implications. The system of payment affects how the principals act in the system today, but also who and where the principals are tomorrow. There is no shortage of physicians in training who vie for residencies in dermatology or cosmetic surgery, but pediatrics is always in need. A simple capitation system will encourage physicians (and other providers) toward healthier patients. Similarly, a system rewarding outcomes may encourage physicians away from riskier cases. The challenge of rew Third-Party Payers Insurance (Risk Management) - Correct Answer-Who should pay for health care? As important as how we pay for health care is who controls the payments. Although ultimately all costs of health care are borne by the people, how the money gets from the people to the providers of goods (antibiotics, vitamins, wheelchairs, etc.) and services (physicians, hospitals, chiropractors) shapes the system. A system where people purchase directly from the providers, just as they purchase cars and hire mechanics, will be very different from one in which the people give their money to the government, which then maintains a health care system much like all governments maintain a military. Although most people do not need very much health care in a given year, any significant health care incident is likely to be very expensive. Severe illness can easily cost tens of thousands of dollars, and heroic measures (e.g., trauma and organ transplants) can easily cost in the hundreds of thousands of dollars. Some rare conditions can even cost into the millions of dollars to treat (Thomas, 2006; Zhang, 2006). A health care condition requiring $500,000 in treatment would exceed the lifetime income of most people and would be financially devastating for all but a small percent of the population. As noted earlier, whereas a significant number of people retain their health expenditure rank from year to year, a sizeable number do not. Therefore, most people desire some sort of insurance to protect themselves against wild swings in health care costs. As Glied (2001) pointed out, people do not buy health insurance to insure their health, but rather to insure their ability to pay for (and obtain) health care in the event that their health status changes. Historically, health insurance was intended to cover major medical events. Matching Different Provider and Patient Payment Approaches - Correct Answer-The other motivation for having third-party payers is to bridge the gap between how people want to pay for health care and how providers want to be paid. Although there is little need for a third-party payer in a case where a person wants to pay a fixed monthly amount for health care to a provider who is paid on a capitation basis and offers the entire range of medical services, in reality people do not usually have this option. More often, people obtain their health care from a variety of providers who may be operating under any one of those aforementioned models, and quite often an individual provider will offer services under multiple and differing charging models. A third-party payer adds value by converting a stream of monthly payments into a stream of service-driven or ailment-driven payments to providers. Maintaining a Network of Providers - Correct Answer-To maintain this conversion, the third-party payer maintains a network of providers with which it has negotiated contracts. These contracts detail which payment models will be used and what rates will be used, as well as other details common to commercial contracts. Price and Provider Expertise - Correct Answer-With the most extensive databases of patient visits, especially over time, third-party payers have the benefit of expertise. The databases of third-party payers are a wellspring of information for longitudinal studies and better cover? - Correct Answer-Key government programs are Medicare, Medicaid, and CHIP. Medicare was first founded in the 1960's and was a service for those who were 65 and older to help pay for medical expenditures. Medicaid covers the people who are not available for Medicare and CHIP. There is a variety of levels in Medicaid, Medicaid is a federal based program. There is different requirements for applicants to go through to see if they are eligible for this program. Chip pays for children who are not available for Medicaid. Payments are based on the expenditure and the plans that are approved. There is many kids in this program. SQ 3) Compare and contrast the six payment modes that are used to buy and sell health services? - Correct Answer-The six payment modes that are used to buy and sell health services. There is: cost/cost-plus, hourly or time and materials, fee-for-service, fixed price, capitation, and value. The cost/cost-plus method is known as reimbursement. Many hospitals think of this as the patients paying the service plus a little more so that the hospital can profit for the services provided. Some people enjoy this method since there is transparency and they know where the fee is coming from. Hourly or time and materials is what many have in offices since there is a fixed hourly rate. This works when neither party know what should be charged for the services provided. This is a common method in hospitals, and it decreases the overhead, but some patients do not like this method since the patient does not know if the hospital is working hard to decrease the time that the patient is there, or if they are trying to increase the amount of money that they are getting. Fee-for-service. This method is more common when both parties know the scope of practice unlike the hourly or time and materials method. This method is common, but it is thought that is comes with problems since the payer does not know if they are overpaying for the service. Also, some providers do not like this method since there is no reward for the provider. This ignores preventative medicine as well. Fixed Price method: This is where there is a known price for the service. This is compared to the fee for service method. This method was founded for Medicare. The provider can sometimes be rewarded based on how well they have done, but sometimes the providers take advantage of this and over state the condition. Capitation: This is a fixed prepayment per person. This works well in some cases since the payment is the same no matter the number of services or what type. This does not pr QUALITY OF HEALTH CARE - Correct Answer-Using the model originally developed by Avedis Donabedian, health care quality is assessed in terms of structure, process, and outcomes (Donabedian, 1980- 1985). "Structure . . . is meant to designate the conditions under which care is provided" (Donabedian, 2003, p. 46). It includes material resources, such as facilities and equipment; human resources, such as number and qualities of professional and support personnel providing health care; and organizational characteristics, such as (for individual facilities such as hospitals) nonprofit status, academic affiliation, and governing structure. Examples of structure-oriented questions are: What is the nurse-to-patient ratio on a hospital floor? What is the age of the facility? What proportion of a hospital's patients do not have insurance, are receiving Medicaid, or are covered by Medicare? Are the physicians in a practice salaried employees or paid on a fee-for-service basis? Process "is taken to mean the activities that constitute health care— including diagnosis, treatment, rehabilitation, prevention, and patient education— usually carried out by professional personnel, but also including other contributions to care, particularly by patients and their families" (Donabedian, 2003, p. 46). For example, a study of health care process might ask the following questions: Is infection control policy followed by the hospital staff? How long does it take for the primary care physician to receive the test results needed for diagnosis? How does the treating physician transmit information about a drug's side effects to the patient? What is the waiting time in the emergency room? How much time does a physician spend with a patient, on average, for an annual physical? What is the standard practice among the CLINICAL EFFECTIVENESS - Correct Answer-A major concept used in defining the quality of health care in the present era is the evaluation of its effectiveness , that is, whether the care produces the desired or intended result. This term is synonymous with efficacy . Assessing the effectiveness, or efficacy, of health care at the microlevel of physician practices, hospitals, and other health care settings is becoming increasingly evidence based, that is, based on scientifically valid, empirical research. One of the best and most well-known definitions of evidence-based medicine is from an article in the British Medical Journal (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996): Evidence- based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. (p. 71) Thus, the standards against which quality is measured are based on clinical research. Clinical outcomes research is the foundation of quality-improvement efforts at the microlevel. Beginning in the last decade of the 20th century, and funded by the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and other organizations, researchers have continually generated, updated, and published the results of clinical outcomes studies. These studies have then been synthesized by experts in the field, and the synthesized results are translated into clinical practice guidelines (or alternatively, clinical practice protocols). A standard definition of clinical practice guidelines was developed by Field and Lohr (1992): "systematically developed statements to assist practitione PATEINT SAFETY - Correct Answer-Another aspect of health care quality is patient safety. The patient safety movement of the 1990s led to a great deal of interest in improving the quality of health care delivery through the application of methods borrowed from other industries and pioneered by W. Edwards Deming. Deming was an American statistician, considered the father of the modern quality assurance movement. He developed his system following the end of World War II. Unable to get a hearing in this country, he went to Japan. His methods, designated Statistical Process Control (SPC) and Total Quality Management (TQM), strongly influenced the rebirth and eventual massive expansion of Japanese industry post- World War II. Patient safety has been defined by the Institute of Medicine (2000) as "freedom from accidental injury; ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximizes the likelihood of intercepting them when they occur" (p. 211). Therefore, patient safety encompasses all events and situations that result in accidental harm to patients, including medication errors, surgical mistakes, falls, improper use of medical devices, and nosocomial infection. The Institute of Medicine report, To Err Is Human (2000), has played a major role in bringing national attention to the issue of patient safety. The Report converted an issue of gradually growing professional awareness over a great deal of time to one of substantial public concern in a manner and pace unprecedented in modern experience with matters of healthcare quality. The epidemiologic finding that more than one million injuries and nearly 100,000 deaths occur in the United States annually as a result of mistakes in medical care came from studies nearly a decade old. But this was new information for the public, ORGANIZATIONS WITH MAJOR INFLUENCE ON HEALTH CARE QUALITY - Correct Answer-The following section describes the efforts of public and private organizations to improve the quality of health care in the United States. These efforts are increasingly collaborative. Many businesses that pay for the health care of their employees have banded together. Public initiatives are increasingly coordinated. And, private- public partnerships have developed. However, it is difficult to say which organizations are the most influential. Clearly, The Joint Commission and the Centers for Medicare & Medicaid Services (CMS), as one of the largest payers of health care services in the country, are extremely influential. However, private organizations and other public agencies have very important roles, as well. The impact of these significant