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NURS 104 > Unit 16: Financing Healthcare in US > Flashcards

Unit 16: Financing Healthcare in US Flashcards

1
Q

how is health care paid?

A

-direct out-of-pocket payments

-third-party public or private insurers

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2
Q

what is public insurance

A

government health programs: medicare, medicaid, veterans administration

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3
Q

who was primarily responsible for decision making

A

physicians: controlled access to health care services; tests or procedures were provided if physicians determined that any marginal benefit might be obtained

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4
Q

what was objective for financing health care

A

provide the best care to everyone

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5
Q

sophistication and cost of medical technology rapidly

A

increased

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6
Q

fee-for-service payment method and economic incentives contributed to

A

increased costs (retrospective)

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7
Q

patients were __________ because insurance was paying the bill

A

insulated from costs

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8
Q

the more tests and procedures performed, the _____________ because earnings tied to procedures

A

greater the physician’s earnings

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9
Q

what was created in 1965

A

medicare and medicaid

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10
Q

-comprehensive health care available to millions of Americans
-provides health insurance/coverage for people meeting certain criteria

A

Medicare and Medicaid

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11
Q

-largest health insurance program in the US
-entitlement program based on age or disability criteria rather than on need

A

Medicare

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12
Q

-covers primarily disabled persons, low-income households with children, and those in nursing homes who qualify on the basis of low income

A

Medicaid

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13
Q

Medicare costs began to _______

A

escalate

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14
Q

what did medicare influence

A

federal budget deficit

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15
Q

what happened in 1983

A

Medicare moved to a prospective payment system (PPS) based on diagnosis-related groups (DRGs)

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16
Q

-common method of reimbursement for health care services based on a predetermined fixed price-per-case or diagnosis

A

diagnostic related groups (DRG)

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17
Q

hospitals face a strong financial incentive to___________

A

reduce length of stay and minimize procedures performed

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18
Q

payment to hospital is set based on this DRG, _______________________

A

regardless of length of hospital stay or procedures/tests performed

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19
Q

previous health care financing

A

retrospective - fee for service

incentives for more tests/procedures

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20
Q

modern health financing

A

prospective payment system

incentive to reduce length of stay and minimize tests/procedures

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21
Q

private insurance companies began

A

Managed Care Organization (MCOs)

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22
Q

manage the use of health services:

A

-process in place to review and approve (or deny) coverage for treatment/procedures (in contrast to the previous “if it might help, do it” approach)

-goal is to minimize payment for inappropriate or excessive health services

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23
Q

types of managed care

A

Health Maintenance Organizations (HMO)

Preferred Provider Organizations (PPO)

Point-Of-Service plan (POS)

24
Q

The 1983 “revolution” in health insurance reimbursement that formed the primary method of reimbursement in today’s health care system was due to:

A

rapidly rising health care costs

25
Q

unpaid costs covered by those who do pay - increases insurance premiums

A

cost shifting

26
Q

federal and a state health care insurance plan

A

Medicaid

27
Q

-provides affordable health insurance options through an insurance marketplace
-requires U.S. citizens/legal residents to have a qualifying health insurance coverage or pay a penalty

(2010)

A

Patient Protection and Affordable Care Act (obamacare)

28
Q

addresses many issues including employer requirements, health insurance exchanges, and prevention and cost-reduction approaches

A

PPACA or obamacare

29
Q

-individuals/families with incomes up to 400% of the federal poverty level receive financial assistance to make health insurance more affordable

-employers with more than 200 employees must offer health insurance

A

ACA 2020

30
Q

offer individuals and small businesses qualified coverage at more affordable rates; the plan must cover specified benefits

A

state-based health insurance exchanges

31
Q

insurers cannot deny coverage for

A

pre-existing conditions or change higher premiums based on health status or gender

32
Q

medicare no longer will pay ______________

A

hospitals to treat hospital-acquired conditions (ulcers, infections, falls)

33
Q

what is one rationale in support for health care reform?

A

uninsured populations generate uncompensated care costs, leading to a process known as cost shifting

34
Q

out-of-pocket expenses

A

insurance premiums
deductibles
copayments

35
Q

responses to increases in family plan premiums

A

High Deductible Health Plans (HDHP)
Health Reimbursement Accounts (HRA)
Health Savings Accounts (HSA)

36
Q

how public insurance is paid:

A

generates 1/2 hospital revenues and more than 1/4 of physicians income

37
Q

how medicare is paid

A

-largest insurance program
-entitlement program - based on age or disability rather than need

38
Q

how medicaid is paid

A

-provides health insurance coverage to impoverished families, particularly those with children
-primary payer of long-term care nationwide
-fastest growing component of many states’ budgets

39
Q

new payment methods to control cost and quality

A

pay-for performance

never events

value-based purchasing

reducing readmission

40
Q

2008 - Medicare will no longer pay hospitals the extra costs for treating preventable errors

-encouragement to hospitals to prevent errors rather than being paid for them

A

never events

41
Q

hospital reimbursement for value-based purchasing is based on:

A

-patient experience of care: based on the hospital’s scores on the Hospital Consumer Assessment of Healthcare Providers and Systems, standardized patient satisfaction survey

-clinical processes of care: examples including discharge instruction for heart failure patients, fibrinolytic therapy received with 30 minutes of hospital arrival for a patient with acute myocardial infarction

42
Q

components of hospital consumer assessment of healthcare providers and systems (HCAHPS)

A

-communication with nurses
-communication with doctors
-responsiveness of hospital staff
-communication about medicines
-cleanliness and quietness and hospital environment
-discharge information
-overall rating of hospital

43
Q

admission to a hospital withing 30 days of a discharge from the same or another hospital

A

readmission

44
Q

have a highly important role to ensure effective discharge planning and education so the patient and family are fully prepared to recover at home and prevent readmissions

A

nurses

45
Q

economic issues and trends:

illness treatment –>

A

prevention and population health driven

46
Q

economic issues and trends:

acute care –>

A

preventive care, home care

47
Q

economic issues and trends:

hospital or institution based –>

A

noninstitutional based

48
Q

economic issues and trends:

fee-for-service –>

A

value-driven payment models

49
Q

economic issues and trends:

if it might help, use it –>

A

outcomes measurement and cost-effectiveness

50
Q

economic issues and trends:

independent decisions –>

A

protocols and guidelines

51
Q

ensure positive patient outcomes and maximize reimbursement

A

nurse

52
Q

efficiency and effectiveness of care:

A

-decrease duplication of services and reduce wasted health care resources

-ensure care is delivered in the community through home care, outpatient clinics, and ambulatory care centers at less costly rates and to decrease more expensive inpatient hospital-based care

-ensure patients have resources to get effective treatment at the appropriate level of care across the continuum of care

53
Q

expansion of technology

A

-under examination for cost-efficiency vs. outcome delivery

-nurses will play a key role in educating patients and families about the cost/benefit ratio and assist in selecting alternatives

-internet offers promise for innovative programs

-nurses can combine clinical skills with information technology skills to meet a critical need for health information and data managment

54
Q

consumer empowerment

A

-customers or patients as health care consumers are demanding quality services at affordable rates

-nurses must understand and provide customer-focused care

-new relationships with consumers are developing that emphasize cost sharing based on individual health practices

-legislation is in place to protect individuals enrolled in managed care plans: access, quality, and cost

-nurse can take the lead in demonstrating the value of wellness and of teaching health consciousness

-reducing health care costs as a consumer

55
Q

reducing health care costs as a consumer

A

-take good care of yourself; manage minor illnesses by yourself at home

-use the internet to learn more about your health and ways of preventing disease

-recognize early warning signs of disease and get prompt treatment

  • practice preventive health with health screenings and routine self-examinations

-develop an active relationship with health care providers to improve communication

NURS 104 (4 decks)

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