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11 Cards in this Set

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Describe Managed Care
Managed Care: A planned coordinated approach to providing quality cost-effective Healthcare

It is a Cost effective method of delivering quality health care.
Risks shift from insurance company to the healthcare provider
Reduced insurance premiums for both employer and employees
Attractive to the “well”/ “healthy” population
Describe managed care companies
Managed care companies are organizations that employ or contract healthcare providers to deliver care for enrolled members through several mechanisms.
Discuss how current technology's ability to prolong/save people's lives have escalated overall health care costs?
People have health problems and the medical system can treat the problems, but it is expensive.
People are living longer, in a more compromised health care state COPD, diabetes, renal failure, meds and treatments help these people live longer but it is expensive.
Why have Health Maintenance Organizations (HMO's) been perceived in a negative light?
Less expensive plans have the most restrictions
Negative Light-More restrictions, can’t pick your physician and have other restrictions on care issues
Discuss the concept of capitation. Why might a patient utilizing services be considered an "expense."
A fixed prospective amount for each covered life enrolled in the plan, regardless of the cost of care provided
Opposite of fee for service type plans.
A company would contract with a managed care group to provide all health care services for employees and family members for x amount of dollars a month, paid per month. What the family needs they just pay the x amount of dollars and still get the care. No additional expense
Example: General practitioner take on a number of patients, and receives a monthly amount for having the number of patients.
Providers have no more interest in assuming this risk to do this type of plan

Pts must be generally healthy.—to have a low liability issue. If pts are not healthy, doctors don’t want to do everything and lose money. Healthcare providers don’t want to assume the risk.
Discuss how the concept of Consumer-Directed Health Plans (CDHP) works.
Health care providers no longer willing to assume the risks
Control of escalating costs were not achieved in managed care
Consumer disconnect between demanding healthcare choices and wanting lower out of pocket expenses. We want very best, we want what we want.

Consumer directed health plan: puts the consumer in control of medical decisions and cost. Consumer driven, self directed
Consumers have a choice: bear financial and clinical consequences of those choice
Usually associated with a health plan that also includes a Health Reimbursement Account (HRA) on top of a high deductible PTO plan
Consumers have a choice.
Consumers will bear the financial and clinical consequences of those choices
Employers will pay specified amount into a medical savings account (MSA)
Pay money to MSA Medical savings account. After MSA is depleted: Bridge amount. Deductible kicks in. PPO style benefit.
Cost containment issue
Why are Consumer-Directed Health Plans (CDHP) considered by some to be an unethical and inappropriate health care plan?
OPPONENTS: These plans are nothing more than an attempt to force American workers to pick up higher costs for healthcare. This new trend shifts costs to the consumer and the public, instead of to insurance companies and healthcare providers. Giving them options to healthcare choices
Consumers should not be expected to be the decision makers when it comes to health care treatment options. Consumers do not have enough education. Average person does not have medical expertise to make healthcare decisions, or cost effective decisions
Many people will go into debt, because people use more healthcare than others because they have cancer or major diseases and can’t cover all the costs.
Discuss the ethical issues related to having all plan participants experience equal increases in health care premiums regardless of service usage.
Those plan participants that have major diseases and have to use their healthcare insurance to pay for the expensive medical tests/treatments, benefit from the increases in health care premiums, because they will still be covered, and will not have to pay as much as if it was out of pocket.
For those that do not use the health insurance as much, these people see it as unfair, because they do not use the insurance very much and don’t like paying more, but they don’t realize that as they get older, they might have problems and need to rely on those higher premiums, so that their healthcare can be paid for.
Why is it important for all nurses to recognize their role as a "case manager" for their patients?
We provide education and guidance to help patients find the most affordable, most efficient, highest quality care that is available and appropriate for their needs
Health promotion and disease prevention-More emphasis placed on this. We need to generate an interest in this area
Health coaches-innovating plan with individuals with chronic conditions, people may be paid a certain amount of money when they have a coach and go through a program. Members agree to have health risk assessments, and get lower premiums and higher level of benefits…Smoking cessation, diabetes management, obesity issues.
Case Management-A system designed to ensure that quality care is provided in the most cost effective manner focused on patient oriented outcomes.
Foundation in prevention and wellness promotion. Compliments managed care goals by minimizing healthcare resource utilization by reducing illness
Every nurse is a manager of patient care
Review plan of care, set priorities around what needs to be accomplished for your patient!
Discuss the concept that regardless of the type of health care coverage that a patient has, the nurse's primary goal should be "outcome focused" for the patient.
We should always be focused on what the patient needs to learn, and how much the patient needs to recover in order to meet discharge goals
We will work closely for case managers. Communication is essential, both ways.
On the day of admission we are already talking about discharge plans and expected outcomes.
Describe the concept of a "critical pathway" and give an example of a positive variance and a negative variance to the critical pathway.
A tool that describes anticipated measurable outcomes of care on a timeline. Generally critical pathways are diagnosis specific, outlining patient care activities over an established time period. Serves as a “template” comparing “expected” with actual care provided
Provides a roadmap for a patient for someone who has a knee replacement
Day 1: patient should be able to do this with PT
Day 2: Pt should be able to do this, or ambulate this much
Care map, plan of care multidisciplinary approach all health care people use it.
Variances: Positive or negative, doesn’t mean pt or nursing staff has failed. That patient did not follow critical pathway timeline that average pt does. Meet the clients needs still in order to reach the desired outcome
If pt has other co morbidities, diabetes, CHF, etc. length of stay may be longer than anticipated. Negative variance.
Young athlete, knee repair, average length of stay 4 days, able to go home in two. Positive variance