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89 Cards in this Set
- Front
- Back
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Is the traditional method of paying health care bills
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fee-for-service
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Set monthly fee charged by the provider for each member of the insurance group for a specific set of services
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capitation
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____ is an alternative to the traditional fee-for-service method of payment
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capitation
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Monthly fee a person must pay for health insurance coverage
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premium
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Yearly amount an insured person must spend out of pocket for health care services before a health insurance policy will begin to pay its share
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deductible
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____ and ____ require the patient to pay an increased share of the of the cost of treatment, thus imporving the profit margin for the insurer. They benefit the ____ more than the agency
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deductible and copayment
insurer |
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The amount an insured person must pay at the time of an office visit, when picking up a prescription, or before a hospital service
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copayment
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percentage of the total bill paid by the insured person
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coinsurance
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A licensed health care person whose health care services are covered by a health insurance plan
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health care provider
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Personal Payment (Private Pay)
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- payment directly by the patient
- usually discouraged b/c of the high cost of health care services - sometimes patient can negotiate a discount w/ some health care agencies |
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____ attempt to reduce costs by providing services aimed at keeping members healthy
- give 2 examples |
HMO
-smoking cessation classes -weight loss programs |
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Private Group Health Insurance (Nongovernmental)
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-pools individual contributions for a common group goal (protection from financial disaster as a result of health care bills)
-offered by most employers in the US - ex: Blue Cross Blue Shield, HMO's (capitation), commerical insurance |
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Private Nongroup Health Insurance (Nongovernmental)
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-premiums are based on a person's age and health risk
-offered by insurance companies to individuals who are not part of a group - higher costs (premiums) than private group plans |
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Medicare (Social Secruity program)
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-federally sponsored entitlement program and public health insurance plan
-finances health care for those 65 and older (and their spouses) -least a 10 year record of Medicare covered employment -US citizen or US permanent resident |
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In regard to Medicare, ____ should include medications prescribed for the patient and whether the patient is medication compliant. Often patients are ____ when funds are limited. Medicare ___ and ___ limits funding for prescription drugs when living at home.
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-data collection
-without medication -A and B |
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What componenet of Medicare is known as hospital insurance for inpatient hospital care
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Part A
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What componenet of Medicare is known as medical insurance for physician services, outpatient care, and diagnostic testing?
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Part B
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What componenet of Medicare is known as a medicare advantage plan offered by private insurance companies?
ex: AARP, Peoples Health, Humana |
Part C
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What componenet of Medicare is known as medicare drug legislation that provides prescription drug coverage?
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Part D
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A math formula that is used to arrive at a fee that the government will pay for hospitalization
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Diagnosis-Related Group (DRG)
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Both ___ and ___ systems have resulted in cost-containment efforts by health care agencies. ___ and ___ are responses to the need to contain costs. ___ originated with Medicare.
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-DRG's and prospective payment
-managed care and critical pathways -DRG's |
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Medicaid (medical assistance)
-government sponsored (public) health insurance |
-individuals with low incomes and resources and eligible families
-each state establishes own program services and eligibility requirements -Children's Health Insurance Program (CHIP) covers uninsured children up to 200% of the poverty level |
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Sources of funding:
-Private Health Insurance -Medicare -Medicaid |
-Private: individual contributions are pooled
-Medicare: funded by federal government -Medicaid: jointly financed by federal and state government |
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____ provides for 20 days of post-hospitalization care in extended care or skilled nursing facility for rehabilitation services
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Medicare
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The need to hold costs to within fixed limits
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cost containment
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2 sources of income for government health care
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-income tax
-payroll tax |
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2 ways to cut costs in government provided health care
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-pass new laws to change eligibility
-pass new authorization bills to alter funding |
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The cost of commonly prescribed drugs in the US has risen ___ as much as ___
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-twice the rate of inflation
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2 classes of employed uninsured
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-Low wage employees: less likely to offer insurance benefits
-Middle class: rapidly rising health insurance premiums |
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Uncompensated Care
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-results huge yearly deficits for health care organizations
-includes services for which hospitals did not receive full payment for 1. free care- for patients who can not pay 2. bad debt- expecting to receive payment but never do |
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Give examples of incremental changes in health care:
-Federal level -State level -Local level |
Federal- HIPPA, CHIP
State- reduce rising health care costs and cover the uninsured Local- retail stores (Wal Mart and CVS) added wellness clinics to treat common health conditions |
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Give 2 examples of comprehensive changes in health care:
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-Single Payer System: payment for medical care for everyone comes from a single fund (regardless of past medical history) ex: Medicare
-Health Savings Account: tax free service that allows individuals to save for medical expenses via a medical savings account; linked with health care plans with high deductibles and lower monthly premiums (consumer directed plans) |
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Partnerships among hospitals, clinics, laborotories, health acre systems, and physicians
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Alliances (seamless systems)
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By joining together allliances can coordintate the delivery of care and contain costs among providers of health care services
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Networking
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Includes hospital systems found nationwide
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Consolidation
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Give 4 alternatives in insurance coverage
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-Managed care
-HMO's -Open Access Plans -Preferred provider organizations |
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One survival strategy for acute care facilities continues to be the use of ___
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Unlicensed Assistive Personnel (UAP)
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What allows staff to be assigned from units with low census to units that have staffing needs caused by absences or increased patient census?
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Cross Training
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What involves recording all the patient's data in a computer; increases efficiency by reducing/eliminating the need for paper records, medical history forms, test request forms, drug Rx, written physician comments, etc.?
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Electronic Medical Records (EMR)
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This cost effective method helps the patient reach discharge is the fastest time possible
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Critical Pathways
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What stresses the need to search continually for new ways to improve the process of patient care, prevent errors, and identity, and fix problems?
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Quality Improvement
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____ will monitor and improve processes involved in providing safe, effective care for patients
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Quality Improvement
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-look at change in a negative way
-fear the worst will happen because of the proposed change and feel helpless in the situation -do not willingly participate in the change process, allowing change to control them |
Victims
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-resist change but go along for the ride
-claim the change will never work -typically say "I told you so" |
Survivors
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-feel in control of the situation
-feel confident and excited about the possibility of being part of the solution to a problem -believe they have some control over change rather than being controlled by the change |
Navigators
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Acitivities that provide information critical to total quality management
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Continuous Quality Improvemwnt (CQI)
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What is one data collection method for CQI?
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feedback from patients
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It is important to provide information to elderly people, regardless of income, can receive federal payment for hospital and physician services through ____
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Medicare
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When the government tells the hospitals what it will pay for specific health care in advance; paying a set fee or flat rate for Medicare services
-___ can result in a profit for the hospital, creating an incentive |
Prospective Payment System
early discharge |
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What trend negatively impacts the number of licensed nurses employed by an agency?
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inexpensive personnel who preform nursing care
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The number one thing a LPN can do with care plans it to ___
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collect data
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The creation of ___ is a major way of improving the quality of patient care.
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care plans
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The nurse who sees change as an opportunity to be part of the solution to a problem is a ____
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navigator
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___ and ___ are important not only in patient care, but in nonclinical situations in the health care agency
-these skills will help the LPN navigate changes |
critical thinking and problem solving
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____ is the traditional method of paying health care bills in which physicians are paid a fee for each service they provide
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Fee-for-Service
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____ is the is the combination of all goods and services produced in a nations economy
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gross domestic product
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___ is a general rise in prices usually persisting over several years
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inflation
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____ is the monthly fee a person must pay for health care insurance coverage
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premium
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____ is the yearly amout an insured person must spend out of pocket for health care services before a health insurance policy will begin to pay its share
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deductible
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____ is the amount an insured person must pay at the time of an office visit, when picking up a prescription, or before a hospital service
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copayment
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____ is when the percentage of the total bill is paid by the insured person when the deductible is met
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coinsurance
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Health care services are ___, ___, and ___
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-health promotion
-diagnosis and treatment -illness prevention |
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Identified problems in health care in the US:
-health care costs are ___ than any other developed country -is ___% of our gross national product -there is an identified ____ of professional nurses in both acute and long term care agencies |
-higher
-16% -widespread shortage |
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5 cost containment measures
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-charge patient for all supplies used in their care
-documentign patient care according to reimbursement policy -time management priciples to work efficiently -using supplies carefully to avoid waste -implement measures to prevent complications |
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trends that affect long term care
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-patient acuity: likely to increase; due to shortened stay in acute care units
-decentralizatio: removing middle managers |
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____ is an example of payment methods for health care bills known as capitation, there are no deductibles or copayments
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HMO
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Medicare
- no person is ___ coverage based on past medical history - save money by not having to ____ |
- denied
- screen out high risk patients |
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Medicare Part A
- purpose - cost - funded - covers - not cover |
- purpose: hospital coverage for inpatient care
- cost: free, available w/o cost - funded: payroll tax - covers: hospice care for terminally ill patient and their beneficaries not cover: long term custodial care |
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Medicare Part B
- purpose - cost - funded - cover - not cover |
- purpose: medical insurance for physician services, outpatient care, and diagnostic care
- cost: 20% of services - funded: monthly premiums (income related), deducted from social security or retirement payments - cover: 80% of most charges, medically necessary services (those needed for diagnostic treatment of a medical service) - not cover: most Rx drugs or routine services (dental,eye, hearing aids) |
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Medicare Part C
- purpose - cost - cover - examples |
- purpose: medicare advantage plan offered by private insurance companies
- cost: low copayments w/ additional services (vision, hearing aids) - cover: includes Parts A and B, sometimes D - examples: Medicare HMO, PPO, PFFS |
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Personal Responsibility and Work Opportunity Reconciliation Act
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created temporary assistance for families in need (welfare)
- Medicaid program |
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Balanced Budget Act
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made welfare to work grants available to states to create additional jobs
- Medicaid program |
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In DRG's, the fee the government will pay depends on the ___ causing the patient's hospitalization
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DRG category (illness)
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Cost of Rx Drugs
- after decades of soaring drug prices, employers and health plans expect employees to ____ - drugs are expensive in the US becuase drug companies can charge ___ for the drugs, which includes the ___ and ___ |
- pay more for their Rx
- full price - cost of research and development of new drugs |
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4 alternatives to pay for health care include
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- Medicaid (if qualified)
- Private Pay (if affordable) - charity care (if found) - medical bankruptcy |
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Lack of access to health care prevents individuals from receiving ___ and ___ when a health problem is developing
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- preventive care
- seeking treatment |
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Many people rely on ____ for all levels of health care due to lack of insurance
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emergency departments
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Changes that occur here and there without affecting the health care system as a whole
- level(s) it occurs at |
Incremental Method
- federal, state, local |
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Changes that affect the health care system as a whole and not in a piecemeal fashion
- level(s) it occurs at |
Comprehensive Method
- federal |
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National Committee for Quality Assurance (NCQA)
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nonprofit group that provides oblective nationwide assessment of managed care plan
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Mangaed Care
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- developed to provide quality care with cost and utilization controls
- physicians are paid to care for groups of patients at a set fee and limit services |
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Open Access Plan
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- allows memebers to see specialists within the network for treatment w/o need of a referral
- may affect coinsurance |
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Preferred Provider Organizations (PPO)
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-fee-for-service as method of payment
- preferred providers: contracts w/ certain physician's and hospitals, will cover more of the cost - family practice physicians |
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Health Maintenance Organizations (HMO)
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- physician's are hired specifically for HMO services
- physician receive pre paid fee to prvide comprehensive services - need referrals to see specialists outside of network - POS option charges fee |
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2 forms of quality improvement
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- nursing care plans
- health care providers demonstrating competency throughout their careers |
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5 ways the LPN can present themselves as valuable assets to the health care agency:
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- be self-directed, motivated, problem solver
- identify what needs to be done and do it - be flexible to change - identify tasks or protocols that could be more efficient - role model for other LPN's |
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Comprehensive care system of medical services based on a set, prepaid fee
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HMO
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Similar to HMO's except physician's maintain their own practice and continue to be part of their own physician group. Part of the day is spent treating patients who are enrolled in this particular health care plan
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PPO
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A system of controlling costs of health care by arranging care at predetermined rates
- example |
Managed Care
- ex: HMO |
