Impact of Managed Care Organizations on Long-Term Care and Healthcare System, Exams of Nursing

Download Impact of Managed Care Organizations on Long-Term Care and Healthcare System and more Exams Nursing in PDF only on Docsity! Healthcare Exam 3 Questions with Answers Latest Update 2024 Test Name the four functions of managed care. - Correct Answers Financing Insurance Delivery Payment How is managed care organizations evaluated on quality? - Correct Answers Healthcare Effectiveness Data and Information Set (HEDIS) evaluate performance on important dimensions of clinical care and service. The seven domains included are Effectiveness of care Access and availability of care Experience of care Utilization Relative resource use Health plan descriptive information Measures collected using electronic clinical data systems. What was the Health Maintenance Organization Act of 1973? - Correct Answers provided some federal support for the creation of HMOs and created widespread awareness of an alternative to fee-for-service medicine. Why was the fee for service model flawed? - Correct Answers Moral hazard prevailed Uncontrolled utilization Uncontrolled prices and payments Focusing on illness rather than wellness Higher insurance premiums A weakened economic position for providers What is utilization review? - Correct Answers the process of evaluating the appropriateness of services provided. Name the three types of utilization review - Correct Answers Prospective utilization Concurrent utilization Retrospective utilization Prospective utilization review - Correct Answers A process that determines the appropriateness of utilization before the care is actually delivered. An example of prospective UR is the decision by a primary care gatekeeper to refer or not refer a patient to a specialist. Concurrent utilization review - Correct Answers A process that determines on a daily basis the length of stay necessary in a hospital. It also monitors the use of ancillary services and ensures that the medical treatment is appropriate and necessary. For example, if a patient is admitted with a hip fracture, it is important to determine whether a rehabilitation hospital or a skilled nursing facility would be more appropriate for convalescent care. Retrospective utilization - Correct Answers A review of utilization after services has been delivered. Retrospective review may also involve an analysis of utilization data to determine patterns of overutilization or underutilization. Be able to describe key features of HMOs - Correct Answers Provides medical care during illness and services to help people maintain their health A PCP must be chosen from select physicians Providers receive a capitated fee All health care must be obtained within network Specialty services are usually not covered Services must comply with established standards of quality. Be able to describe key features of the PPOs - Correct Answers Establishes contracts with select groups of physicians and hospitals Enrollees can choose out of network providers, but cost sharing increases Discounted fee arrangements are made with providers Fewer restrictions to care are present. Be able to describe key features of the POSs - Correct Answers Retain the benefits of tight utilization management found in HMOs, but offer alternatives to the restricted provider choices It's a mix of HMO and PPO plans. Is willing to be held clinically and fiscally accountable for the outcomes and health status of the population serviced What is long-term care and who are the predominant users of long-term care services? - Correct Answers a variety of individualized, well-coordinated services that are designed to promote the maximum possible independence for people with functional limitations and are provided over an extended period of time in accordance with a holistic approach, while maximizing the care recipients' quality of life. Predominant users are 65 and older Name the essential characteristics of long-term care - Correct Answers Variety of services Individualized services Well-coordinated total care Maintenance of residual function Variety of services - Correct Answers Necessary because individual needs, as determined by health status, finances, and other factors, vary greatly among people who require these services: (1) fit the needs of different individuals, (2) Address their changing needs over time, and (3) Suit their personal preferences. Individualized services - Correct Answers LTC services are tailored to the needs of the individual patient Well-coordinated total care - Correct Answers Requires any health care need to be recognized, evaluated, and addressed by appropriate clinical professionals as many health care services need to be managed all at the same time Maintenance of residual function - Correct Answers Maintaining the patients previous functioning and preventing further decline. Let a patient do as much as they can before offering assistance Extended period of care - Correct Answers For most LTC clients, the delivery of various services extends over a relatively long period because the underlying causes of functional decline are often irreversible. Once admitted to LTC most individuals don't leave so care is needed until death In other cases, rehabilitation therapies or post acute convalescence may be needed for a relatively short duration, generally less than 90 days, with the patient subsequently returning to independent living. Holistic care - Correct Answers Focuses on every aspect of what makes a person whole and complete while incorporating a person’s needs and preferences into the care that is delivered Quality of life - Correct Answers a multifaceted concept that recognizes at least five factors: lifestyle, pursuits, living environment, clinical palliation, human factors, and personal choices to promote satisfaction, fulfillment, and self- worth Medical care, nursing and rehabilitation - Correct Answers Post acute continuity of care, clinical management of chronic illness and comorbidity, and restoration or maintenance of physical function Mental health services and dementia care - Correct Answers As the quality of life tends to decline in old age; along with the increase of chronic diseases the need for adequate mental health care is imperative as elderly individuals over often overlooked An estimated 25% of older adults have depression, anxiety disorders, or other significant psychiatric conditions, and mental health disorders are frequently comorbid in older adults, occurring in conjunction with common chronic illnesses such as diabetes, cardiac disease, and arthritis Social support - Correct Answers LTC clients need social and emotional support to help them cope with changing life events that may cause stress, frustration, anger, fear, grief, or other emotional imbalances. Preventive and therapeutic long-term care - Correct Answers Prevention generally refers to preventing or delaying institutionalization. Various community-based LTC services perform a preventive function by providing good nutrition and access to services, such as vaccinations, flu shots, and routine medical care. Therapeutic services, such as nursing care, rehabilitation, and therapeutic diets, are specified in a plan of care and administered as directed by a physician. Prevention occurs at the community level and therapeutic services are specified in a plan of care and administered as directed by a physician Informal and formal care - Correct Answers Informal care is performed by family, friends, neighbors, church members, or other community organizations. Formal care is performed in an institution by trained medical providers Respite care - Correct Answers A service that provides temporary relief to informal caregivers, such as family members. Community-based and Institutional services - Correct Answers Deliver LTC in the most economical and least restrictive setting To supplement informal caregiving when advanced services are needed or to substitute informal services when a person lacks a social network to receive informal care Provide temporary respite to informal caregivers, To delay or prevent Housing - Correct Answers Non-institutional housing other than a person's home, including: Independent living facilities Retirement living center/communities End of life care - Correct Answers Focuses on preventing needless pain and distress for terminally ill patients and their families, and places a high emphasis on maintaining patient dignity and comfort. What are Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs)? Provide examples. - Correct Answers ADLs are commonly used to measure disability, which includes whether an individual needs assistance to perform basic activities, such as eating, bathing, dressing, toileting, and getting into or out of a bed or chair. IADLs are a person's ability to perform household and social tasks, such as home maintenance, cooking, shopping, and managing money. What are the primary objectives of community based long-term care? - Correct Answers to deliver LTC in the most economical and least restrictive setting whenever appropriate, To supplement informal caregiving when advanced services are needed or to substitute informal services when a person lacks a social network to receive informal care, To provide temporary respite to informal caregivers, and To delay or prevent institutionalization. What are the common types of community based long-term care - Correct Answers Home health care Adult day care Senior centers Home delivered and congregate meals Homemaker services Continuing care at home Main culprits: hospital services, prescription drugs, and physician services What are some generalities of the U.S. healthcare system with respect to access - Correct Answers Access Disparities? Expansion of access will increase health care expenditures. The changes have led to an increase in the integration and coordination of care for patients who utilize a full range of health care services. What are some generalities of the U.S. healthcare system with respect to quality - Correct Answers Quality is increasingly taking center stage Cost is a factor in quality Quality is achieved when accessible services are provided The implications of the ACA for health care access, cost, and quality by initiating the National Quality Strategy to set national goals to improve the quality of healthcare The new payment model holds organizations accountable as a value-based model where organizations are reimbursed based on quality measures. Primary reasons for why our system is high in cost: - Correct Answers Third party payment Imperfect market Growth of technology Increase in the elderly population Medical model of healthcare delivery Multi-payer system and administrative costs Defensive medicine Waste and abuse Practice variations Third party payment - Correct Answers Payments are made by the government or by a private insurance company, which lowers patients out of pocket expenses Imperfect market - Correct Answers Utilization remains largely unchecked; prices charged for health care services remain higher than the true economic costs of production Growth of technology - Correct Answers Innovation, diffusion, and utilization drive costs and technological developments are expensive to develop Increase in the elderly population - Correct Answers Life expectancy has increased leading to the growth of the elderly population, but they use the most health care services Medical model of healthcare delivery - Correct Answers Care is given only when a patient is sick with no emphasis on prevention to promote better health Multi-payer system and administrative costs - Correct Answers Utilization review and authorization of care incur higher costs as more providers have to review medical information Defensive medicine - Correct Answers Fear of legal liability causes providers to do more tests, procedures, and follow-up visits so they're not liable for patient malpractice Waste and abuse - Correct Answers Disregarding the truth when filing billing claims or cost reports leads insurance companies to pay more for the care given even though services are often left out Practice variations - Correct Answers Physician behavior leads to wide variations in treatment protocols which causes some providers to charge different prices for the same services Why do we need to contain costs and why have we been unsuccessful in controlling costs? - Correct Answers No regulations are in place to keep providers from driving prices up in the long run. Controlling costs have been unsuccessful as providers want to gain as much revenue as they can One reason that cost-control efforts have not been successful is cost shifting: providers make up for lost revenue by increasing utilization and/or they charge higher prices in other areas free of controls Name some of the common types of cost containment measures we have used in the past - Correct Answers Health planning Price controls Peer review Competitive approaches Health planning - Correct Answers When a government takes steps to align and distribute health care resources so the system will achieve desired health outcomes Price controls - Correct Answers Price savings occurs between inpatient and outpatient services with the higher cost of inpatient services being less desirable Peer review - Correct Answers The process of medical review of utilization and quality carried out by or under the supervision of physicians Under Medicare, peer review organizations were established to determine if care was reasonable, necessary and of adequate quality Competitive approaches - Correct Answers Rivalry among seller providers of healthcare services try to attract patients who have the ability to choose from several different providers Can be in the form of price, technical quality, amenities, access or other factors What are some examples of competitive approaches to cost containment? - Correct Answers Demand-side incentives Supply side regulation Payer-driven price competition Utilization controls Demand-side incentives - Correct Answers Cost sharing encourages consumers to ration their own health care. Premiums, copayments, deductibles Supply side regulation - Correct Answers Antitrust laws prohibit business practices that stifle competition among providers. Price fixing, price discrimination, exclusive contracting arrangements, and mergers Payer-driven price competition - Correct Answers Employers shopping for the best value of cost premiums and benefits, and MCOs shopping for the best value from providers of health services Competition among insures Competition among providers Utilization controls - Correct Answers Managed care How do we define access to healthcare services? - Correct Answers the ability of a person to obtain needed, affordable, convenient, acceptable, and effective personal health services in a timely manner What is the status of access in the U.S. and what do we mean by disparity in healthcare access? - Correct Answers Barriers to access still exist at the individual and systematic levels of care.