HP 353 Exam #1 questions well answered already passed, Exams of Nursing

Download HP 353 Exam #1 questions well answered already passed and more Exams Nursing in PDF only on Docsity! HP 353 Exam #1 questions well answered already passed What happens if someone can't pay the cost of someone coming in who needs emergency care? - correct answer ✔✔The hospital has to cover the costs. How does a hospital compensate for the costs it covers - correct answer ✔✔The way they compensate is by raising the prices of their services. 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. There are 4 primary determinants that can lead to premature death. These include - correct answer ✔✔1) Lifestyle and behaviors Smoking, opioid crisis 2) Genetics 3) Social and environmental factors Occupation (construction workers) 4) Medical care Access (can't afford copayments) What is the primary goal of a health care system? - correct answer ✔✔To enable all individuals to access HC that is cost effective and meets quality standards What are the strengths of the U.S. health system? (3) - correct answer ✔✔-Technology -Research -Medical training Weaknesses of the U.S. health care system (6) - correct answer ✔✔-financing -administrative costs -access -long term care insurance coverage -prevention -per capita cost Why is financing a weakness of the US health care system - correct answer ✔✔Financing is primarily employer-based as a fringe benefit Why are Administrative costs a weakness of the US health care system - correct answer ✔✔Lack of overall planning, direction, and coordination- Administrative costs in the U.S. are 300% higher than in Canada Why is access a weakness of the US health care system - correct answer ✔✔Access to health care is compromised for people with low socioeconomic status (income, education, occupation) Why is long term care insurance coverage a weakness of the US health care system - correct answer ✔✔Lack of long term care insurance coverage Why is prevention a weakness of the US health care system. - correct answer ✔✔Only 2.9% of health care dollars, $2.5 trillion in 2015 was spent on programs that focus on illness prevention Why is per capita cost a weakness of the US health care system. - correct answer ✔✔High per capita cost in contrast to low health outcomes ranking Total spending on health in the US in 2017= - correct answer ✔✔$9892/person What is a premium like? - correct answer ✔✔A membership cost The average annual premium for employment-based care in 2017... - correct answer ✔✔was $18764 why would we see an increase in out of pocket payments? - correct answer ✔✔in an effort to control premium costs What are the problems with Individual Private Insurance? - correct answer ✔✔Very Expensive More expensive than group rates What % of the population has Individual Private Insurance - correct answer ✔✔5% of the population In contrast to the consumer-driven development of health insurance in the European nations, coverage in the United States was initiated by... - correct answer ✔✔health care providers seeking a steady source of income The growth of Employment-Based Private Insurance - correct answer ✔✔WWII Wage and Price Controls prevented wage increases --Allowed growth of fringe benefits Unions began negotiating for benefits Employer premiums were a tax-deductible business expense Employee "benefit plan" was not taxable income Government subsidy of private health insurance = $200 Billion/yr The Great Depression Drove an initiative for... - correct answer ✔✔more hospital specific insurance plans to be developed American Hospital Association (late 30's) and Blue Cross impacts - correct answer ✔✔consolidation of plans, expanding prepayment plans across other states, allowing choice of hospitals Commercial Insurance Entry Competed with - correct answer ✔✔the Blues (Blue Cross/Blue Shield) Commercial Insurance introduced - correct answer ✔✔"Experience Rating" Experience Rating - correct answer ✔✔Setting of insurance rates on the basis of a group's actual health care expenses in a prior period. Who does experience rating benefit - correct answer ✔✔healthier groups Commercial insurance Overtook the Blues in what market? - correct answer ✔✔private health insurance California Medical Association in 1939 developed Blue Shield , an insurance plan to cover...? - correct answer ✔✔-physician services. Was in response to Great Depression where patients were not able to pay physicians as much for care The American Medical Association supported expansion of Blue Shield to other states Private Physician Insurance Community Rating - correct answer ✔✔same insurance rate for everyone in the area. Everyone in the plan pays the same premium "The most positive aspect of health insurance - that it assists people with serious illness to pay for their care - has also become one of its main drawbacks... - correct answer ✔✔- the difficulty of controlling costs in an insurance environment. With ______, the "invisible hand" of each individual's ability to pay holds down the price and quantity of health care. - correct answer ✔✔direct purchase Cost Control Prob lems in an Insurance Environment - correct answer ✔✔"Moral hazard" -Increased usage -Windshields Increase in provider (hospital, doctor, pharmacy, etc) fees charged to insurance companies -Due to third-party payment -Initially no direct impact on patient Windshields - correct answer ✔✔Nothing stopping someone Unnecessary use of healthcare insurance Reason for copayment -But now someone might have to get better in 30 days because that is all the amount of visits you're allowed. Or you have to pay $75 per visit but you need PT 2x a week. Government Financing Prior to 1960s - correct answer ✔✔was involved in municipal hospitals and dispensaries giving care to the poor Government financing - correct answer ✔✔Medicare A (1965) Medicare B Medicaid (1965) Medicare Advantage Program Part C & Medicare D (2003) "public insurance programs for privately operated health services became a major feature of health care in the US" - correct answer ✔✔Med A, Med B and Medicaid -Title XVIII to the Social Security Act -Hospital Insurance for over 65 who are eligible for Social Security --Disabled --Chronic Renal Disease - correct answer ✔✔Medicare - Part A Medicare - Part A Funding - correct answer ✔✔Social security taxes Government collects from employers and employees Physician (and other out patient) services insurance for people over 65 - correct answer ✔✔Medicare - Part B Medicaid RESULTS: - correct answer ✔✔More individuals covered Billions $$$$ new Medicaid costs Subsidies for people under the ACA that qualify due to - correct answer ✔✔income, age, # in family, where you live Masshealth= - correct answer ✔✔Medicaid State Children's Health Insurance Program - correct answer ✔✔Medicaid companion program (1997) -Low income requirement GOAL: increased coverage for children 2012: 9.4 million children Chip is funded through 2026 Impact of Government Programs - correct answer ✔✔Increased taxpayer (healthy middle-income employees) involvement in health insurance picture -Medicare (social insurance) for eligible beneficiaries -Medicaid (public assistance) for other beneficiaries Good News/Bad News of government funded programs - correct answer ✔✔"..improved financial access to care for some people but in turn aggravated the problem of rising costs." Rising Costs - correct answer ✔✔-In 2009, 46% of health care expenditures were financed by out of pocket payments and premiums (regressive financing) -In 1999, the poorest paid more than 18% of income on health care, richest paid 3% Health Care is Not - correct answer ✔✔a Normal Economic Market "Information Asymmetry - correct answer ✔✔Patients, providers, hospitals, and insurers know things that the others don't know Insurance as insulation - correct answer ✔✔Cost-sharing by insurance hides the real cost from consumers Conflicting interests - correct answer ✔✔Physicians may act as the patient's agent and also as someone who profits from provided care Tax subsidies - correct answer ✔✔Market is distorted by subsidies provided to employers and employees Failure of competition - correct answer ✔✔individual nature of insurance plans and hospitals keeps them from competing as market goods Suppliers are either legally or morally required to - correct answer ✔✔provide services Access to health care Definition: - correct answer ✔✔The ability to obtain health services when needed. Measurement of access: - correct answer ✔✔-Quantitative- The number of times people use health care services e.g. MD and clinic visits, hospital admissions, health outcomes -Qualitative- People's perception of whether they delayed care because of inability to obtain services What are the benefits of health insurance? - correct answer ✔✔-Increases access to care -Improves health outcomes Financial barriers to health care - correct answer ✔✔-Lack of Insurance -Underinsurance --Coverage limits --Deductibles and copayments --Medicare coverage gaps ----Medicare paid only 48% of the average beneficiary's expenses in 2006 --Lack of coverage for long term care Who are the uninsured? - correct answer ✔✔Employed uninsured -Low pay, part time, no health insurance Unemployed uninsured -Low income but ineligible for Medicaid Higher percentage people of color Lower annual household income Healthcare system trying to move working people off____ but it is expensive for those individuals. - correct answer ✔✔Medicaid what groups have the highest rates of Lack of access to health care - correct answer ✔✔- Hispanics:highest percent -People with incomes less than $25K -Part-time workers and unemployed workers looking for work -Small job firms- people in firms with less than 25 people Why Do People Lack Insurance? - correct answer ✔✔-Premiums for employer-sponsored health insurance increased by 160% between 2000- 2014 -Changing labor force ---Increased job layoffs and lack of insurance ---Slower economy causing many employers to decrease health benefits or shift increased percent of premium cost to employees. ---Shift from full time unionized workers to part-time low-wage non-unionized service and clerical workers -Unstable nature of employment Cost Sharing Outcomes - correct answer ✔✔Poorer health outcomes: e.g. People with hypertension with cost sharing plans had higher diastolic blood pressure What programs increase access to health care? - correct answer ✔✔1. COBRA 2. Medicare 3. Medicaid Cobra - correct answer ✔✔Consolidated Omnibus Budget Reconciliation Act of 1985 Cobra pros - correct answer ✔✔+ Guarantees insurance at group insurance rates for 18 months for people who lose insurance because of divorce, job loss, death of working family member, or when a child is no longer a dependent. Cobra cons - correct answer ✔✔- Premiums may be unaffordable Medicare pros - correct answer ✔✔+Medicare A: Provides inpatient hospital and skilled nursing care without premiums for people 65 and older or younger people who have a disability medicare cons - correct answer ✔✔-Enrollee must pay deductibles and coinsurance in both Med A and B -Medicare includes no long term care coverage -Outpatient services and equipment come under Medicare B and patients must pay premiums, deductibles, and coinsurance Medicaid pros - correct answer ✔✔+Provides funding for medical and health-related services for those people within broad federal guidelines at or below 138% of the federal poverty level . As of 2010, under the ACA, an individual with income of $15,856 would be eligible for Medicaid. +/- The Supreme Court ruled that states are not required to follow this rule in the ACA. Many states continue to establish their own eligibility standards and scope, amount, and duration of services and set service payment rates People with Medicaid +Generally have health care access intermediate between the uninsured and the insured +Compared to uninsured are more likely to have regular source of medical care, get more preventive services, report fewer delays in getting care medicaid Cons - correct answer ✔✔-not all providers accept Medicaid due to low reimbursement -Compared to insured,people with Medicaid are more likely to have trouble obtaining medical care, prescription drugs, dental care, and eyeglasses. +/- The Supreme Court ruled that states are not required to follow this rule in the ACA. Many states continue to establish their own eligibility standards and scope, amount, and duration of services and set service payment rates People with Medicaid Non financial barriers to health care - correct answer ✔✔-Primary Care Physician shortage -Physical distance between facility and patient- rural areas -Language, cultural incompatibility between provider and patient -Gender -Ethnic background Whitehall Study - correct answer ✔✔Investigated mortality rates of among British males civil servants ages 20-64 The Whitehall II Study, examined the health of 10,308 civil servants aged 35 to 55, of whom two thirds were men and one third women. Whitehall Study Results - correct answer ✔✔Results: There was a strong association between grade levels of civil servant employment and mortality rates from a range of causes. Men in the lowest grade (messengers, doorkeepers, etc.) had a mortality rate three times higher than that of men in the highest grade (administrators). Compared to White women, more minority women experience higher percents of - correct answer ✔✔Fair or poor health New HIV/AIDS cases Obesity Diabetes However, more White women experience a higher percent of smoking and serious psychological distress Fair or Poor Health in Minority Women - correct answer ✔✔Poverty No high school diploma No health coverage No doctor visit due to cost No personal doctor Minority women have a higher incidence of new HIV Aids cases Determinants that may help explain this problem. - correct answer ✔✔No personal doctor No doctor visit due to cost No checkup in the past 2 years Poverty No high school diploma Health Models Used in the U.S. System - correct answer ✔✔Medical Behavioral Holistic Medical model - correct answer ✔✔-Assumes the existence of illness or disease -Emphasizes clinical diagnosis and medical interventions to treat disease and disease symptoms -Definition of health assumes absence of disease or illness Behavioral model - correct answer ✔✔-Assumes that health results from interaction between the individual and the environment. -World Health Organization (WHO) definition Health is "a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity" Holistic model - correct answer ✔✔Philosophy of holistic health emphasizes the well-being of all aspects of a person's life and adds the spiritual dimension E.g. Surgery, Obstetrics Some recommend a similar payment system for all physicians Physician: Capitation - correct answer ✔✔A set amount (established rate) to cover a person's medical care for a specified time (per member per month) -Who takes on the RISK? -How can the RISK be lessened? Three Tiered - payment to intermediary group (IPA) --With financial risk for diagnostic and specialty services borne by IPA and spread across PCPs ---PAST: Bonus for use of specialists spread over group ---NOW: Bonus tied to quality measures in Pay for Performance ----Who takes on the RISK? Capitation: Primary Care Physician - correct answer ✔✔-Adjustments for financial risk -Carve-outs = Paid separately (limited reintroduction of Fee for Service) ---Type of services (i.e. immunizations, office tests, etc) ---Diagnosis or condition ---Minor surgical procedures Risk Adjusted Capitation (limit risk skimming) - correct answer ✔✔-Higher rate for higher risks pts. (i.e. elderly, chronic diseases) -Challenge/Problem of setting rates based on patient health risks Capitation: Merits - correct answer ✔✔-Better ability to plan, manage and control costs --Nurses/assistants can provide "virtual" visits -Improved care delivery- each patient has a Primary Care Physician -Stronger bargaining position to arrange best ancillary services and specialty service rates -Can provide care without uncertainty about how much and whether a service will be paid for Capitation Payment Models - correct answer ✔✔Two Tiered - --One tier is the Health Plan, the other the Primary Care Physician --U.S. - some HMO's, however 3-tiered HMO capitation is more common Physician Payment: Time - correct answer ✔✔-Salary - payment for time -Public sector - VA, military, state, community facilities -Private sector ---Staff model HMO - salaried physicians ---Group model HMO - has a capitation contract with the IPA who then pays a salary to physicians -----Who takes on the RISK? Hospital: Fee For Service - correct answer ✔✔Fee for service rates were based on "reasonable costs" In this era of cost containment, insurers are questioning "reasonable cost" and negotiating lower payments Are shifting to per diem, episode of illness, or capitation payments Who takes on the RISK? Hospital: Per Diem - correct answer ✔✔Daily Rates Bundling of services per day Reverses incentive of Fee For Service to do more Utilization Review (UR) by hospital & insurer What is the risk to the hospital? To the insurer? Hospital: Episode - correct answer ✔✔Diagnosis Related Groups (DRGs) --Medicare established in 1983 Lump sum for based on diagnosis --What is the risk to Medicare...to the hospital? Hospital: Per Patient - correct answer ✔✔Capitation payments Not common nowadays WHY??? Hospital: Global Budget - correct answer ✔✔Fixed payment for all services for one year --Kaiser Permanente --Veteran's Hospitals --Defense Department --Canada --European countries Who takes on the RISK? Telemedicine: Reimbursement - correct answer ✔✔As of 2015, 25 plus DC states have passed full parity laws that require insurers (and Medicaid plans in some states) to reimburse providers for services provided via video conferencing on the same basis as they would for in-person consultation. Reimbursement for Telemedicine through Medicare is still limited. Reimbursement trend is toward - correct answer ✔✔Value Based Purchasing Cost containment in the 90's focused on - correct answer ✔✔-Pressure to limit # & costs of services, with bundling of services into one payment, shifting risk to providers -Traditional FFS was then replaced by fee schedules and rate negotiations Cost containment now - correct answer ✔✔era of blended payments with negotiation between payers and providers and use of fee schedules for FFS Quality of care can be maintained with use of fewer resources -Research shows comparable outcomes for patients treated by General practitioners and Nurse practitioners It is not consistent with the health needs of the majority of the population "Common disorders commonly occur and rare ones rarely occur" -e.g. (URI, skin disorders, emotional disorders, preventive care needs) Is costly -Research shows that generalists in contrast to specialists practice a less resource intensive style of medicine -Costs are lower for patients treated by generalists vs. specialists after controlling for severity of illness. Access to medical records (diff. Hospitals can't check your medical records) Lacks coordination History of Health Care - correct answer ✔✔Traditional Fee for service practices -Physicians were in solo or small group practices, not hospital employees, controlled hospital admissions 1900s-1950s development of -Multi-specialty group practices -Prepaid group practices ---HMOs based on these Community health centers- Have helped to improve care of low income ambulatory patients -Generate income by billing patients and Medicare and Medicaid -Over 10 million people served in 2003 -Community health centers serve as safety nets Development of HMOs - correct answer ✔✔Pre-paid group practices- -Kaiser one of the first -Several variations of HMOs developed First generation HMOs Kaiser Permanente model - correct answer ✔✔A vertical integration model: consolidates all levels of care, staff, and facilities under one organizational ownership Does not cover an entire population but responsible for delivering all services to a population of enrollees Physician group practice provides care to members under a capitated plan. Enables a more population based model of health All under one roof Need a new health insurance plan to go outside of network Second generation HMOs • Independent Practice Associations • (IPAs) and Integrated Medical Groups (IMGs) - correct answer ✔✔Virtual integration: Hospitals and insurers recruit office based fee for service community physicians into an IPA creating a basis for an HMO and negotiate contracts with the physicians to provide care. Dispersed, more contracts IPA model -Allows insurers, etc. to respond to market changes by renegotiating contract bargains with providers -Has the advantage of low capital costs because the HMO does not have to own buildings Integrated medical group model -Physicians do not own their practices but the medical group organization employs them Why might a physician choose to work in an IPA model, an IMG model? Developed in California in response to potential threat from Kaiser moving into San Joaquin County Factors explaining HMO development - correct answer ✔✔HMO Act 1973 under Nixon's health care reform gave federal funds to promote expansion of pre-paid practices and IPAs --Medium and large business had to offer one HMO plan to employees IPAs grew- easier to organize than pre-paid practices --1980'90s IPAs took on more financial risk Some problems for providers and consumers: Gatekeepers used for cost containment, Physicians who see patients from several HMOs do not know which hospital or specialist can accept a patient HMOs showed cost savings in early years through lower hospitalization rates Conventional Health Maintenance Organization (HMO) - correct answer ✔✔Must have a primary care physician, who is responsible for your health care, making referrals to specialists and approving any medical treatment. HMO Emphasizes preventative care -Must pay a copayment for services. -Care received from caregivers outside the network in not covered. Pro- No paperwork, policy is relatively inexpensive, emphasis is on preventative care Con- May be limited in your choice of physicians and getting specialized care may be difficult. Managed Care: Point of Service (POS) - correct answer ✔✔Is a HMO hybrid An Organizational Solution - correct answer ✔✔Hospitalists -A physician whose primary role is to care for hospitalized patients and return them to their regular physicians at discharge. -Has grown in past 8 years from a few hundred to 8000; projected growth is 20,000 (about the same # of cardiologists in the country) (Wachter, 2004) A Solution for Complex patients: Patient- Centered Medical Home - correct answer ✔✔Characteristics PCP becomes source of first contact Care is person focused over time Comprehensive care Coordinated care when patients need outside specialist care Patient Centered Medical Home - correct answer ✔✔All patient needs are coordinated through a single center using bundled payments. High need patients are targeted, e.g. patients with chronic illnesses that require regular medical monitoring, advising, or treatment To qualify, a practice must meet standards and be certified Accountable Care Organizations - correct answer ✔✔Networks of physicians and other providers that are held accountable for the cost and quality of the continuum of care delivered to a group of Medicare patients. Organizational Reform - correct answer ✔✔Increases fees for primary care delivery Supports patient-centered medical home systems Organizational Reform: People System Skills - correct answer ✔✔Dr. Atul Gawande holds that people that work in effective systems develop "system skills". They are: 1- Interested in collecting, refining and understanding what data says about their performance 2- Have the ability to devise solutions for the problems that data uncovers 3- Have the ability to scale up...get everyone on the chain of care functioning in concert, in collaboration and disseminating new knowledge into practice Involves the belief that standardization or doing things the same way each time can reduce failures and it involves teamwork Organizational Reform: Community Health Centers - correct answer ✔✔Affordable Care Act improves access to care by increasing funding to community health centers and to the National Health Service Corps Establishes new programs to support school-based health centers Next steps: Medical Neighborhoods Services are functionally integrated similar to traditional - correct answer ✔✔- HMOs. PCP coordinates care. Patients are informed and involved. The coordinated care contributes to the health of a population. Medical Neighborhoods Are based on - correct answer ✔✔"Patient Centered Medical Homes" "Patient Centered Medical Homes" - correct answer ✔✔where the primary care physician is in charge of care provided by all people and places where care is provided including specialists, pharmacies, hospice, home health, nutritionists, etc. What forces could help push the U.S. health toward an integrated delivery system? - correct answer ✔✔1-An aging population- increase in chronic illness and greater demand for integrated care 2-Technology developments in biotech, bio medicine and pharmacology- will be able to better predict health needs of people and groups over lifespans 3-The empowered consumer- baby boomer generation will push for coordinated care 4-Payment innovations-system will be challenged to manage health within fixed sum of money -will push toward payment for prevention 5-Ability to partner- an internal response- recognition that all will share in the risk and we all must be accountable Optimal care Depends on developing a model of care that includes : (5) - correct answer ✔✔Appropriate level of care and practitioner roles Regionalization for some if not all services Effective patient progress through the system Greater integration and coordination of services Continuity of primary care