Healthcare Policy and Finance in the US and UK, Exams of Nursing

Download Healthcare Policy and Finance in the US and UK and more Exams Nursing in PDF only on Docsity! NUR 4837 Healthcare Policy and Finance FINAL Including general internists and general pediatricians, what does the total supply of generalist amount to in the United States? How does this number compare with the UK? - correct answersthe total supply of generalists (including internists and pediatricians) amounts to 1/3 (33%) of all physicians in the US. In the UK it is about 50%. What is one action taken to fill the primary care gap in the United States? - correct answersSome physicians at the secondary and tertiary care levels have also acted as PCPs for their patients. Who is more likely to work in primary care settings than physicians? - correct answersNurse practitioners and physicians assistants Who is the Care Coordinator and "Gatekeeper"? - correct answers- The primary care provider is the gatekeeper Example: Polly sees a nurse practitioner who discovers that the reason she is vomiting is due to the medication she is taking. The NP consults with the oncologist to change her medication/prescription Stories such as Polly's demonstrate the importance of having a generalist care coordinator who can advocate on behalf of his or her patients and work in partnership with patients to integrate an array of services involving multiple providers to avoid duplication of services, enhance patient safety, and care for the whole person. NUR 4837 Healthcare Policy and Finance FINAL What are the forces driving healthcare in the U.S.? - correct answers- Biomedical model among medical educators - Financial incentive for physician specialization and hospital expansion - Professionalism- acting in patient's best interest Who benefits from Medicare? - correct answersMedicare is for the elderly Part A of Medicare - correct answersHospital insurance plan for the elderly financed largely through social security taxes from employers and employees Part B of Medicare - correct answersInsures the elderly for physician services and is paid for by federal taxes and monthly premiums from the beneficiaries Part D of Medicare - correct answersOffers prescription drug coverage and is paid for by federal taxes and monthly premiums from beneficiaries. Enacted in 2003 Medicaid - correct answersA program run by the states and is funded by federal and state taxes, which pays for the care of millions of LOW- INCOME PEOPLE NUR 4837 Healthcare Policy and Finance FINAL -PPO -HMO Fee- for- Service Payment with Utilization Review - correct answersThis is the traditional type of payment, with the addition that the third-party payer, whether private insurance company or government agency, assumes the power to authorize or deny payment for expensive medical interventions such as hospital admissions, extra hospital days, and surgeries. Preferred Provider Organization (PPO) - correct answers-Patients are able to see physicians not included within their insurer's physician network if they desire, but have to pay a higher share of "out of pocket" costs as a result when they use physicians/hospitals outside the "preferred" network. -PPO's allow patients to choose their own providers outside of a traditional HMO model. However, there may be increased costs to the patient in this type of model compared with HMO models Health Maintenance Organization (HMO) - correct answers-They are prepaid medical group services available through large businesses, instead of the traditional fee-for-service model. -Based off of early models such a Kaiser Permanente and Group Helath Cooperative of Puget Sound NUR 4837 Healthcare Policy and Finance FINAL What is the Nixon HMO Act of 1973 based on? - correct answersthe Kaiser Permanente Model What are the different methods of payment? - correct answers- payment per procedure: fee-for-service -payment per episode of illness -per diem payments to hospitals -payment per patient: capitation -payment for all services delivered to all patients within a certain time period DRG's (Diagnosis Related Groups) - method for hospital care Payment Per Procedure: Fee-for-Service Payment - correct answersThe unit of payment is the visit or procedure. The physician or hospital is paid a fee for each office visit/service/supply provided. Example: Roy is seen by his doctor for recent onset of diabetes. The doctor spends 20 mins performing an examination, glucose test, urinalysis and ECG. Roy is charged $92 for the visit, $8 for the glucose test, $15 for a urinalysis, and $70 for an ECG. Payment per Episode of Illness - correct answersThe physician or hospital is paid ONE SUM for all services provided/delivered during one NUR 4837 Healthcare Policy and Finance FINAL illness, as is the case with global surgical fees for physicians and *DRGs for hospitals. Example: Dr. Belli removes Tom's gallbladder and is paid $1300 by Blue Cross. Besides performing the surgery, Dr. Belli sees Mr. Stone three times in the hospital and twice in his office for post- op visits. Because surgery is paid by means of a global fee, Dr. Belli may not bill separately for the visits, which are included in his $1300 cholecystectomy fee. Per Diem Payments to Hospitals - correct answersThe hospital is paid a set amount per day for all services delivered to a patient (e.g., $1000/day) Capitation Payment - correct answersPayments made "by the head"; one payment is made for each patient's care during a month or year. Example: Jane is enrolled in Blue Cross HMO, which contracts with Upscale Hospital to care for Jane if she requires hospitalization. Upscale receives $60 per month as a capitation fee for each patient enrolled in the HMO. Jane is healthy, and during the 36 months that she is an HMO member the hospital receives $2160, even though Jane never sets foot in the hospital. Wayne is also enrolled in Blue Cross HMO. 24 months following his enrollment he contracts pneumonia and in the following 12 months spends 6 weeks in Upscale Hospital at a cost of $35,000. Upscale NUR 4837 Healthcare Policy and Finance FINAL Health Status and Income - correct answersThe incidence of chronic diseases increases as family income decreases Health Status and Race - correct answers- Different races such as African Americans, hispanics, etc. may experience worse health than white Americans Example: Life expectancy is lower for African Americans than for whites Primary Disease Prevention - correct answers- Seeks to avert the occurrence of a disease or injury Example: immunization against polio, taxes on the sale of cigarettes to reduce their affordability, and thereby use Secondary Disease Prevention - correct answers- Refers early detection of a disease process and intervention to reverse or retard the condition from progressing Example: pap smears to screen for premalignant and malignant lesions of the cervix, and mammograms for early detection of breast cancer First level of strategy for disease prevention - correct answers- The broadest level of disease prevention; includes measures to address the NUR 4837 Healthcare Policy and Finance FINAL fundamental social determinants of illness and to improve the STANDARD of living Example: Lower income is associated with higher morbidity and mortality rates. Improvement in the standard of living and social equity through job creation programs to reduce or eliminate unemployment, may have a greater impact on preventing disease than specific public health programs or medical care services. Second Level of strategy for disease prevention - correct answers- Involves public health interventions to reduce the incidence of illness in the population as a whole. Examples: water purification systems, the banning of cigarette smoking in the workplace, and public health education on human immunodeficiency virus (HIV) prevention in the schools Third Level of strategy for disease prevention - correct answers- Involves individual health care providers performing preventive interventions for individual patients; these activities can be either primary or secondary prevention Example: screening and treatment of hypertension, periodic breast examinations, prenatal care NUR 4837 Healthcare Policy and Finance FINAL Physicians - correct answersThere are approximately 860,000 physicians in the US with about one-third practicing in primary care. State medical boards require that physicians applying for licensure document a passing grade on national licensing examinations, certification of graduation from medical school, and completion of at least 1 year of residency training after medical school. Nurses - correct answersThe national licensing examination for registered nurses is administered by the National Council of State Boards of Nursing, a nonprofit organization comprising representatives of each of the state boards of nursing. Nursing is single largest health profession and most practice in hospital settings. Pharmacists - correct answersAlthough historically most pharmacists were educated in baccalaureate degree programs, in 2004 all programs were required to extend the training period by 1 to 2 years and award Doctorate of Pharmacy degrees. SIX core dimensions of quality outlined by the IOM - correct answers1. Safe 2. Effective 3. Patient-centered 4. Timely 5. Efficient 6. Equitable NUR 4837 Healthcare Policy and Finance FINAL The American Association for Labor Legislation Plan - correct answersin 1912 the AALL published a national health insurance proposal to provide medical care, sick pay and funeral expenses to lower-paid workers, those earning less than $1200 a year and to their dependents The Wagner and Murray Dingell Bill (1943) - correct answersin 1943 these two senators introduced a health insurance plan in which the employer and employee contributions to cover physician and hospital care would be paid to the federal social insurance trust fund, which would in turn pay health providers Medicare and Medicaid (1950s) - correct answersin the 1950s there was a strong social movement to come up with a solution to face the issue that less than 15% of the elderly had insurance The Kennedy Bill (1970s) - correct answersin 1970 senator Kennedy drafted legislation calling for a single federally operated health insurance system that would replace all public and private health insurance plan The Affordable Care Act (2010) - correct answersObama passed the affordable care act and reformed health care financing FOUR main components to the Affordable Care Act - correct answers1. *Individual mandate*: the ACA requires virtually all US citizens and NUR 4837 Healthcare Policy and Finance FINAL legal residents to have insurance coverage meeting a federally determined "essential benefits" standard. 2. *Employer mandate*: beginning in 2015, employers with 50 or more full-time employees face a financial penalty if their employees are not enrolled in an employer-sponsored health plan meeting the essential benefit standard and 3. *Medicaid eligibility expansion*: to qualify for Medicaid required not only low income, but also meeting "categorical" eligibility criteria such as being a young child, parent, pregnant, elderly, or disabled, leaving out non-disabled, non-pregnant adults without dependent children. 4. *Insurance market regulation*: the ACA also imposes new rules on private insurance. Private health insurance plans are required to include young adults up to age 26 under their parents' policies. The ACA also eliminates caps on total insurance benefits payouts, prohibits denial of coverage based on preexisting conditions, and limits the extent of experience rating to a maximum ratio of three-to-one between a plan's highest and lowest premium charge for the same benefit package. FOUR major actors in the U.S. Healthcare System - correct answers1. *Purchasers*: supply the funds. These include individual health care consumers, businesses that pay for the health insurance of their employees, and the government, which pays for care through public programs such as Medicare and Medicaid and through various tax subsidies. NUR 4837 Healthcare Policy and Finance FINAL 2. *Insurers*: receive money from the purchasers and pay the providers. Traditional insurers take money from purchasers (individuals or businesses), assume risk, and pay providers when policyholders require medical care 3. *Providers*: including hospitals, physicians, Accountable Care Organizations (ACOs), nurses, nurse practitioners, physician assistants, pharmacists, social workers, nursing homes, home care agencies, and pharmacies, among others, actually provide the care. 4. *Suppliers*: the pharmaceutical, medical supply, and computer industries, which manufacture equipment, supplies, electronic health records, and medications used by providers to treat patients. Dawson Model - correct answersBased off of concept of regionalization, the organization and coordination of all health resources and services within a defined area Regionalized model - correct answersDifferent types of personal and facilities are assigned to a distinct tier in the primary, secondary and tertiary levels Example: they're first seen by their general physician and then they refer them to a more specialized care (model used in the UK)